Full text of DOI:10.1089/10926420150502850

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 11, Number 1, 2001
Mary Ann Liebert, Inc.
State-of-the-Art Review
Does Tumor Size Influence the Outcome of
Laparoscopic Adrenalectomy?
AIRAZAT M. KAZARYAN, M.D.,* TOM MALA, M.D., and BJORN EDWIN, M.D.
ABSTRACT
Background: Laparoscopic adrenalectomy is safe and effective for small adrenal tumors, but its role
for large adrenal tumors and the influence of tumor size on the outcome of laparoscopic adrenal-
ectomy have been questioned.
Patients and Methods: Thirty-one patients with unilateral adrenal tumors operated on between
January 1997 and April 2000 were selected for this study. The indications for surgery were Conn’s
adenoma in 16 patients, pheochromocytoma in 7 patients, Cushing’s adenoma in 4 patients, and in-
,
cidental lesions in 4 patients. The patients were divided in two groups: 19 patients with tumors 3.5
$
cm (Group I) and 12 patients with tumors 3.5 cm (Group II). The outcomes of the two groups
were compared.
Results: None of the laparoscopic procedures was converted to open surgery. The tumor size cor-
5
5
5
5
related with operative time (r 0.434; P 0.015) and blood loss (r 0.513; P 0.003), with both
being significantly greater for larger tumors. No patient required a blood transfusion during or af-
ter surgery. One preoperative complication occurred in Group I. There was no peroperative com-
plication in Group II. The median postoperative hospital stay and opioid requirement did not dif-
fer significantly between the groups. One patient in Group I developed pneumonia, while no
postoperative complications were recorded in Group II.
Conclusion: Surgery for large adrenal tumors can safely be performed laparoscopically with out-
comes comparable to those of surgery for small tumors.
have been published, and laparoscopic adrenalectomy
has been shown to be safe and effective.2 Currently, it
is considered the treatment of choice for small adrenal
tumors.3 However, laparoscopic adrenalectomy for
large tumors and the influence of tumor size on the out-
come of laparoscopic adrenalectomy has not been
specifically addressed. The aim of this study was to
evaluate and compare the results and complications of
laparoscopic adrenalectomies for small and large tumors
INTRODUCTION
INCE THE INTRODUCTION of laparoscopic cholecys-
tectomy in the late 1980s, minimally invasive sur-
S
gical techniques have improved tremendously. Ad-
vances in instrumentation and improved skills allow
laparoscopic treatment for a wide range of indications.
Laparoscopic adrenalectomy was first reported in 1992
by Gagner and associates.1 Since then, several series
The Interventional Center and the Surgical Department, National Hospital, University of Oslo, Oslo, Norway.
*Present address: The Faculty for Training Research Workers and Medical Educators, I.M. Sechenov Moscow Medical Acad-
emy, Moscow, Russia.
1

2
KAZARYAN ET AL.
and define any influence of tumor size on the outcome
of laparoscopic adrenalectomy.
ports, 11-mm trocars were used. The adrenal vein was
located, and the tumor was mobilized after the vein had
been identifiedand divided. The dissectionwas done with
the Harmonic Scalpel (Ethicon, Cincinnati, OH) or Au-
toSonix (AutoSuture, Norwalk, CT). The surgical speci-
men was removed using the Endo-Catch (AutoSuture).
The following peroperative factors were compared in
the two groups: operative time, blood loss, number of
blood transfusions, need for open conversion, and com-
plications. Postoperatively, the following were recorded
and compared: opioid administration, hospital stay, and
postoperative complications. The opioid administration
was recorded from the first postoperative day.
PATIENTS AND METHODS
From January 1997 to April 2000, 31 patients with uni-
lateral tumors underwent laparoscopic adrenalectomy at
the National Hospital (Rikshospitalet) at the University
of Oslo. The indications for surgery were Conn’s ade-
noma in 16 patients, pheochromocytoma in 7, Cushing’s
adenoma in 4, and “incidentaloma” in 4. The distribution
of the tumor sizes is presented in Figure 1.
The patients were divided into two groups. Group I
The data are presented as median and range. For com-
parison of frequencies, Fisher’s exact test was performed.
