1. Andreas Kiriakopoulos MD, PhD, FACS
MINIMALLY INVASIVE TECHNIQUES IN ADRENAL SURGERY: indications and limitations
Andreas Kiriakopoulos MD, PhD, FACS
Department of Surgery
HYGEIA Hospital,
Athens, Greece

2. Perhaps no organ is better suited for laparoscopic surgery than the adrenal gland because of its small size and relatively difficult location in the retroperitoneum, which requires a large, open excision for extraction

3. Open adrenalectomy
Discrepancy between the adrenal tumor size and the abdominal wall incision

4. Open adrenalectomy(posterior approach)

5. Minimally invasive techniques in modern adrenal surgery: have gained a rapid development so today the question open or MIS is obsolete

6. CHOICE OF THE BEST MIS METHOD FOR THE PATIENT
APPLICABILITY OF MIS IN:
- BIG TUMORS
- ADRENAL CANCER
- ADRENAL METASTASIS

7. MINIMALLY INVASIVE ADRENAL SURGERY
LAPAROSCOPIC
APPROACH
- Lateral transperitoneal
- Anterior transperitoneal
- Hand -assisted
RETROPERITONEAL
ADRENALECTOMY
- Posterior
- Lateral
- SARA
SINGLE SITE LAPAROSCOPIC APPROACH
ROBOTIC ADRENALECTOMY
- Transperitoneal
- Retroperitoneal

8. Surgeons should choose the approach they are most familiar with,
have had training in, and
have the best patient outcomes with

9. LAPAROSCOPIC ADRENALECTOMY

10. First appliance of laparoscopic adrenalectomy into clinical practice in 1992 Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.

11. LA
‘‘GOLD STANDARD’’ for the surgical management of most adrenal tumors
Absence of randomized trials comparing laparoscopic with open adrenalectomy

12. Improved postoperative pain levels
Decreased blood loss
Decreased morbidity
Shorter hospital stay
Faster recovery, and quicker return of bowel function
And better overall cost-effectiveness compared with the open approach
Inabnet WB, 3rd et.al Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program. J Am Coll Surg 206:
Thompson GB et. al. Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery 1997; 122:
Linos DA et. al. Anterior, posterior, or laparoscopic approach for the management of adrenal diseases? Am J Surg 1997; 173: 120
Lal G, Duh QY Laparoscopic adrenalectomy--indications and technique Surg Oncol Aug;12(2):105-23

13. INDICATIONS Adrenocortical functional tumors < 6cm
Pheochromocytomas < 6 cm
Nodular adrenocortical hyperplasia with increased cortisol secretion
Non-functioning tumors/ Incidentalomas 4-6 cm
Tumor size ?
Adrenal metastasis (?)
Primary adrenal cancer (?)

14. INDICATIONS OF LAPAROSCOPIC ADRENALECTOMY
ALDOSTERONOMA: ALL
PHEOS: ALL except those with signs of infiltration/local invasion
CUSHING ADENOMAS: ALL except those with signs of infiltration/local invasion
ADRENOCORTICAL CARCINOMA ?
ADRENAL METASTASIS ?
TUMOR SIZE ?

15. CONTRA-INDICATIONS Tumor size (functional or not) > 8 cm (?)
Extensive previous abdominal surgery
Adrenocortical cancer
Patient related (Severe cardiopulmonary disease, uncontrolled coagulopathy, medically untreated pheochromocytoma)

16. LA Big adrenal tumor
Technical merits: (surgeon skilled in advanced laparoscopy and adrenal surgery)
Nevertheless, large adrenal tumors must present without pre- or intraoperative evidence of malignancy/infiltration and
LA increased operative time
increased blood loss
higher conversion rates

17. LA ACC GUIDELINES (ESES, LYON 2011)
An open approach is recommended in case of local invasion, with a view to achieving an R0 resection (level D).
Laparoscopic resection of ACC/potentially malignant tumours, which includes removal of surrounding periadrenal fat and results in an R0 resection without tumour capsule rupture, may be performed for preoperative and intraoperative stage 1-2 ACC and tumours with a diameter < 10 cm (level C).
Carnaille B. Adrenocortical carcinoma: which surgical approach? Langenbecks Arch Surg Feb;397(2):195-9

