In 1992 Gagner et al. described the first laparoscopic adrenalectomy (LA), and since then it became the gold standard surgical technique for adrenal diseases. However there are "winds of change"...
In April 2014 I had the privilege to learn from Prof. Dr. Martin Walz (Essen, Germany) how to perform a posterior retroperitoneoscopic (PR) adrenalectomy. It was easy to understand the potential and the advantages of this minimally invasive technique over the standard method.
In 2012 Cho Rok Lee and Martin Walz (1) published a comparison between the transperitoneal technique (laparoscopic adrenalectomy - LA) and the posterior retroperitoneoscopic (PR) adrenalectomy. Many surgeons use the laparoscopic approach because of the familiar operative field and the wider working space it gives. However, these advantages are overcome by several factors of the posterior retroperitoneoscopic approach as presented by the authors:
1. PR approach provides a direct and rapid access to the adrenal
2. Decreased abdominal viscera lesions because there is no incursion into the peritoneal cavity
3. Less post-operative pain after PR adrenalectomy comparing to LA
4. Shorter time to first oral intake
5. PR adrenalectomy has shorter operative time than LA
Indications for PR approach are also addressed in the article. The smaller operative field might be a disadvantaged of PR approach, but lesions up to 8 cm (occasionally up to 10 cm) and with no signs of malignancy are indications for posterior retroperitoneoscopic approach. LA is a better option for patients with concomitant abdominal pathology. For adrenal tumors with features suggestive of malignancy (more than 8cm, local or vascular invasion, hypersecretion of multiple hormones, local adenopathies) traditional open surgery is indicated.
From the data presented above (from Cho Rok Lee and Martin Walz), we can conclude that posterior retroperitoneoscopic approach has better outcomes than laparoscopic technique, and is indicated in the majority of adrenal tumors. Because lesions bigger than 8-10 cm or with features suggestive of malignancy are indications for open surgery, LA will have only a few indications in the present time (surgeon's option, concomitant abdominal pathology).
In April 2015, I performed in the Surgery C department of "Centro Hospitalar e Universitário de Coimbra - Hospital Geral" (Coimbra, Portugal) the first posterior retroperitoneoscopic adrenalectomy (figure).
Patient had a Conn's syndrome of 2 cm in the right adrenal gland. Operative time was 40 minutes, it was a R0 resection, and he was discharged home in the second post-operative day. No complications occurred. Since then we are using the posterior retroperitoneoscopic approach as the standard technique for hormone producing tumors of the adrenal (Conn's, Cushing's, pheochromocytoma) up to 6-8cm, and if no features of malignancy are present. Size limit will probably be increased with experience gain, and depending on outcomes obtained.
If you have any question or doubt, please feel free to contact me.
References:
Dr. Carlos Eduardo Costa Almeida
General Surgeon