For analysis of the continuous variables, the Mann-Whit-
,
consisted of 19 patients with tumors 3.5 cm, and Group
$
II consisted of 12 patients with tumors 3.5 cm. There
was no statistical difference between the groups regard-
ing age, sex, ASA classification,or tumor location (Table
1). The groups also were similar in regard to the learn-
ing curve of the surgeon.
r
ney rank sum test was used. Pearson’s was used to ex-
amine the association between tumor size and operative
time and between tumor size and blood loss. A value
P
,
0.05 was regarded as significant.
During surgery, the patients were placed in a lateral
position. Three trocars were used for operations on the
left side and four for tumors on the right side. The tro-
cars were inserted 3 to 5 cm below the costal margin from
the pararectus line in the dorsal direction. On the right
RESULTS
All tumors were removed, and there were no conver-
side, a fourth trocar was inserted just below the costal sions to open surgery. The median operative time was
margin in the pararectus or median lines. An open tech- significantly longer and the blood loss significantly
nique was used for placing the first, 12-mm, trocar with greater in Group II than in Group I (Table 2). The tumor
r 5
P 5
30° laparoscope into the abdominal cavity, 4 to 5 cm lat- size correlated with operative time (
0.434;
0.003). Blood
r 5 P 5
eral to the pararectus line and 3 to 5 cm below the costal 0.015) and blood loss (
0.513;
margin. Carbon dioxide was insufflated until the intra- transfusions were not required in any of the patients dur-
abdominal pressure reached 8 to 9 mm Hg. For the other ing or after the operation. One peroperative complication
FIG. 1. Distribution of adrenal tumor sizes.

TUMOR SIZE AND LAPAROSCOPIC ADRENALECTOMY
3
TABLE 1. PATIENT CHARACTERISTICS IN GROUP I
(TUMOR ,3.5 CM) AND GROUP II (TUMOR $3.5 CM)
Group I
Group 2
(N 19)
(N 12)
value
P
5
5
Median age (years)
Sex (male/female)
50 (34–76)
13/6
08/11
2 (2–3)
52 (31–65)
7/5
8/4
2 (1–3)
NS
NS
NS
NS
Tumor location (left/right)
a
ASA classification
Median tumor size (cm)
1.7 (1–3)
5.75 (3.5–11)
,0.001
aASA-American Society of Anesthesiologists.
.
occurred in Group I: a small hole was created in the di-
6 cm, and some cortical carcinomas are small. Hence,
aphragm, which was sutured. No peroperative complica- this conception is contraindicated by some authors.9 In
.
our experience, one of the five tumors 6 cm (consid-
tions occurred in Group II.
The postoperative hospital stay did not differ signifi- ered preoperatively to be an incidentaloma) turned out to
cantly in the two groups. In both groups, two patients re- be a metastasis from a renal carcinoma. The operation
quired opioid administration for pain control (Table 2). was completed without any difficulties, consuming 170
In Group I, one patient developed postoperative pneu- minutes with 150 mL of blood loss. There has been no
monia. No other postoperative complications were recurrence of the tumor at the follow-up of 24 months.
recorded.
However, this case accents the importance of compre-
hensive preoperative CT or MR investigations or both in
the planning of laparoscopic surgery for adrenal glands.
Previous surgery in the adrenal region may also be con-
sidered a contraindication to the laparoscopic approach.2
Large adrenal tumors have been said to be more diffi-
DISCUSSION
Since the initial report of laparoscopic adrenalectomy
by Gagner and associates in 1992,1 the laparoscopic ap- cult to dissect laparoscopically, and the operation is of-
proach has become the preferred surgical treatment for ten associated with more complications.10,11 In this re-
benign adrenal tumors.2,3 Principally, there are two lap- port, the outcomes of laparoscopic adrenalectomy were
aroscopic approaches: transabdominal and retroperi- similar for large and small tumors. The only differences
toneal.3–6 In our experience,the transabdominalapproach found between the groups were slightly greater blood loss
is preferable because it facilitates intra-abdominal orien- and longer operative times in Group II. These differences
tation, and access to the adrenal glands is easier. This ap- were without consequences for the patients, however, as
proach also enables removal of larger tumors.
no blood transfusions were given and no peroperative
There are contraindications to laparoscopic adrenalec- complications were recorded in Group II. The postoper-
tomy,3,6 some of which are not specific to adrenal surgery ative hospital stay, pain medication needs, and compli-
(uncorrectable coagulopathy,severe cardiopulmonaryin- cations were also the same in the two groups. In one re-
.
sufficiency). Invasive adrenal carcinoma is an absolute port, tumors 8 cm were considered a contraindication
contraindication. Tumors 6 cm are considered proba- to a laparoscopic approach.12 In our investigation, the
.