18. SAGES Guidelines LA ACC
If a laparoscopic approach is chosen (due to unknown malignancy status preoperatively or suspected early stage ACC), conversion to open surgery is strongly recommended when difficult dissection is encountered due to tumor adhesion or invasion or enlarged lymph nodes are seen
SAGES Guidelines

19. LA Metastasis SAGES Guidelines
Solitary metastasis to the adrenal gland without evidence of local invasion can be approached laparoscopically.
If local invasion is found intraoperatively, conversion to an open approach is warranted
SAGES Guidelines

20. LAPAROSCOPIC RIGHT ADRENALECTOMY
DISADVANTAGE: NUMBER OF TROCARS USED

21. LAPAROSCOPIC RIGHT ADRENALECTOMY

22. LAPAROSCOPIC RIGHT ADRENALECTOMY
Right adrenal vein ligation using endo-clips
Watch out for accessory veins!!!

23. LAPAROSCOPIC LEFT ADRENALECTOMY

24. LAPAROSCOPIC LEFT ADRENALECTOMY
Left colon mobilization – gastrocolic division
Identification of the left kidney and the pancreas
‘‘Opening the book’’ maneuver
MOBILIZATION OF THE SPLEEN
DISADVANTAGE: EXTENSIVE MOBILIZATION OF INTRAABDOMINAL ORGANS

25. LAPAROSCOPIC LEFT ADRENALECTOMY
DIRECT METHOD-NO SPLEEN MOBILIZATION

26. SINGLE ACCESS TRANSPERITONEAL ADRENALECTOMY

28. SINGLE ACCESS TRANSPERITONEAL ADRENALECTOMY
Safe and feasible method
no advantage over other standard laparoscopic approaches to adrenalectomy. Additional, better quality evidence is needed before this approach can be recommended
SAGES Guidelines

29. RETROPERITONEOSCOPIC ADRENALECTOMY: posterior approach

30. RA Alternative to laparoscopic adrenalectomy Not very popular
Initially used for small adrenal tumors
Walz et al.Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: Results of 30 adrenalectomies in 27 patients World J Surg 1996;20:

31. RA Small working space Difficult orientation
No access of abdominal cavity for evaluation
Experienced surgeon
- training ?
-learning curve?

32. INDICATIONS Adrenocortical functional tumors < 6cm
Pheochromocytomas < 6 cm
Non functional tumors/ incidentalomas < 6 cm
Metastasis < 6 cm

33. Retroperitoneal fibrosis Adrenal cancer
INDICATIONS
CONTRA-
Tumor size > 8cm
Previous surgery
Retroperitoneal fibrosis
Adrenal cancer

34. ADVANTAGES OVER LA?
TECHNICAL
CLINICAL

35. DIRECT ACCESS TO THE RETROPERITONEAL SPACE
ADVANTAGES
DIRECT ACCESS TO THE RETROPERITONEAL SPACE
EXCELLENT VIEW
OF THE OPERATIVE FIELD
OPERATIVE MANOUVERS SOLELY IN THE RETROPERITONEAL SPACE

36. BILATERAL PROCEDURES CAN BE DONE WITHOUT PATIENT REPOSITIONING
ADVANTAGES
DISSECTION AND DIVISION OF THE SHORT RIGHT ADRENAL VEIN IS SAFER THROUGH THE RETROPERITONEAL ACCESS DUE TO THE SUPERIOR VIEW AND CONTROL OF THE POSTEROLATERAL ASPECT OF THE VENA CAVA
BILATERAL PROCEDURES CAN BE DONE WITHOUT PATIENT REPOSITIONING

38. IMPACT OF POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY IN A TERTIARY CARE CENTER: A PARADIGM SHIFT
A.Kiriakopoulos, D. Linos . Surg Endosc Nov;25(11):3584-9
“…Posterior retroperitoneoscopic adrenalectomy compared to laparoscopic adrenalectomy was safe, fast, although vastly superior in terms of postoperative pain and hospital stay in this series. Being able to produce such excellent operative results along with the impressive patient recovery and the significantly reduced operative cost constituted the retroperitoneal approach the method of choice in minimally invasive adrenal surgery for us’’
POSTERIOR RETROPERITONEOSCOPIC vs LAPAROSCOPIC ADRENALECTOMY IN SPORADIC AND MENIIA PHEOCHROMOCYTOMAS
A. Kiriakopoulos, D. Linos SAGES 2014, Salt Lake City, Ut, USA
‘‘Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.

