1. Adrenalectomy from the back
Dr Leung Yuen Ki
Department of Surgery, Kwong Wah Hospital

2. Content Anatomy of the adrenal glands
Indication of different surgical approaches
Surgical technique of retroperitoneal adrenalectomy (RPA)
Outcome of transperitoneal adrenalectomy (TPA) vs RPA
Learning curve of RPA
Special condition: Phaeochromocytoma

3. Anatomy of the adrenal glands
Retroperitoneal structure
located on the superior medial aspect of the upper pole of each kidney
Gerota’s fascia and pararenal fat separate the adrenals from the ribs, pleural reflection, sacrospinalis and lattisimus dorsi muscles

4. Minimal Access Adrenalectomy
2 main approaches
Laparoscopic transperitoneal (TPA) or the retroperitoneal approach (RPA)
Transperitoneal approach is favored by many because of the familiarity of intraperitoneal anatomy and larger working space

5. Transperiotneal Approach
Transperiotneal laparoscopic adrenalectomy was first described in 1992
Now considered the gold standard for the removal of most benign adrenal tumors
Gagner M, et al. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J med. 1992;327:1033
Higashihara E, et al. A case report of laparoscopic adrenlaectomy. Nihon hinyokika Gakkai Zasshi.
1992;83:

6. Approach by indication
Dictated by surgeon expertise
Laparoscopic transabdominal adrenalectomy (TPA)
Laparoscopic retroperiotneal adrenalectomy (RPA)
Large tumours (>8cm)
Obese patients
Potential need for other abdominal procedures
History of extensive upper abdominal surgeries
Bilateral adrenalectomy
Primary functioning tumors (size < 6-7cm)
Metastasis (< 4cm and without infiltration of surrounding structures)
Agaoglu O, et al, Selection algorithm for posterior versus lateral approach in laparoscopic adrenalectomy.
Surgery 2012; 151:731

7. Surgical technique of RPA
Position: Prone Jack-knife position
Lee L Swanstrom. Mastery of Endoscopic and Laparoscopic surgery

8. Surgical technique of RPA
Port insertion
A 12mm transverse incision near the tip of the 12th rib
medial 10mm trocar along the border of the paraspinal muscles at a 45-degree angle cephalad, pointing directly at the adrenal gland
A lateral 5mm trocar at the tip of the 11th rib
Andreas Kiriakopoulos, et al. Impact of posterior retroperitoneoscopic adrenalectomy in a tertiary care center:
a paradigm shift. Surg Endosc (2011) 25:3584–3589

9. Surgical technique of RPA
A 12mm blunt balloon trocar or blunt dissection to create retroperitoneal space
Society of American Gastrointestinal and Endoscopic Surgeons
V109 Retropeitoenal endoscopic left adnrelaectomy

10. Surgical technique of RPA
CO2 insufflation with pressure of 25mmHg
Perinephric fascia entered and working space created
M. K. Walz. Adrenal Glands Diagnostic Aspects and Surgical therapy

11. Creation of working space
Retroperitoneal insufflation pressures of 20 to 25 mmHg greatly facilitate exposure
Do not result in the adverse hemodynamic consequences if these pressure achieved within the peritoneal cavity
Higher CO2 pressures tend to tapenade bleeding from small vessels, further improving visibility.
Giebler RM, Behrends M, Steffens T, et al. Intraperitoneal and retroperitoneal carbon dioxide insufflation evoke different effects on caval vein pressure gradients in
humans: evidence for the starling resistor concept of abdominal venous return. Anesthesiology. 2000;92:1568–1580.
Giebler RM, Kabatnik M, Stegen BH, et al. Retroperitoneal andintraperitoneal CO2 insufflation have markedly different cardiovascular effects. J Surg Res 1997;68:153–160.
Giebler RM,Walz MK, Peitgen K, Scherer RU. Hemodynamic changes after retroperitoneal CO2 insufflation for posterior retroperitoneoscopic adrenalectomy.
Anesth Analg 1996;82:827– 831.

12. Left sided RPA
Adrenal vein in space between the gland and diaphragmatic branch medial to the upper pole of the kidney
Walz et al. Posterior retroperitoneoscopic adrenalectomy – results of
560 procedures in 520 patients. Surgery. 2006;140:

13. Left sided RPA
After dissection of the main vein, preparation of adrenal gland is continued medially, laterally and cranially
M. K. Walz. Adrenal Glands Diagnostic Aspects and Surgical therapy

14. Right sided RPA The adrenal arteries cross the IVC posteriorly
Separate the vessels by electorcoagulation or clip application
By lifting up the adrenal gland, the IVC is visualized posteriorly
Walz et al. Posterior retroperitoneoscopic adrenalectomy – results of
560 procedures in 520 patients. Surgery. 2006;140:

15. Right sided RPA
The suprarenal vein then becomes clearly visible running posterolaterally and can be divided
Mobilization of the right adrenal gland is completed by lateral and cranial dissection
M. K. Walz. Adrenal Glands Diagnostic Aspects and Surgical therapy

16. Surgical technique of RPA
The gland placed into a retrieval bag and removed through the middle port
Society of American Gastrointestinal and Endoscopic Surgeons
V109 Retropeitoenal endoscopic left adnrelaectomy

17. Results of RPA
This is the landmark study by walz et al published in Journal of Surgery 2006
First introduced by author in 1994 and prospective study to evaluate the results in 12 years of 560 procedures in 520 patients

