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Open versus laparoscopic adrenalectomy for Pheochromocytomas Dr.Osama Saffarini Project Submitted Towards Completion Of Diploma In Minimal Access Surgery, World Laparoscopy Hospital, Gurgaon, NCR Delhi, India. September 2007. Abstract:
Introduction: Pheochromocytomas are rare tumours of the adrenal gland that arise from chromaffin cells in the adrenal medulla. The most common symptoms of pheochromocytoma are headaches, palpitations, and sweating. It has been estimated that approximately 10%–15% of pheochromocytomas are due to hereditary causes. Heritable causes of pheochromocytoma include MEN2A, MEN2B, von Hippel Lindau disease (VHL), neurofibromatosis type 1, paraganglioma syndrome, and hereditary pheochromocytoma. Estimates of hereditary etiology among apparently sporadic cases of pheochromocytoma ranges from 10%-15%. The diagnosis of pheochromocytoma is made upon biochemical and radiological studies. That is US MRI CT-scan. norcholesterol (NP-59) or 131I- metaiodobenzylguanidine(MIBG), The first laparoscopic adrenalectomy was performed by Michel Gagner in 1992 [24]. Objective: Materials and methods: Treatment: Surgical Technique: The adrenalectomies can be performed laparoscopically through a lateral decubitus or supine transperitoneal approach, or lateral retroperitoneal approach [1-2] .Briefly, a diagnostic laparoscopy was performed at the beginning of each procedure to rule out local tumor invasion or diffuse metastatic spread.The lateral decubitus transperitoneal approach; which is the most popular; starts with three subcostal ports (5–12 mm) allowed for the introduction of a 30° laparoscope and 2 working instruments. During right adrenalectomies, a fourth 5-mm port was placed in a subxyphoid position for liver retraction. Occasionally during left adrenalectomies, a fourth port was added below the tip of the left twelfth rib to provide blunt retraction of the kidney and/or adrenal gland. This technique was particularly useful for larger tumors, which often encroached upon the vascular hilum of the kidney, making exposure of the adrenal vein difficult. Early ligation and division of the adrenal vein was carried out prior to gland manipulation and dissection when possible. For right adrenalectomies, the right hepatic lobe was completely mobilized to provide adequate visualization and safe access to the vena cava and adrenal vein. The triangular ligament was incised to the level of the diaphragm. The retroperitoneum was then opened longitudinally along the medial aspect of the adrenal gland, and immediately adjacent to the lateral edge of the liver, until the vena cava was clearly identified. Development of the plane between the inferior vena cava and the medial margin of the gland was performed to expose the right adrenal vein. Early dissection and mobilization of the inferior retroperitoneal attachments to the tumor increased gland mobility and made venous control considerably safer. On the left, the splenic flexure was mobilized to allow access to the splenorenal ligament. The retroperitoneal plane superficial to Gerota fascia was developed to the level of the diaphragm, allowing for medial rotation of the spleen and the pancreatic tail. A complete medial rotation of adjacent structures was critical to provide adequate exposure of the adrenal gland and vein. Gerota fascia was incised medial to the superior pole of the kidney to provide access to the left adrenal vein and the adrenal gland. The vein was then ligated and divided at its confluence with the left renal vein. On either side, the borders of the adrenal gland were first identified and then dissected away from the retroperitoneum, using periadrenal fat as a “handle.” The larger glands, especially those greater than 5 cm, were most often resected with periadrenal fat, exposing the psoas muscle from the renal hilum cephalad to the diaphragm. The gland was never grasped to avoid hemodynamic liability, troublesome bleeding, or tumor disruption. Large adrenal veins, typically those greater than 7 mm in width, were divided with an endovascular stapler. Specimens were placed into an impervious extraction bag prior to morcellation (if necessary) and removal. The peritoneum and fascia at the trocar sites were closed endoscopically Outcome and Analysis: Discussion: Thompson andassociates [25] performed a matched case-control study comparing50 patients having open adrenalectomy to 56 patients having adrenalectomy through a posterior approach. They found that LA, compared to OA, was significantly associated with shorter hospital stay, less postoperative narcotic use, more rapid return to normal activity, increased patient satisfaction, and less late morbidity. However, the laparoscopic procedure was associated, with longer operating room time and higher cost. Similar results have been reported by Prinz [26] and by Brunt et al [27] , who found that LA had distinct advantages compared to OA. This stimulus may be via either a direct tumor compression or a change in tumor perfusion. The pneumoperitoneum with CO2 may lead to hypercapnia and acidosis, which, in turn, are known stimuli of catecholamine secretion and hypertension.