Laparoscopic Adrenalectomy in Giant Masses

Background: Laparoscopic adrenalectomy is considered the treatment of choice in the surgical management of the most majority of the adrenal diseases. Nevertheless, one of the much discussed topics is the dimensional cut-off for the laparoscopic treatment and it is not clear if laparoscopy should be used in large adrenal masses.Introduction. Laparoscopic adrenalectomy is the goal standard in benign adrenal masses smaller than 6 cm, while its advantages in masses larger than this cut-off and in malignant lesions is still discussed. Materials and methods: We present six cases of laparoscopic adrenalectomy since November 2008 for masses between 7 and 15 cm; 4 men and 2 women. 3 right and 3 left. A complete adrenal endocrinological evaluation demonstrated that the lesions were not secreting tumors. All patients were studied with CT scan.The technique was performed using a flank approach with a 45° tilt. We used 5 trocars in patients who had the masses on the right side, and 4 in those who had the lesions on the left side. After creating an adequate pneumoperitoneum through an open access, the posterior peritoneum cutting, mobilization of the colon, medial dissection of the adrenal gland, and ligation of the main adrenal vein were performed. The adrenal gland was carefully dissected by Ultracision. The mass was extracted by endobag through an additional subcostal port. The mean operative time was 120 minutes. Blood loss was about 50 cc. The drainage was removed on day 2 after surgery and the patient was discharged on day 3. No postoperative complication occurred. The anatomopathologic exam gave evidence of myelolipoma and hemorrhagic cyst. Discussion: The benefits of the laparoscopic approach are widely demonstrated and consist of a shorter hospital stay, reduced morbility, decreased analgesic requirement, and reduced intraoperative blood loss. One of the most discussed topics is the dimensional cut-off and it is not clear if the laparoscopy approach should be used in large adrenal masses (considering the longer operative time and increasing blood loss). Many surgeons performed laparoscopic adrenalectomy for masses of up to 13 cm, thus demonstrating that this procedure is safe and effective. A limitation of laparoscopic approach for adrenal giant masses is the increased risk to treat an adrenal cortical carcinoma. Conclusions: Our experience, supported by the literature, demonstrates that the laparoscopic adrenalectomy is a feasible and effective surgical technique also in the case of giant masses. Preoperative diagnosis has a predominant role to determine the contraindication of this technique (invasive adrenal carcinoma).