18. Results of RPA Patients demographic n = 560 (R: 258, L: 302)
Tumour size mean: 2.9cm
Mainly primary adrenal tumors with 119 phaeochromocytoma
49 underwent bilateral adrenalectomy
Walz et al. Posterior retroperitoneoscopic adrenlaectomy – results of 560 procedures in 520 patients.
Surgery. 2006;140:

19. Results of RPA Conversions A total of 11 conversions in 9 patients
4 conversions in left sided and 7 in right
3 missing progress
2 severe obesity
2 dense adhesion
1 cardiac instability due to decrease cardiac output with compression on IVC
Walz et al. Posterior retroperitoneoscopic adrenlaectomy – results of 560 procedures in 520 patients.
Surgery. 2006;140:

20. Results of RPA Outcome No mortality
1 case need reoperation on POD1 due to large retrperitoneal hematoma
47 of the cases reported hypesthesia of abdominal wall which mainly are temporary
Walz et al. Posterior retroperitoneoscopic adrenlaectomy – results of 560 procedures in 520 patients.
Surgery. 2006;140:

21. Outcome of TPA vs RPA
Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoeanl adrenalectomy
From international journal of surgery 2016
21 studies comparing a total of 1,205 TPA and 688 RPA
Similar patient demographics, age, BMI, laterality, size of tumor
Similar patient demographics, age, BMI, laterality and size of tumor
Nigra G et al. Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy.
International Journal of Surgery; Apr2016 Supplement 1, Vol. 28, pS118-S123, 1p

22. Outcome of TPA vs RPA
No statistically significant difference:
Operative time
Blood loss
Hospital stay
Mortality
No statistical significant difference in OT time, blood loss, hospital stay and mortality
Nigra G et al. Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy.
International Journal of Surgery; Apr2016 Supplement 1, Vol. 28, pS118-S123, 1p

23. Learning curve of RPA
X axis is the no. of patient
Y axis is the operating time
Group A is the inventor team with the initial 50 cases from
Group B is the initial 50 cases done by surgeons taught by group A surgeons 10 years later
The steep segment of the learning curve took about cases in each group
Group A: The inventor team, initial 50 cases ,
Group B: Teaching by Group A surgeon (10 years later),
initial 50 cases of group B surgeon
Barczynski et al. Posterio: Retroperitoneoscopic Adrenalectomy:
A comparison between the initial experience in the inventive phase
And introductory phase of the new surgical technique.World J Sur (2007)31: 65-71

24. Learning curve of RPA
2 experienced laparoscopic urologists have performed a minimum of 50 laparoscopic renal en adrenal operations each for 8 years
The no. on x axis is the group per 20 patient
Y axis is the operating time
Significant decrease in median operating time when comparing the first 20 patinets to patients and (100 mins to 83 mins to 60 mins, p<0.05)
No significant decrease in blood loss, conversion rate, hospital stay, perioperative and post-operative complications
Van Uitert et al. Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center
for laparoscopic adrenal surgery. Surg Endosc 2017

25. Special condition: Phaeochromocytoma
Intraoperative concern
Secretion of catecholamine during surgical manipulation liable blood pressure
Highly vascularized adrenal gland bleeding

26. Special condition: Phaeochromocytoma
Retrospective cohort study from Li et al
Total 99 patients were recruited
Comparable patient demographics in terms of sex age BMI diameter of tumor and side
Comparable patient demographics in sex, BMI, size of tumor and laterality
Li. et al. Laparoscopic adrenalectomy in pheochromocytoma: Retroperitoneal Approach vs Transperitoneal approach
Journal of Endourology 2010

27. Special condition: Phaeochromocytoma
RPA takes less time, lower blood
loss and shorter hospital stay
RPA takes less time, lower blood loss and shorter hospital stay in operation than TPA
No statistical difference in blood pressure control between the 2 groups of patient
5 cases of cx in TLA
(2, PTX, 1 colon injury, 1 hematoma)
4 case of cx in RLA
(2 peritoneum injury, 1 pleural injury)
FU 6-36 months with no mortalities or recurrence of tumors in all patient
Li. et al. Laparoscopic adrenalectomy in pheochromocytoma: Retroperitoneal Approach vs Transperitoneal approach
Journal of Endourology 2010

28. Special condition: Phaeochromocytoma
Ischemic heart disease is a frequent concern of adrenalectomy in phaeochromocytoma
A muticentered retrospective cohort studied included 341 patient
Comparable postoperative overall morbidity and cardiovascular mobidity
Statistically shorter operative time and shorter hospital stay in RPA group
Comparable post-operative cardiovascular morbidity
Wessel et al. Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal
and retroperitoneal approach in a multicenter analysis of 341 patients. Journal of Surgery 2017

29. Special condition: Phaeochromocytoma
RPA
Avoid respiratory and hemodynamic effects of CO2 pneumoperitoneum
Direct access without the need to mobilize abdominal organs
Lack of large scaled RCT to evaluate the outcomes of 2 approaches on the disease
Li. et al. Laparoscopic adrenalectomy in pheochromocytoma: Retroperitoneal Approach vs Transperitoneal approach
Journal of Endourology 2010

30. Conclusion
Posterior retroperitoneoscopic adrenalectomy is a safe and feasible option
There may be circumstances where one approach may be preferable, and surgeons should be able to perform each approach routinely

31. Thank You

32. Characteristics of the included studies

33. Forrest plot of TPA vs RPA
Nigra G et al. Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy.
International Journal of Surgery; Apr2016 Supplement 1, Vol. 28, pS118-S123, 1p