[6-11] Rocha et al found a more than 10-fold elevation in catecholamines during abdominal insufflation to 12 mm Hg with CO2, with about 50% of patients experiencing hypertensive episodes.[6] As a result, helium has been suggested as an alternate insufflation agent to eliminate the deleterious effects of CO2 during laparoscopic adrenalectomies for pheochromocytoma. In a prospective evaluation of 11 patients undergoing helium insufflation during laparoscopic pheochromocytoma resection, the authors demonstrated that its use avoided significant intraoperative hypercarbia or acidosis and provided greater intraoperative hemodynamic stability [7]. Interestingly, though, there were no differences between the CO2 and the helium insufflation groups in either serum catecholamine surges or overall surgical outcomes. [7] When compared with other indications for adrenalectomy, laparoscopic resection of pheochromocytomas results in longer operative times, higher complication rates, and longer hospitalization. With growing experience using advanced laparoscopic techniques, conversion rates have decreased from 22% to 0%–4%.[12-13-14] The “learning curve” may play a significant role in improving the efficiency and safety of advanced laparoscopic procedures. Pheochromocytomas have a malignant potential and are frequently larger in size than other functional adrenal tumors. Extreme care must be exercised to avoid intraoperative capsular disruptions and possible iatrogenic pheochromocytomatosis. Li et al[15] reported 3 cases of pheochromocytoma recurrence 3 to 4 years after initial laparoscopic resection and possible tumor spillage. As a result, many investigators have suggested that laparoscopy be avoided for pheochromocytomas larger that 7 to 8 cm.[12-16-17] Conversion to an open procedure is warranted, however, when laparoscopic dissection cannot be performed safely or a complete resection cannot be performed without undue trauma to the gland. It has been agreed by several authors that a posterior retroperitoneal LA is preferable to an anterior LA, especially inpatients who have either bilateral adrenal tumors, prior to The question is not weather laparoscopic adrenalectomy for pheochromocytoma should be done or not, but by whom should it be performed. A surgeon who is very proficient laparoscopically and significantly knowledgeable about adrenal anatomy may be able to perform this operation in a hospital that offers an appropriate level of anesthesia and ICU care. Conclusion: Reference:
[2].Gagner M, Pomp A, Heniford BT, et al. Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg. 1997;226:238–246; discussion 246–247.
[12].Cheah WK, Clark OH, Horn JK, et al. Laparoscopic adrenalectomy for pheochromocytoma. World J Surg. 2002;26:1048–1051. [13].Kercher KW, Park A, Matthews BD, et al. Laparoscopic adrenalectomy for pheochromocytoma. Surg Endosc. 2002;16:100–102. [14]. Kim AW, Quiros RM, Maxhimer JB, et al. Outcome of laparoscopic adrenalectomy for pheochromocytomas vs aldosteronomas. Arch Surg. 2004;139:526–529; discussion 529–531. [15].Li ML, Fitzgerald PA, Price DC, et al. Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy. Surgery. 2001;130:1072–1077. [16].Inabnet WB, Pitre J, Bernard D, et al. Comparison of the hemodynamic parameters of open and laparoscopic adrenalectomy for pheochromocytoma. World J Surg. 2000;24:574–578. [17]. Staren ED, Prinz RA. Adrenalectomy in the era of laparoscopy. Surgery. 1996;120:706–709; discussion 710–711. [18].Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eigler FW. 1996 [19]. Bonjer HJ, Lange JF, Kazemier G, deHerder WW, Steyerberg EW, Bruining [20]. Ross NS, Aron DC. 1990 Hormonal evaluation of a patient with an incidentally [21]. Page DL, DeLellis RA, Hough AJ. 1986 Tumors of the adrenal. In: Hartmann [22].Soper NJ, Brunt LM, Kerbl K. 1994 Laparoscopic general surgery. [23]. Duh QY, Siperstein AE, Clark OH, et al. 1996 Laparoscopic adrenalectomy: [24]. Gagner M, Lacroix A, Bolte E, 1992 Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 327: 1033. [25]. Thompson GB, Grant CS, van Heerden J, et al. 1997 Laparoscopic versus open [26]. Prinz RA. 1995 A comparison of laparoscopic and open adrenalectomies. Arch [27]. Brunt LM, Doherty GM, Norton JA, Soper NJ, Quasebarth MA, Moley JF. |
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