Last updated January 5, 2022

Minimally Invasive Treatment Of Adrenal Pathology

Recommendations

Minimally invasive adrenalectomy is associated with less postoperative pain, shorter hospital stay, earlier recovery, and similar long-term outcomes compared with open surgery and has been established as the preferred approach to all non-primary adrenal cancer pathology. (Moderate, Strong)
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Several approaches to laparoscopic adrenalectomy have been described in the literature. Surgeons should choose the approach they are most familiar with, have had training in, and have the best patient outcomes with. (Moderate, Strong)
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Surgeons should also take into consideration that in specific clinical circumstances some surgical approaches to adrenalectomy may be more beneficial than others: (, )
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In patients with previous abdominal surgery, a retroperitoneal approach may be associated with less operative time and fewer complications. (Low, Weak)
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For bilateral adrenalectomies, the posterior retroperitoneal approach may be advantageous, as it eliminates patient repositioning during the case. (Low, Weak)
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In morbidly obese patients (BMI >35 kg/m2) and for large tumors (>6 cm), the lateral transabdominal approach may increase the feasibility of the procedure compared with the other approaches. (Low, Weak)
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Compared with standard laparoscopic techniques, robotic adrenalectomy may offer advantages for large tumors and in morbidly obese patients. (Very Low, Weak)
However, given the increased cost, longer operative times, and lack of clear patient outcome benefits using this technique, additional higher quality evidence is needed before a firm recommendation can be provided.
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Based on the available evidence, single port adrenalectomy is feasible and safe when undertaken by an experienced surgeon but offers little if any advantage over other standard laparoscopic approaches to adrenalectomy. Additional, better quality evidence is needed before this approach can be recommended. (Very Low, Weak)
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Partial adrenalectomy is safe and feasible in the hands of appropriately trained surgeons. For patients requiring bilateral adrenalectomy, such as for hereditary pheochromocytomas, laparoscopic cortical sparing surgery may be the procedure of choice. (Low, Weak)
Additional evidence is needed before a recommendation can be provided for partial adrenalectomy of single gland, non-hereditary tumors.
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The classic teaching for early vein control during open adrenalectomy has not been confirmed for laparoscopic adrenalectomy, because patient outcomes do not appear to be affected by early versus late ligation. Thus, the type and timing of adrenal vein control depends on surgeon preference and the specific anatomic variables associated with each case. (Low, Weak)
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For adrenocortical carcinoma, the best determinant of patient outcomes is an appropriate oncologic resection that includes en bloc resection of any contiguous involved structures and regional lymphadenectomy. Thus, an open approach to resection may be best. If a laparoscopic approach is chosen (due to unknown malignancy status preoperatively or suspected early stage carcinoma), conversion to open surgery is strongly recommended when difficult dissection is encountered due to tumor adhesion or invasion or enlarged lymph nodes are seen. (Low, Strong)
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Local Invasion

Solitary metastases to the adrenal gland without evidence of local invasion can be approached laparoscopically by a surgeon skilled in advanced laparoscopy and adrenal surgery. (Very Low, Weak)
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If local invasion is found intraoperatively, conversion to an open approach is warranted. (Very Low, Strong)
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Large adrenal tumors

Large adrenal tumors without pre- or intraoperative evidence of primary adrenal cortical carcinoma can be approached laparoscopically by a surgeon skilled in advanced laparoscopy and adrenal surgery. (Very Low, Weak)
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Laparoscopic adrenalectomy for larger tumors may be associated with increased operating room times, blood loss, and conversion rate to open surgery. (Very Low, Weak)
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If there is any evidence for carcinoma found intraoperatively, conversion to an open approach is warranted (should be strongly considered). (Very Low, Strong)
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Pheochromocytoma

Before laparoscopic adrenalectomy for pheochromocytoma, alpha adrenergic receptor blockade should be considered in all patients. When used preoperatively, alpha blockade should be continued until signs of orthostatic hypotension are evident. (Moderate, Weak)
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Short acting alpha blockers may be preferable to long acting ones. Beta blockade should also be considered in appropriately selected patients and should only be instituted following adequate alpha blockade. (Low, Weak)
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Invasive hemodynamic monitoring should be considered during LA for pheochromocytomas. (Low, Strong)
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To minimize hemodynamic instability due to catecholamine release during surgery, minimization of direct manipulation or compression of the adrenal gland is necessary. (Low, Strong)
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Early ligation of the vein does not prevent hemodynamic instability. (Very Low, Weak)

Due to the added challenge of intraoperative hemodynamic variability, frequent communication between the surgical and anesthesia teams is important for optimal perioperative outcomes.

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Due to the potential for hemodynamic instability after pheochromocytoma resection, all patients should be closely monitored in the early postoperative phase. (Low, Strong)
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Capsular disruptions of the adrenal gland during surgery should be avoided to minimize the risk of disease recurrence. (Very Low, Weak)
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Given the lack of clear predictors of malignancy to detect recurrences, patients with pheochromocytoma should be monitored long term with blood pressure measurements and serum and/or urinary metanephrine levels. (Low, Strong)
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Learning curve

Minimally invasive adrenalectomy is associated with a learning curve that may be difficult to overcome given the paucity of these cases in general practice. Dedicated, advanced training should be pursued by surgeons unfamiliar with this technique. Until proficiency with laparoscopic adrenalectomy is attained, consideration should be given to referral to a center with expertise in minimally-invasive adrenal surgery. (Low, Strong)
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Recommendation Grading

Overview

Title

Minimally Invasive Treatment Of Adrenal Pathology

Authoring Organization

Publication Month/Year

February 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The guidelines for the minimally invasive surgical treatment of adrenal pathology are a series of systematically developed statements to educate and guide the surgeon (and patient) in the appropriate use of minimally invasive techniques for the treatment of adrenal disease.

Target Patient Population

Patients with adrenal disease

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D013502 - General Surgery, D000315 - Adrenalectomy, D000314 - Adrenal Rest Tumor, D010673 - Pheochromocytoma

Keywords

surgery, adrenal pathology, adrenal disease, adrenalectomy

Source Citation

https://www.sages.org/publications/guidelines/guidelines-for-the-minimally-invasive-treatment-of-adrenal-pathology/