Over the years, a number of different surgical approaches to the adrenal glands have been devised. The anterior transabdominal approach is considered to be a source of postoperative morbidity. However, this conviction can be changed. The laparoscopic approach was used in four patients. One had a right 5 cm nonfunctioning tumor, the second had a 1.8 cm right aldosterone-producing adenoma, the third patient had a 4 cm adrenocortical adenoma, and the fourth patient had a bilateral pheochromocytoma (tumor size was 3.5 cm and 4.5 cm in the right and left adrenals, respectively). Carbon dioxide pneumoperitoneum was used in three patients, but helium pneumoperitoneum was used in the patient with bilateral pheochromocytoma to prevent CO2 retention. Single right adrenalectomy lasted between 2 h and 2 h 30 min, and bilateral adrenalectomy lasted 5 h 30 min. The hospital stay was between 3 and 4 days. Unilateral or bilateral adrenalectomy through laparoscopy can be performed safely and has the advantage of avoiding the muscular trauma related to laparotomy or rib resection necessary for the extraperitoneal approach.

Adrenalectomy is usually performed through a transabdominal or a posterior approach. These approaches are associated with a painful syndrome postoperatively and long hospital stay. We report a series of five successful laparoscopic adrenalectomies, performed on: a 35-year-old male with a 5-cm right nonfunctioning tumor; a 32-year-old female with a 1.8-cm right aldosterone-producing adenoma; a 17-year-old female with a 4-cm right adrenocortical adenoma; and a 33-year-old female with bilateral 3.5-cm right and 4.5-cm left pheocromocytoma. Single right adrenalectomy lasted between 2 h and 2 h 30 min and bilateral adrenalectomy 5 h and 30 min. No transfusion was required. The hospital stay was between 3 and 4 days. This technique adequately removes adrenal tumors surgically and results in less postoperative pain and rapid recovery.

Primary aldosteronism is characterized by hypertension and hypokalaemia caused by excessive aldosterone secretion. A majority ( 80 per cent) of aldosterone-producing adrenocortical tumours are > 1 cm in diameter and are detectable by computed tomography (CT), magnetic resonance imaging and ultrasonography. For patients with unilateral adrenocortical adenoma, adrenalectomy should be performed. Until now, a laparoscopic approach to right adrenalectomy has not been described. Surgical techniqueA 33-year-old woman presented with a history of headaches and hypertension (blood pressure 180/ 100 mmHg ). Biochemical studies showed a marked increase in aldosterone concentration to 63 (normal range 4-30)ng/dl and a low potassium level of 3.0 (normal range 3.5-4.5) mmolil. A 1.8-cm tumour was detected by CT. Spironolactone, 200 mg daily for 2 weeks before surgery, corrected the hypertension and potassium deficiency.The patient was positioned with an exaggerated lordosis and draped to allow immediate laparotomy if necessary. Pneumoperitoneum was established by puncture at the umbilicus and controlled electronically at a constant abdominal pressure of 13 mmHg. A straight telescope (0-) attached to a videocamera was inserted through a 10-mm cannula and abdominal exploration performed. Five other cannulas were then inserted as shown in Figure I .Operative exposure of the right adrenal gland commenced once the transverse colon and omentum had been carefully separated downward with an atraumatic angled dissector and the right and left lobes of the liver had been retracted anteriorly.Once the overlying peritoneum lateral to the duodenum had been incised, careful dissection using an electrical hook coagulator freed the anterior and right sides of the vena cava. Gerota's fascia was opened and the fatty tissue attached to the adrenal gland was held up with a grasping forceps.After identification of the renal vein, dissection was continued in a cephalad direction (Figure 2). The high-magnification image from the laparoscope facilitated dissection of the many branches from the renal artery and the main adrenal vein coming directly from the vena cava. All vascular elements were divided between clips.Meticulous dissection using endoscopic scissors facilitated localization ofa second adrenal vein entering the vena cava from the superior portion of the adrenal gland and arterial branches from the inferior phrenic artery, which were also clipped and divided. Attachments of the gland to the superior pole of the kidney were divided with a hook coagulator.The right adrenal gland containing the tumour was then gently extracted via the umbilicus, which was widened slightly in a circular fashion to allow easier removal of the specimen.The procedure lasted for 2 h 30 min. Histological examination showed an adrenocortical adenoma 1.8 cm in diameter.The patient experienced minimal pain after operation, started a full liquid diet 24 h later, and was discharged 72 h after the procedure. She became normotensive and returned to full activity 5 days afte...

No abstract