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PubMed2004

Laparoscopic adrenalectomy for Conn's syndrome complicated by ipsilateral congenital pelvic kidney.

A patient presented with hypertension, hypokalemia, and a 1.2-cm left adrenal tumor. Conn's syndrome was diagnosed, for which laparoscopic adrenalectomy is now the therapy of choice. This case was complicated by an ipsilateral ectopic pelvic kidney. A laparoscopic left adrenalectomy was performed via a lateral transabdominal approach. Without the usual anatomic landmark of the ipsilateral kidney, the left adrenal gland was difficult to identify, so intraoperative ultrasound was used to locate the lesion. Postoperatively, the patient's blood pressure and potassium normalized. This is the first documented report of a laparoscopic adrenalectomy performed for adrenal adenoma with the anatomic disruption of an ipsilateral pelvic kidney.

Adrenalectomy↗

PubMed2000

Laparoscopic adrenalectomy by the anterior transperitoneal approach: results of 108 operations in unselected cases.

BACKGROUND: The feasibility, safety, and results of 108 laparoscopic anterior transperitoneal adrenalectomies (six bilateral) were evaluated in a series of 105 patients. Three patients with a preoperative diagnosis of primary adrenal carcinoma were excluded from the study. METHODS: A total of 102 patients were included in the study based on exhaustive endocrinological and imaging assessment. Twenty-nine patients with nonsecreting adenoma, 34 with aldosterone-producing adenoma, 27 with cortisol-producing adenoma (five bilateral), 13 with pheochromocytoma (one bilateral), two with androgen-secreting adenoma, and three with metastases were considered eligible for adrenalectomy. Lesion size ranged from 3.5 to 12 cm. Concurrent surgical procedures were performed in 10 patients (9.8%). RESULTS: One (0.9%) intraoperative complication, a colon tear in a bilateral adrenalectomy, required conversion. There were two (1.9%) postoperative complications: one patient with thrombocytopenia developed hemoperitoneum and required a second laparoscopic procedure, and an intraabdominal abscess was treated medically. Mean postoperative hospital stay was 2.5 days (range, 1-7 days). Postoperative mortality was 0.9%; the patient with the colon tear died of sepsis 60 days after the operation. At a mean follow-up of 30 months (range, 1-62), normalization or improvement in hormone levels was observed in all patients with secreting adenomas, and significant improvement or cure was achieved in all patients with hypertension. CONCLUSION: Patients with secreting and nonsecreting adrenal lesions can be treated safety and effectively by laparoscopy with the anterior transperitoneal approach.

Adrenalectomy↗

PubMed2000

Vena cava injury. A serious complication during laparoscopic right adrenalectomy.

We report our experience with a case of vena cava injury during laparoscopic right adrenalectomy. A laparoscopic right adrenalectomy was performed in a 22-year-old woman who suffered from a right surrenalian adenoma. Four trocars were used for the transperitoneal laparoscopic approach with the patient in the lateral decubitus position. After isolation of the medial margin of the gland and clipping and sectioning of the main adrenal vein, the right side of the vena cava was injured during dissection of the right upper pole, due to the use of monopolar scissors. The hemorrhage was managed immediately with the aid of fenestrated atraumatic forceps and an aspiration probe. A fifth trocar was inserted to evaluate the size of the lesion, which was then sutured laparoscopically with croised 5/0 nonresorbable stitches. No transfusion was needed. Operating time was 210 min. The post-operative course was uneventful. Hospital stay was 7 days. At 10-month follow-up, the patient had no problems related to the intraoperative complication. Our preliminary experience shows that the laparoscopic approach enables safer management of lesions involving large abdominal vessels. We believe that the transperitoneal approach is the preferential route for laparoscopic adrenalectomies. Monopolar coagulation can be dangerous and must be avoided when dissecting large vessels.

Adrenalectomy↗

PubMed2001

Outpatient laparoscopic adrenalectomy in patients with Conn's syndrome.