39. RA vs LA
…Twenty-one studies comparing a total of 1,205 lateral transperitoneal adrenalectomies and 688 retroperitoneal adrenalectomies were suitable for meta- analysis.
…There were no statistically significant differences between lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy in terms of operative time, blood loss, hospital stay, time to oral intake, overall and major morbidity, and mortality
… Both lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy are associated with very low rates of perioperative complications. According to our meta- analysis, clinical outcomes after either technique are similar.
… For most adrenal lesions requiring operation, minimally invasive adrenalectomy can be performed safely and effectively with either transperitoneal or the retroperitoneal approach. Additional studies may be needed to analyze if any difference in long-term results exist.
Nigri G et. al. Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy Surgery 2013 Jan;153(1):111-9

40. RA vs LA
…Twenty-two studies were included, reporting on 1257 LAs, 471 LRAs and 238 PRAs. Both PRA and LRA were associated with a reduced length of hospital stay: SMD - 1·45 (95 per cent confidence interval - 2·76 to - 0·14) and - 0·54 (-1·04 to - 0·03) days respectively compared with LA.
… When considering only the two randomized clinical trials (RCTs) there was no statistically significant difference in this outcome. One RCT, however, found a reduction in the median time to convalescence of 2·4 weeks in the LRA group.
… There were no differences in duration of operation, blood loss, time to ambulation and oral intake, or complication rates between techniques.
… RA overall has equivalent outcomes to LA but may be associated with a shorter hospital stay.
Constantinides VA et. al. Systematic review and meta-analysis of retroperitoneoscopic versus laparoscopic adrenalectomy Br J Surg 2012; 99(12):

41. Patient position

44. Port placement

46. Working port (grasper)
Camera
Working port (U/S scissors)
Working port (grasper)

47. C02 pressure

48. RIGHT ADRENAL INCIDENTALOMA 4.1cm

49. LEFT CORTICAL ADENOMA- CUSHING 6.1 cm

50. LEFT PHEO 5cm

51. RIGHT PHEO
5 cm

52. RIGHT CORTICAL ADENOMA 4.2cm

53. LEFT PHEO
MEN2A - 6 cm

54. RIGHT PHEO
VON RECKLINHAUSEN DISEASE

55. LEFT ALDOSTERONOMA
1.1cm

56. RIGHT CORTICAL ADENOMA-OVERT CUSHING- 6 cm

57. LATERAL RETROPERITONEAL
APPROACH

58. LATERAL RETROPERITONEAL APPROACH

59. SINGLE PORT LATERAL RETROPERITONEAL APPROACH

60. SINGLE PORT RETROPERITONEAL ADRENALECTOMY (SARA)

61. Walz MK, et. al. Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): a case-control study. World J Surg Jun;34(6):
… Fifty single-access retroperitoneoscopic adrenalectomies (SARA) were performed in 47 selected patients. Another 47 patients served as control group; they were treated by the traditional retroperitoneoscopic three-port approach (CORA
… Mortality was zero and no major complications occurred in both groups. SARA was completed in 41 cases (86%). The overall complication rate was 8.5% in SARA and 6.4% in CORA. Operative time was longer for SARA (56 +/- 28 min) than for CORA (40 +/- 12 min) (P < 0.05). Postoperatively, pain medication was administered in 47% of SARA patients and in 75% of CORA patients (P = 0.01). Mean hospital stay was 2.4 +/ days (SARA) and 3.1 +/- 1.2 days (CORA) (P < 0.01).
… Because feasibility and safety of SARA could be demonstrated in a large group of selected patients, this surgical technique may represent a new milestone in minimally invasive endocrine surgery.

