Synchronous Bilateral Laparoendoscopic Single-Site Adrenalectomy

Abstract

We present the first report of simultaneous laparoendoscopic single-site surgery (LESS) for bilateral primary aldosterone-producing adrenal adenomas. A 40-year-old man with hypertension that was resistant to pharmacotherapy was shown to have bilateral aldosterone-producing adrenal adenomas. A right partial and a left total adrenalectomy were performed at the same time via a single umbilical incision. The surgery and recovery were uncomplicated. This is the first report of synchronous bilateral LESS.

Introduction

A fter the first report of laparoscopic adrenalectomy in 1992, laparoscopic surgery for benign adrenal tumors has become the gold standard of treatment.^1,2 The benefits of less invasive surgery compared with open surgery have led to wide acceptance of laparoscopic adrenalectomy among surgeons and patients.³ Recently, a much less invasive surgical technique, laparoendoscopic single-site surgery (LESS), has been developed. LESS uses a single incision, usually through the umbilicus, so better cosmetic satisfaction and less potential morbidity, including less pain, are expected. We have already demonstrated the technical feasibility and improved cosmetic outcomes of LESS adrenalectomy compared with the conventional laparoscopic approach for a benign adrenal adenoma.⁴

We report a patient who benefited from single-step bilateral LESS adrenal surgery for primary aldosterone-producing tumors.

Patient and Methods

Patient

A 40-year-old man presented with uncontrolled high blood pressure that was resistant to pharmacotherapy. Hypertension had been diagnosed 5 years previously, and he had been receiving antihypertensive drugs since. At the first visit to our hospital, his blood pressure was 200/120 mm Hg, even though he took amlodipine (5 mg twice a day). He was shown to have hypokalemia (2.6 mmol/L). Endocrinologic testing revealed elevated plasma aldosterone (28.9 ng/dL; normal value, 5.0–19.4 ng/dL) and decreased plasma renin activity (0.3 ng/mL/h; normal value, 1.0–2.5 ng/mL/h). Results of other endocrinologic laboratory tests using serum and 24-hour urine were within normal ranges, except a mildly elevated level of urine cortisol (138 μg/d; normal value, 19.5–115.6 μg/d).

A CT scan showed 1.5- and 1.0-cm masses in the right and left adrenal glands, respectively (Fig. 1). A postural stimulation test did not show different serum aldosterone levels between the supine (69.4 ng/dL) and upright positions (52.1 ng/dL). Results of bilateral adrenal vein and inferior vena cava blood sampling suggested bilateral aldosterone-producing tumors (Table 1).

FIG. 1.

CT shows 1.5- and 1.0-cm cortical tumors in the right (white arrow) and left (white line arrow) adrenal glands. (A) Axial view; (B) coronal view.

Table 1.

Bilateral Adrenal and Inferior Vena Cava Blood Sampling

	First sampling			Second sampling
	Right	Left	IVC	Right	Left	IVC
Aldosterone (ng/dL)	10,330	5,510	175	9,050	8,700	90
Cortisol (μg/dL)	550	710	35	700	790	19
Aldosterone/cortisol	18.8	7.8	5.0	12.9	11.0	4.7

IVC = inferior vena cava.

Because additional antihypertensive medication (amlodipine [10 mg]; spironolactone [100 mg]; doxazosin [4 mg]) could not normalize his blood pressure (150–160/100–120 mm Hg), he desired to undergo bilateral extirpation of all functioning tumors.

Surgical plan

After counseling the patient regarding all surgical options, the decision was made to proceed with bilateral LESS at the same time via a single umbilical incision. Because the right-side adenoma was more prominent, we planned to operate on the right side first. If the right-side adenoma was shown to be discrete, we planned to perform a partial right adrenalectomy. Then, we planned to remove the left adenoma only, or the entire adrenal gland based on the operative findings. If a right partial adrenalectomy was not possible, we planned to attempt a left partial adrenalectomy.

Operative technique

Under general anesthesia, the patient was placed in the flank position with the right side elevated 70 degrees. We placed an OCTO^™ Port (Model OT303S-D; Dalim SurgNet, Seoul, Korea) as an access port through a 30-mm umbilical incision. The OCTO Port is a multi-instrument access port that allows the simultaneous use of up to three or four laparoscopic instruments through separate channels. After insufflation of the abdomen with CO₂ to 14 mm Hg, a 5-mm flexible tip laparoscope with an integrated camera head (EndoEye^™; Olympus, Orangeburg, NY) was inserted through the 5-mm channel. We used a Roticulator^™ grasper and shear (Covidien, Norwalk, CT) to create triangluation, along with a pencil grip handle hook electrocautery (ENDOPATH Surgery Probe Plus-II; Ethicon Endo-Surgery, Cincinnati, OH), and a 5-mm laparoscopic Harmonic Scalpel^® (Ethicon Endo-Surgery), which were part of the standard rigid laparoscopic instrumentation set.

After retraction of the liver upward using a Diamond Flex^® angled circular retractor (Snowden Pencer, Cardinal Health, Dublin, OH), we incised the Toldt line and reflected the colon medially to permit adequate exposure. With the inferior vena cava and the right renal vein visualized, we incised the peritoneum laterally to the vena cava. We identified a discrete adenoma in the adrenal gland. Thus, a right partial adrenalectomy was performed with a Harmonic Scalpel.

The specimen was placed in the laparoscopic bag and retrieved through the abdominal incision without morcellation. The resected adrenal bed was sealed using Surgicel^® (Ethicon Inc, Somerville, NJ). After removal of the access port, we applied an iodophor-impregnated incision drape (3M Ioban^™; 3M Health Care, St. Paul, MN).

The patient's position was changed in the opposite flank position. We placed an OCTO Port through the same umbilical incision again. The Toldt line was initially incised from the splenic flexure of the colon down to the sigmoid junction; the left colon was then reflected medially. The pancreatic tail and spleen were carefully separated. The Gerota fascia was incised, and the adrenal vein connected to the renal vein was identified. The adrenal gland was dissected; however, a well-defined adenoma was not easily identified.

Thus, we performed a total adrenalectomy, because the functional adrenal gland was preserved on the right side. The adrenal vein was clipped (two on the renal vein side and one on the adrenal side) and transected. A total adrenalectomy was performed using a Harmonic Scalpel without difficulty. The operative field was sealed using Surgicel, and the specimen was placed in the bag and retrieved through the abdominal incision without morcellation. A draining tube was not placed on either side. The fascia and subcutaneous tissue were closed with 2-0 and 3-0 Vicryl^® (Ethicon Inc.) interrupted suture, respectively. The skin was closed with a 3M Steri-Strip^™ (3M Health Care).

The total operative time was 160 minutes, including 20 minutes for the necessary position change and redraping. The estimated blood loss was minimal, and there were no perioperative complications (Fig. 2).

FIG. 2.

(A) External view of access port and instrumentation when the LESS left adrenalectomy was performed. The port was placed through a 30-mm umbilical incision. The flexible tip laparoscope was inserted to the 5-mm channel and a 12-mm one was used for main instrumentation. (B) Internal view of LESS right partial adrenalectomy. Adenoma (white arrow) was well demarcated. (C) Internal view of LESS left total adrenalectomy. (D) Postoperative view of the wound before skin closure using adhesive surgical tape. There was no additional elongation or extra trocar insertion. LESS = laparoendoscopic single-site surgery.

Results

On postoperative day 1, the visual analog pain score was 3 of 10, and the patient began a soft blend diet. On postoperative day 2, the patient was discharged after tolerating a normal regular diet. At the time of discharge, the blood pressure was 150/100 mm Hg with the patient receiving amlodipine (5 mg twice a day). The pathologic examination revealed bilateral adrenal cortical adenomas (Fig. 3). At 2 weeks postoperatively, he discontinued steroid replacement completely, and the serum potassium level (4.1 mmol/L), plasma aldosterone level (5.6 ng/dL), and renin activity (1.5 ng/mL/h) were normalized. With the patient continuing to receive amolodipine, blood pressure was controlled at 130/90 mm Hg.

FIG. 3.

Histopathologic examination macroscopic finding of both specimens. Yellow, round mass measured 1.4 × 1.0 × 1.0 cm in the right specimen. The left specimen contained normal adrenal gland and 1.1 × 1.0 × 0.8 cm yellow, round mass. There was no necrosis, internal hemorrhage, or calcification in both tumors.

Discussion

Laparoscopic surgery has evolved rapidly in the last two decades and has achieved excellent standards of efficacy.⁵ Laparoscopic adrenalectomy is considered the standard surgical procedure for patients with benign adrenal adenomas.^2,5 Continued advances in laparoscopic procedures and a desire for less invasive surgery has led to the development of innovative surgical approaches, such as LESS. LESS reduces the number of ports necessary to complete laparoscopic surgery and could potentially reduces the intraoperative complications and postoperative morbidity.⁶

The feasibility of LESS in various urologic diseases has been verified; however, the definitive benefit of LESS over the conventional laparoscopic procedure has not yet been determined. Our group has been pursuing less invasive surgeries. Even in pediatric urology, we have reported a case of LESS nephrectomy for single-system ectopic ureter in a child.⁷ Based on the adrenalectomy, we demonstrated the technical feasibility of LESS compared with the conventional laparoscopic procedure in the removal of a benign adenoma by a matched case-control study.⁴

LESS adrenalectomy is a safe technique that results in improved cosmesis, with the additional benefit of being more minimally invasive. The definitive benefits of LESS over conventional laparoscopy with respect to adrenal surgery, however, should be studied by a prospective, randomized control trial.

Hirano and associates⁸ reported a series of 54 LESS adrenalectomies in 2005, and the current case represents the first report involving a LESS adrenalectomy. They used a 4-cm diameter rectoscope tube, which is used for transanal endoscopic microsurgery, as an access device. They performed retroperitoneal adrenalectomies with conventional laparoscopic instruments without gas insufflation. Desai and colleagues⁹ reported one transumbilical LESS adrenalectomy in their initial experience of 100 cases. They used commercialized ports and articulating instruments that were specialized for LESS. They converted to conventional laparoscopic surgery, however, because of renal vein injury. Ryu and coworkers¹⁰ reported 2 retroperitoneal LESS adrenalectomies in their initial LESS experience of 14 cases. They used a homemade single-port device fashioned from an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA) and surgical glove. In our case-control study, we used a similar homemade single port through an umbilical incision in all nine cases (Table 2).

Table 2.

Clinical Reports on Laparoendoscopic Single-Site Adrenalectomy

Reports	No. of patients	Approach	Port and method	Mean operative duration (min)	EBL (mL)	Mean hospital stay (days)	Remark
Hirano⁸	54	Retroperitoneal, midaxillary	4-cm diameter rectoscope tube (Wolf, Knittlingen, Germany)	203 (92–320)	252 (10–1,700)	13.4 (5–57)	• Without CO₂ insufflation • One conversion to open surgery because of bleeding from adrenal vein injury • Twelve (22.2%) patients had perioperative complications
Desai⁹	1	Transperitoneal, umbilical	R-port (Advanced Surgical Concepts, Wicklow, Ireland)	150	650	3	• Conversion to conventional laparoscopic surgery because of bleeding from right renal vein injury
Ryu¹⁰	2	Retroperitoneal, midaxillary	Home-made single- port device	Not available	Not available	Not available	• Report of 14 retroperitoenal LESS initial experience
Jeong⁴	9	Transperitoneal, umbilical	Homemade single-port device	169.2 (89–289)	177.8 (50–400)	3.2 (2–4)	• One conversion to conventional laparoscopic surgery because of bleeding from the splenic laceration • One complication of small bowel serosa tearing

EBL = estimated blood loss; LESS = laparoendoscopic single-site surgery.

We used an OCTO Port (Dalim SurgNet) (Fig. 4) for access in this case. This novel port has three or four instrument channels of various diameters, one insufflation and one smoke exhaust valves. This port has a detachable cap; thus, it is easy to extract the specimen during surgery. Other merits of this port are durable airtight sealing of instrument channels, a wide range of motion, and a semitransparent cover that makes it easy to find a safe spot inside. The price is about $300 to $400 US, according to models. The products are on track for FDA clearance and will be available worldwide soon.

FIG. 4.

OCTO Port used in this case. This novel port has a detachable cap, including one 12-mm and three 5-mm instrument channels, one insufflating and one smoke-evacuating valves.

Even though bilateral adrenal tumors are not common, several studies have reported the safety and technical feasibility of laparoscopic simultaneous bilateral adrenal surgery.^11

–14 Although operative time was longer than total adrenalectomy, the adrenocortical-preserving operation in patients with bilateral functioning tumors mitigated the need for lifelong external steroid supplements in long-term follow-up.¹⁵ We considered the simultaneous bilateral LESS adrenalectomy for bilateral cortical adenoma as a preferable surgical option because it could omit the bilaterally located five to seven trocar incisions. In this case, we used only one 30-mm umbilical incision for a bilateral procedure without any other extraumbilical incisions or elongation of the original incision.

All surgical procedures were successful within a reasonable time without complications. Even the operative time was much shorter than the mean operative time of published series of conventional laparoscopic bilateral adrenalectomies (288 minutes).¹¹ The normalized endocrinologic outcomes support the feasibility and effectiveness of this technique. We preserved a normal functioning adrenal gland, so the patient avoided lifelong steroid replacement. The patient has not been able to discontinue antihypertensive drugs; however, his blood pressure has become medically controllable.

We suggest that synchronous bilateral LESS is the more reasonable option over conventional bilateral laparoscopic surgery in terms of cosmetic outcome and minimal invasiveness.

Conclusion

We presented a case in which synchronous bilateral LESS was applied to manage bilateral adrenal aldosterone-producing tumors. The surgery and postoperative recovery were uncomplicated. The greatest advantage was that only a small, single incision at the umbilicus was used for bilateral surgeries. To our knowledge, this is the first report of synchronous bilateral LESS in any kind of surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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