BACKGROUND: [corrected] We set out to record the operative times of an experienced laparoscopic team and assess the feasibility of outpatient laparoscopic adrenalectomy when optimal anesthesia was also offered to all patients. METHODS: The study included 13 patients with aldosterone/cortisone hypersecretion and/or adrenal gland tumors, excluding those with pheochromocytoma. They had to live within 30 min travel from the hospital, and adult company had to be present at home. All patients received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic adrenalectomy was performed by the transabdominal lateral flank approach. Postoperatively, all patients were contacted by phone in the evening and the next morning. RESULTS: All 13 patients were discharged 3-6 h postoperatively. None were readmitted; thus, the day care success was 100%. The mean operative time was 38 min (range, 35-112). Patient satisfaction was excellent in all but one case, due to pain on the 1st postoperative day. CONCLUSION: Laparoscopic adrenalectomy can be a fast operation. It is feasible and safe and yields satisfactory results for patients as an outpatient procedure when the necessary surgical experience and optimal anesthesia are both available.

Adrenalectomy↗

PubMed1996

Does hormonal function of the tumor influence the outcome of laparoscopic adrenalectomy?

BACKGROUND: Patients with hypertension, with catecholamine hypersecretion, and with cortisol excess may associate intraoperative cardiovascular instability and postoperative complications. METHODS: To compare the outcome of laparoscopic adrenalectomy (LpA) in patients with aldosterone adenoma (11), Cushing's adenoma (six), Cushing's disease (four), pheochromocytoma (Pheo) (11), and nonfunctioning tumor (five). Intra- and postoperative parameters were studied and in patients with Pheo intraoperative catecholamine plasma levels were correlated with cardiovascular derangements. RESULTS: Operative time, estimated blood loss, hospital stay, analgesic requirements, and time to return to normal activity were significantly higher in patients undergoing total bilateral adrenalectomy for Cushing's syndrome compared with other groups undergoing unilateral adrenalectomy, but these latter groups showed no significant differences among themselves in all parameters analyzed. One patient with nonfunctioning tumor and another with Cushing's adenoma were converted to open surgery, and two patients with Cushing's disease had urinary infection. Isolation of Pheo was associated with significant release of catecholamines but not with hemodynamic changes. CONCLUSION: LpA may be the most suitable method for removing functioning adrenal tumors.

Adenoma↗

PubMed1996

Confluence of the right adrenal vein with the accessory right hepatic veins. A potential hazard in laparoscopic right adrenalectomy.

Confluent drainage of the right adrenal vein and large accessory right hepatic veins was encountered during a laparoscopic right adrenalectomy. In a review of previous reports of laparoscopic adrenalectomies we found no mention of this finding. However, an anatomic study reported that the right adrenal vein joins with an accessory right hepatic vein in as many as 22% of individuals. A complete understanding of the anatomic variations in the drainage of the right adrenal vein is required for the safe performance of laparoscopic right adrenalectomy.

Adrenal Glands↗

PubMed1997

Thoracoscopic transdiaphragmatic left adrenalectomy. An experimental study.

The endoscopic approach to adrenal glands has been limited to laparoscopic and retroperitoneal access due to the relative inaccessibility of the retroperitoneal space in the former case and to the limited working space in the latter. We undertook this study to investigate the possibility of performing a left adrenalectomy through a thoracoscopic transdiaphragmatic approach in a swine model. Five pigs were anesthetized, intubated, and ventilated. Four laparoscopic trocars were inserted and a left pneumothorax was accomplished by CO2 insufflation. A peripheral posterior phrenotomy was made starting from the aortic hiatus and extended laterally for about 6 cm. The resulting pneumoretroperitoneum facilitated the subsequent identification of anatomic structures, allowing an easy exposure of the left adrenal gland. The gland was progressively dissected downward, interrupting the tributary vessels with endoscopic clips, and it was finally extracted through one of the trocar ports. Adrenalectomy was accomplished in all the animals without intraoperative mortality. Complications included splenic injury with prolonged bleeding and difficulty in performing the diaphragmatic suture (one case each). Through this approach direct and rapid exposure of the left adrenal gland was allowed, and adrenalectomy was accomplished in all the animals. These results suggest further investigations of the clinical application of this procedure.

Adrenalectomy↗

PubMed1999

Retroperitoneal approach in laparoscopic adrenalectomy: is it advantageous?