62. ROBOTIC ADRENALECTOMY

64. ROBOTIC ADRENALECTOMY
…No definitive advantages of robotic compared to laparoscopic adrenalectomy…
Morino M, Beninca G, Giraudo G, Del Genio GM, Rebecchi F, Garrone C Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial. Surg Endosc Dec;18(12):1742-6
… No difference in the quality of life after robotic adrenalectomy Brunaud L, Bresler L, Zarnegar R, Ayav A, Cormier L, Tretou S, Boissel P Does robotic adrenalectomy improve patient quality of life when compared to laparoscopic adrenalectomy? World J Surg Nov;28(11):1180-5
… Remote surgery may be an advantage of the robotic procedure… Bentas W, Wolfram M, Brautigam R, Binder J.Laparoscopic transperitoneal adrenalectomy using a remote-controlled robotic surgical system. J Endourol Aug;16(6):373-6

65. ROBOTIC vs LA
Pineda-Solís K et. al. Robotic versus laparoscopic adrenalectomy: a comparative study in a high-volume center. Surg Endosc.2012
… robotic adrenalectomy is as safe and technically feasible as laparoscopic adrenalectomy. Subjective benefits for the surgeon with robot-assisted surgery include three-dimensional operative view, ergonomically comfortable position, and elimination of the surgeon's tremor. The operating time is significantly longer but patient outcomes are similar to those of the laparoscopic technique

66. ROBOTIC RA vs LA vs RA
Karabulut K Surgery Apr;151(4): Comparison of intraoperative time use and perioperative outcomes for robotic versus laparoscopic adrenalectomy.
Agcaoglu O Arch Surg 2012 Mar;147(3):272-5 Robotic vs laparoscopic posterior retroperitoneal adrenalectomy
… mean (SEM) operative time was shorter for the robotic group than for the laparoscopic group (139.1 [10.9] vs [8.2]). The mean (SEM) pain score on postoperative day 1 was lower in the robotic group than in the laparoscopic group (2.5 [0.3] vs 4.2 ); however, the mean (SEM) pain scores for the groups were similar on postoperative day 14 .
… beyond the learning curve for experienced laparoscopic surgeons, robotic posterior retroperitoneal adrenalectomy shortens the skin-to-skin operative time compared with the laparoscopic approach. Our results also suggest that the immediate postoperative pain may be less severe for patients who undergo robotic posterior retroperitoneal adrenalectomy

67. ROBOTIC RA
Perrier ND. Robotic-assisted retroperitoneoscopic adrenalectomy: making a good procedure even better. Am Surg Jan;79(1):84-9
… Thirty consecutive RA-PRAs were performed in 28 patients (26 unilateral and 2 bilateral. Mean tumor size was 3.8 ± 1.6 cm
… Mean operative time was 154 ± 43 minutes for unilateral total adrenalectomy. Three patients experienced perioperative complications (one pneumothorax, one urinary retention, one required postoperative blood transfusion
… Robotic surgical technology is an excellent complement to retroperitoneoscopic adrenalectomy. The three-dimensional view and ergonomic advantages of a robotic procedure promote better visualization and a more flexible approach to dissection. We believe these features may optimize the ability to maintain a vascularized remnant during minimally invasive cortical-sparing adrenalectomy.

68. SINGLE PORT RETROPERITONEAL ROBOTIC ACCESS

69. MINIMALLY INVASIVE
ADRENAL-SPARING
SURGERY

70. MINIMALLY INVASIVE ADRENAL-SPARING SURGERY
* Partial excision < 50 % of the gland
* Subtotal excision > 50% of the gland
Concerns:
* radicality
* recurrence vs benefit

71. MINIMALLY INVASIVE ADRENAL-SPARING SURGERY
- Technically feasible and safe method
Imai T et. al. Laparoscopic partial adrenalectomy. Surg Endosc 1999; 13:
- Applied for bilateral pheos in MEN 2A cases
Janetschek G et. al. Laparoscopic partial adrenalectomy. J Urol 1998; 160:
Neumann HPH et. al. Preserved adrenocortical function after laparoscopic bilateral adrenal-sparing surgery for hereditary pheochromocytoma. J Clin Endocrinol Metab 1999; ; 84:
- Posterior retroperitoneoscopic approach even for unilateral pheos or Conns’ in highly selected patients
Walz et.al. Subtotal adrenalectomy by the posteiror retroperitoneoscopic approach. World J Surg 1998; 22: