Open adrenalectomy

Abstract

In an era when minimally invasive adrenalectomy is the gold standard treatment for majority of patients presenting with adrenal tumours, open adrenalectomy has become an operation that should be centralised in regional referral centers. Its main indication is represented by patients with large (>8 cm) phaeochromocytomas and patients with cortical adrenal tumours suspected of malignancy either because of their size (>4-6 cm) or because of radiological appearance of local invasion. Based on local expertise some of these patients might benefit from multidisciplinary input from liver or transplant surgeons. This chapter will discuss the anatomical landmarks and will comment on different steps in the procedure for right- or left-sided procedure. It is outside the scope of this chapter to settle the ongoing debate about patient selection for laparoscopic or open adrenalectomy when the diagnosis of adrenocortical cancer is suspected preoperatively.

Keywords: Adrenalectomy; surgical technique.

Figure 1

Size of tumour in patients with adrenocortical cancer undergoing adrenalectomy only or multi-visceral resections.

Figure 2

Right-sided adrenalectomy for adrenocortical cancer. Patient presented with clinical signs of excess androgen secretion and was found to have a 16-cm right-sided adrenal tumour (A). At laparotomy the mass was easily apparent under the lower border of the liver (B). After removal of the mass in continuity with right kidney, the IVC is clearly seen without any soft tissue in front of the posterior abdominal wall muscles (C). Specimen was resected intact (D). IVC, inferior vena cava.

Figure 3

Left-sided adrenalectomy for adrenocortical cancer. Patient with non-functional ACC identified during cross sectional imaging for respiratory complaints. CT scan shows splenic artery stretched over the top the tumour (A) and tail of the pancreas in extensive contact with the tumour (B). PET scan showed no local lymphadenopathy (C). Tumour was resected intact together with the spleen and tail of pancreas (D). ACC, adrenocortical cancer.

Figure 4

Lymph node yield in patients with adrenocortical cancer. In a group of unselected patients with ACC, the number of lymph nodes described on pathology reports varied widely even though for all cases the surgeon aimed a radical local excision of adrenal tumour and surrounding soft tissue. ACC, adrenocortical cancer.

Figure 5

Unresectable adrenocortical cancer.