Recently, the retroperitoneal laparoscopic approach has been described as advantageous in avoiding the respiratory and hemodynamic effects of CO2 pneumoperitoneum and giving direct access without the need to move abdominal organs. Forty-two laparoscopic adrenalectomies (LpA) were performed in 36 patients with a variety of adrenal disorders, including 9 patients with nonfunctioning tumors, 11 patients with aldosterone adenoma, 10 patients with Cushing's adenoma, and 6 patients with Cushing's disease. Twenty-two adrenalectomies were performed using the transperitoneal approach (TLpA), and 20 via the retroperitoneoscopic approach (RLpA). Arterial blood samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. At the end of the operation, the PaCO2, PetCO2, and base deficit all increased significantly in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values. Arterial pH decreased significantly in both TLpA and RLpA groups. All clinical parameters evaluated (operation time, analgesic dosing requirements, hospital stay, and the days until return to normal activity) were similar in the TLpA and RLpA approaches. Two patients in the TLpA (10.5%) group and two patients in the RLpA (10%) group needed conversion to open surgery. This study shows the safety and efficacy of laparoscopic adrenalectomy via the transperitoneal or retroperitoneal route in patients with a variety of adrenal disorders. The retroperitoneoscopic approach could be the primary choice in patients with previous abdominal surgery.

Adolescent↗

PubMed1999

Safety of adrenal vein ligation during endoscopic adrenalectomy: a technical note.

Endoscopic adrenalectomy has been recommended for the treatment of several benign adrenal diseases. The safety of this procedure largely depends on a careful surgical dissection and appropriate hemostatic technique. An established slipknotting technique was employed to control the main adrenal vein in a consecutive series of 14 patients undergoing endoscopic adrenalectomy. The operative steps to ligate the adrenal pedicle are described. A Medline search also was conducted to identify all reported bleeding episodes associated with this procedure. All attempted ligatures of the main adrenal vein were completed successfully by the described technique, and none of our patients required perioperative blood transfusion. Twenty-eight episodes of bleeding collected from the literature were analyzed. Hemorrhagic accidents related to dislodgement of clips were documented at least in three patients. The cause of bleeding was unspecified in 10 patients. Extracorporeal ligation of the main adrenal vein is feasible, safe, and advisable to prevent the occurrence of hemorrhage during endoscopic adrenalectomy.

Adrenal Glands↗

PubMed2006

Simultaneous bilateral laparoscopic adrenalectomy for adrenocorticotropic hormone-independent macronodular adrenal hyerplasia: report of a case.

Cushing's syndrome caused by adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH) is an extremely rare disease, which shows bilateral macronodular adrenal hypertrophy and autonomous cortisol production. We herein report a case of AIMAH treated successfully by minimally invasive simultaneous bilateral laparoscopic adrenalectomy. A 73-year-old woman with hypertension, diabetes mellitus, and osteoporosis was referred to our hospital because of an incidentally found huge bilateral adrenal mass. An abdominal computed tomography scan showed large bilateral adrenal glands with multiple nodules. A diagnosis of AIMAH was made and a simultaneous bilateral laparoscopic adrenalectomy was thus performed. The total operation time was 310 min and blood loss was 70 g. Both glands were hypertrophic (right 5 x 3 cm, 48.5 g and left 4 x 2 cm, 39.2 g) and consisted of multiple golden yellow macronodules. The postoperative course was uneventful. A simultaneous bilateral adrenalectomy for AIMAH performed by an experienced surgical team is therefore considered to be a safe and minimally invasive procedure.

Adrenal Glands↗

PubMed2001

Partial adrenalectomy in patients with multiple adrenal tumors.

Most adrenal tumors are found incidentally and appear as small solitary nodules on abdominal imaging. Occasionally, work-up demonstrates multifocal or bilateral adrenal tumors. Certain patients are predisposed to multiple lesions, such as those with hereditary forms of pheochromocytoma as seen in von Hippel-Lindau disease, multiple endocrine neoplasia type II, and von Recklinghausen's disease. Partial rather than total adrenalectomy should be considered for these patients in an attempt to preserve endogenous adrenocortical function. Partial adrenalectomy has also been used to resect other types of adrenal tumors, especially in patients with a solitary adrenal gland. A discussion of the indications for partial adrenalectomy and of the surgical technique follows.

Adenoma↗

PubMed2005

Laparoscopic adrenalectomy for pheochromocytoma.

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland for functional adrenal tumors including aldosteronoma, glucocorticoid, and androgen/estrogen-producing adenomas. Many laparoscopic surgeons also think that for small to moderately sized pheochromocytomas, the laparoscopic approach is as safe and effective as the open technique. Several physiologic considerations specific to pheochromocytoma must be addressed before and during surgery regardless of the operative approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy remain the same for pheochromocytomas as for other pathologic conditions of the adrenal gland. These include a shorter length of stay, a decrease in postoperative pain, a shorter time to return to preoperative activity level, and improved cosmesis.

Adrenal Gland Neoplasms↗

PubMed1982

Adrenalectomy: anterior or posterior approach?

The relative merits of the anterior and posterior approaches to the adrenal gland were assessed in a series of 103 patients with bilateral cortical hyperplasia or unilateral cortical adenoma (less than 25 g). In none of the patients was additional concomitant surgery planned. Sixty-four patients were operated on through the anterior and 39 through the posterior approach. Iatrogenic injury of the spleen necessitated splenectomy in 9 (18 percent) of 49 patients undergoing left adrenalectomy anteriorly. In 10 (26 percent) of 39 patients operated on posteriorly, the pleural cavity was entered. Perioperative blood requirement and postoperative morbidity were lower when the posterior approach was used. The hospital stay was significantly shorter after both unilateral and bilateral adrenalectomy when operation was done through the posterior approach. The results of this study lend strong support to a posterior lumbar approach for adrenalectomy for small benign adrenal cortical lesions.

Adenoma↗

PubMed1983

Effects of castration and adrenalectomy on in vitro rates of tryptophan hydroxylation and levels of serotonin in microdissected brain nuclei of adult male rats.

Rates of 5-hydroxytryptophan (5-HTP) synthesis and levels of serotonin (5-HT) were measured in microdissected brain nuclei following castration or adrenalectomy of adult male rats. Fourteen days following gonadectomy, 5-HTP synthesis decreased in the nucleus raphe dorsalis (DR) and nucleus centralis superior (NCS), while levels of 5-HT were unchanged in the 7 brain nuclei examined. Administration of testosterone to castrated rats not only did not reverse the castration-induced decrease in 5-HTP synthesis in the DR and NCS, but also decreased 5-HT synthesis in the nucleus amygdaloideus centralis (AGC) and the nucleus septalis lateralis (LS). Following administration of testosterone, 5-HT levels were unchanged. 10 days following bilateral adrenalectomy, 5-HTP synthesis increased in the NCS and the median eminence. Levels of 5-HT increased only in the median eminence. The increased 5-HTP synthesis and 5-HT levels following adrenalectomy were not reversed by corticosterone administration. In addition, these selective changes in 5-HT metabolism did not result from hormonal effects on the availability of tryptophan to the brain. We conclude that there are subsets of serotonergic neurons in rat central nervous system which respond uniquely to removal of the gonads and adrenals. Furthermore, the dissociation between serum and brain tryptophan concentrations and changes in rates of 5-HTP synthesis argue against tryptophan availability as being a primary determinant of 5-HT biosynthesis and for a direct endocrine central nervous system interaction with serotonergic neurons.

5-Hydroxytryptophan↗

PubMed1985

Release of prostaglandin E2 and beta-endorphin-like immunoreactivity from rat adenohypophysis in vitro: variations after adrenalectomy or lesions of the paraventricular nuclei.

