Ideal case for adrenalectomy by retroperitoneal approach

Óscar Vidal (Endocrine Surgery Senior Specialist) Hospital Clínic of Barcelona, Spain

Case

A 45-year-old male patient recently diagnosed with hypertension and with a performed appendectomy in childhood, presented episodes of headache, sweating, muscle weakness and cramps, associated with persistent high blood pressure despite correct medical treatment.Hyperaldosteronism was suspected because he had 2.7 mmol/L of serum potassium, plasmatic, aldosterone 250 mmol/L and aldosterone / renin ratio was 500. There was an adrenal mass in the left kidney by ultrasound and the MRI showed a 30 mm left adrenal tumor.

Treatment

A retroperitoneal laparoscopic approach was used. Surgery begins with the patient in prone position with slight flexion of the hip. The surgeon is positioned on the left side of the patient. An incision of 2 cm is made between the 12th rib and the iliac crest, anatomical planes are dissected until the retroperitoneal space is reached. A total of three trocars were used, the first one with a balloon (for the camera) that seals the working space and helps to create a cavity into the retroperitoneum, two additional trocars were placed each one lateral to the camera below the costal margin. The Gerota fascia is identified, which is a key step for the orientation of the surgeon because this approach is completely the opposite to the transabdominal access. The upper pole of the kidney is reached and the surgeon starts to dissect the lower edge of the adrenal gland. The next step is the medial plane were the renal vein is located which helps identify the adrenal vein. Careful identification of the anatomy must be done during this maneuver for secure ligation of the adrenal vein. Once this face is completed the planes becomes more clear and dissection is made through an avascular plane with traction and contraction movements. If the procedure is accomplished without complications there is no need to use a drain. The incision was closed in layers with absorbable running suture and intradermal suture for the skin.

Outcome

The surgery was uneventful; there were no postoperative complications. The patient started the oral intake 1^st day after the procedure and was discharged the next day. The pathology revealed an adenoma without signs of malignancy. The last follow up was 6 months after and he was asymptomatic with normal adrenal function.