bly malignant.7,8 However, many adrenal adenomas are four patients having tumors 8 cm showed no differ-
$
TABLE 2. OUTCOMES OF LAPAROSCOPIC ADRENALECTOMY
IN GROUP I AND GROUP II
Group I
Group 2
(N 19)
(N 12)
value
P
5
5
Operative time (min)
Blood loss (mL)a
Peroperative complications
Conversion
85 (50–160)
50 (20–100)
165 (75–325)
125 (50–400)
0.005
0.001
NS
1
0
0
0
–
Postoperative stay (days)
Patients requiring opioids
Postoperative complications
2 (2–5)
3 (2–5)
NS
NS
NS
2
1
2
0
aNo transfusionswere required.

4
KAZARYAN ET AL.
3. Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A.
Laparoscopic adrenalectomy: Lessons learned from 100
consecutive procedures. Ann Surg 1997;226:238–246.
4. Chee C, Ravinthiran T, Cheng C. Laparoscopic adrenalec-
tomy: Experience with transabdominal and retroperitoneal
approaches. Urology 1998;51:29–32.
5. Walz MK, Peitgen K, Hoermann R, et al. Posterior retro-
peritoneoscopy as a new minimally invasive approach for
adrenalectomy: Results of 30 adrenalectomies in 27 pa-
tients. World J Surg 1996;20:769–774.
6. Duh Q, Siperstein A, Clark O, et al. Laparoscopic adrenal-
ectomy: Comparisonof the lateraland posteriorapproaches.
Arch Surg 1996;131:870–875.
7. Copeland PM. The incidentally discovered adrenal mass.
Ann Intern Med 1989;98:940–945.
ences in peroperative or postoperative outcomes except
greater blood loss and operative time. The greater blood
loss and longer operative time in Group II is explained
by the need for more extensive dissection because of the
greater tumor volume. The predominance of pheochro-
mocytomas in Group II is possibly an additional factor
in the increased blood loss in patients with large tumors
because of the more vascular structure of these lesions.
Cosmetically, there was no major difference between
the groups. In the patients with large tumors, however,
the trocar incision had to be lengthenedto enable removal
of the tumor. The incision was made at the lower trocar
position. In most of the cases, the incision did not exceed
5 cm. The exception was in a patient with an 11-cm tu-
mor, who required a 6-cm incision.
8. Herrera MF, Grant CS, Van Heerden JA, et al. Incidentally
discovered adrenal tumours: An institutional perspective.
Surgery 1991;110:1014–1021.
9. Linos AD. Adrenaloma(incidentaloma).In: Clark OH, Duh
QY (eds): Textbook of Endocrine Surgery. Philadelphia:
WB Saunders, 1997, pp. 495–482.
Conversionfrom the laparoscopicto the open approach
was not necessary in any of the patients. Nevertheless,
one must be prepared to convert in cases of uncontrolled
bleeding, absence of operative progress in a reasonable
time, or discovery of invasive growth.
10. Stoker ME, PatwardhanN, Maini BS. Laparoscopicadrenal
surgery. Surg Endosc 1995;9:387–391.
11. Hobart MG, Gill IS, Schweizer D, Bravo EL. Laparoscopic
adrenalectomy for large-volume ($5 cm) adrenal masses.
J Endourol 2000;14:149–154.
CONCLUSION
12. Henry JF, Denizot A, Puccini M, Kvachenyuk A, Ferrara
JJ. Laparoscopic surgery of adrenal glands: Indicationsand
limits. Ann Endocrinol (Paris) 1996;57:520–525.
Our experience shows that surgery for adrenal tumors
as large as 11 cm performed laparoscopically with safety
and outcomes similar to those of small tumors if there is
no doubt about the benign nature of the lesion.
Address reprint requests to:
Airazat M. Kazaryan, M.D.
Faculty for Training Research Workers and
Medical Educators
I.M. Sechenov Moscow Medical Academy
Bolshaya Pirogovskaya 2/6
REFERENCES
1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalec-
tomy in Cushing’s syndrome and pheochromocytoma. N
Engl J Med 1992;327:1033.
2. Smith CD, Weber CJ, Amerson JR. Laparoscopic adrena-
lectomy: New gold standard. World J Surg 1999;23:389–
396.
Ru-119881, Moscow, Russia
E-mail:
aikazar@hotmail.com