Previous studies in vitro have shown that prostaglandin (PG) E2 is formed in rat adenohypophysis upon stimulation by arginine-vasopressin (AVP) and synthetic ovine corticotropin-releasing factor (CRF-(1-41]. The aim of the present study was to examine whether long-term changes in the hypothalamic stimulation of the pituitary corticotrophs in vivo may influence PG synthesis in subsequent in vitro incubations of rat anterior pituitary quarters. The release of PGE2 from adenohypophyses obtained from adrenalectomized rats was increased to about 300% of controls both under basal conditions and after stimulation by AVP; by contrast, the release of PG D2 was changed neither by adrenalectomy nor by AVP. Simultaneously, basal release of beta-endorphin-like immunoreactivity (beta-EI) was increased after adrenalectomy to about 300% of controls, parallel to the increase in the tissue content, whereas AVP-induced beta-EI release was unchanged. Addition of PG E2 inhibited, whereas blockade of PG formation by indomethacin enhanced AVP-induced beta-EI release both in controls and after adrenalectomy. When anterior pituitary glands were taken from rats with lesions of the paraventricular nuclei, release of PG E2 was decreased as compared to controls both under basal conditions and after stimulation by AVP or CRF-(1-41). Simultaneously, basal and evoked release of beta-EI was unchanged. We conclude that the formation of PG E2 in the adenohypophysis varies according to long-term changes in the hypothalamic stimulation of adrenocorticotropin and beta-endorphin release supporting the view that PG E2 synthesis is related to, and may be involved in mechanisms controlling peptide hormone release from the corticotrophs.

Adrenalectomy↗

PubMed1995

Hippocampal dentate granule cell degeneration after adrenalectomy in the rat is not reversed by dexamethasone.

Although adrenalectomy has been reported to induce a selective and sometimes nearly complete degeneration of hippocampal dentate granule cells, Azmitia and colleagues recently reported (Mol. Brain Res., 19 (1993) 328-332) that normal hippocampal structure can nonetheless be restored within a matter of days by dexamethasone in the drinking water. We have attempted to confirm this remarkable finding. Four months after adrenalectomy, rats were given vehicle or dexamethasone for 5 days and then sacrificed. Histological analysis revealed that vehicle-treated adrenalectomized rats exhibited a full spectrum of granule cell loss, which spanned mild to nearly complete cell loss. Dexamethasone-treated adrenalectomized rats did not differ from vehicle-treated adrenalectomized rats and, in fact, exhibited a virtually identical spectrum of granule cell loss. These results confirm that adrenalectomy reliably induces hippocampal granule cell degeneration in a majority of animals and indicate that dexamethasone does not restore normal hippocampal structure once granule cell loss has occurred.

Adrenalectomy↗

PubMed1988

Dexamethasone and adrenalectomy alter brain (Na+,K+)-ATPase responses to noradrenergic stimulation or depletion.

We investigated the effects of adrenalectomy or dexamethasone treatment on the regulation of brain (Na+,K+)-ATPase by noradrenaline. Noradrenergic stimulation was produced by repeated injections of yohimbine, and noradrenaline depletion by an injection of the selective toxin DSP4 (N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine). Adrenalectomy had no effect on the number of ouabain binding sites in cerebral cortex, but increased the number of sites synergistically with noradrenergic stimulation. Dexamethasone prevented the decrease in ouabain binding in rats treated with DSP4, but did not itself alter ouabain binding. Neither dexamethasone nor adrenalectomy altered the changes in beta-receptor binding associated with the noradrenergic manipulations. Changes in exposure to corticosteroids may alter the coupling between adrenoceptor binding and second messenger activation in a way that affects (Na+,K+)-ATPase regulation.

Adrenal Glands↗

PubMed1989

Effect of adrenalectomy on correlation of analgesia with tissue content of morphine.

Adrenalectomy potentiated the antinociception of s.c. morphine (1.9-fold) but not that of i.c.v. morphine. After s.c. administration, the semilogarithmic plots of morphine content (plasma, brain, cerebrospinal fluid (CSF) or spinal cord) and morphine antinociception showed linearity for both sham-operated (SHAM) and adrenalectomized rats (ADX), and the regression lines for ADX showed leftward shifts (1.5-1.9-fold) compared with those for SHAM. After i.c.v. administration, the semilogarithmic plots of morphine content in brain or CSF and morphine antinociception showed linearity for both groups without difference in the regression lines for SHAM and for ADX, and the correlation between spinal morphine and antinociception was poor. Morphine was distributed in both brain and spinal cord after s.c., but was predominantly found in brain after i.c.v. administration. These results suggest that increased sensitivity to morphine is the main cause of adrenalectomy-induced potentiation of morphine antinociception and that adrenalectomy increases the sensitivity to morphine at the spinal site and/or potentiates the synergistic interaction of supraspinal and spinal morphine action.

Adrenalectomy↗