Adrenal Gland Surgeries May Be Safer if Incisions Made to Back

Making incisions through the back of the body, rather than the front, can lessen bleeding and shorten operation time during surgery to remove the adrenal glands, a new study suggests.

The study, “Comparison of synchronous bilateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy: results of a multicenter study,” was published in Surgical Endoscopy.

Surgical removal of the adrenal glands can be warranted in some circumstances. In Cushing’s syndrome, the adrenal glands often grow abnormally large (hyperplasia), contributing to the excess cortisol production that causes the syndrome.

Adrenalectomy is the term for surgery to remove the adrenal glands. This is generally accomplished via laparoscopy — basically, a small incision is made, and a tube with a camera on it (laparoscope) is fed into the abdomen through the incision to facilitate the surgery. This allows for less bodily trauma than open surgery, where the abdomen is cut open for surgeons to view directly.

Researchers compared two strategies for laparoscopy-based adrenalectomy: the transperitoneal and retroperitoneal approaches. In simplest terms, the difference is where the initial incision is made — on the front (transperitoneal) or back (retroperitoneal) of the abdomen.

The researchers reviewed medical records for 52 people (40 women, 12 men; average age, 43.5) who underwent adrenalectomy at one of six centers between 2012 and 2018. The most common reason (61.5%) was adrenal hyperplasia associated with Cushing’s syndrome.

Of these surgeries, 27 were done via the transperitoneal route, and 25 via the retroperitoneal route. The two groups were significantly different in average age (37 vs. 50.4).

Researchers compared outcomes and complications between the two groups.

The retroperitoneal group had significantly shorter operating times (average of 148 vs. 171 minutes) and less blood loss during surgeries (50.2 vs. 137.9 mL). Of note, these differences were no longer significant after the exclusion of one individual in the transperitoneal group, who experienced “excess blood loss” (1600 mL, nearly half a gallon) during surgery — which also prolonged operating time.

“In our series, one case in transperitoneal group had excess blood loss (1600 ml). When the patient was excluded from statistical analysis, mean operating time did not changed between the groups. However, mean amount of blood loss was similar between the groups (81 ml vs. 50 ml),” the researchers wrote.

“In the current study, we included all patients’ data in statistical analysis and we compared 2 different approaches in terms of perioperative and postoperative parameters.”

They speculated that the difference in blood loss could be, at least in part, because the retroperitoneal approach provides more direct access to the adrenal glands, whereas in the transperitoneal approach, more organs and the like have to be ‘moved out of the way.’

Other factors — including the occurrence of complications during surgery or after surgery, as well as length of time spent in the hospital following surgery — did not differ significantly between the two groups.

No disease recurrence was observed for any of the included patients, regardless of surgical approach.

“Because significant difference was found in terms of operative time and estimated blood loss,” the retroperitoneal approach “seems to be considered the preferable one” for laparoscopy-based adrenalectomy, the researchers concluded.