Laparoscopic Adrenalectomy Is Safe and Effective to Remove Larger Adrenal Tumors, Study Reports

The minimally invasive laparoscopic adrenalectomy (LA) is a safe and feasible procedure for larger adrenal tumors and metastasis, a new Italian study shows.

While the findings suggest that the surgical application of laparoscopic adrenalectomy could be extended, surgeons should undergo a 30-procedure learning curve to improve surgical outcomes, researchers say.

The research, ”Single center experience with laparoscopic adrenalectomy on a large clinical series,” appeared in the journal BMC Surgery.

LA is regarded as the gold standard for the removal of benign — non-cancerous — small and medium-sized adrenal masses (<6 cm) in a broad spectrum of adrenal diseases. This minimally invasive method offers low morbidity rate, short hospitalization periods, less pain, and rapid recovery, which contrast with the disadvantages of open surgery.

However, using LA for lesions greater that 6 cm is a matter of debate for endocrine surgeons.

The researchers reviewed records from 126 patients subjected to LA between 2003 and 2015 to assess the safety and outcomes of laparoscopic procedures in the treatment of adrenal diseases. The data were compared with that of a literature review.

Diagnosis was based on clinical examination, laboratory values, and imaging techniques. The main inclusion criteria were patients less than 80 years of age, and presenting either adrenal benign functioning tumors — those that secrete excess pituitary hormones and cause clinical syndromes, such as Cushing’s disease — up to 8 cm in diameter, non-functioning tumors of 12 cm or less, or adrenal metastases smaller than 6 cm.

Patients were given the anti-hypertensive doxazosin during pre-operative management in case of pheochromocytoma (a rare adrenal tumor, in which excessive release of adrenaline and noradrenaline increase blood pressure). Conversely, the diuretic spironolactone and potassium were used to treat Conn’s disease — characterized by excess production of the hormone aldosterone.

The results revealed that 84 patients had functioning tumors, 27 pheochromocytomas, 29 Conn’s disease, and 28 Cushing’s disease.

The single surgeon conducting the procedures was able to reduce mean operative time from about 137 minutes during the first 30 adrenalectomies (defined as the learning curve) to approximately 96 minutes in subsequent surgeries. Blood loss was also significantly reduced after going through the learning curve.

Only one patient had to undergo subsequent open surgery. No major post-operative complications occurred, and minor complications were observed in only eight patients.

The endocrine profile of 83 out of the 84 functioning tumors was effectively normalized by LA.

Overall, the study showed that “LA is safe and feasible also for benign lesions up to 12 cm,” the scientists wrote.

However, “a skilled operative team, composed by endocrine surgeons experienced in LA after adequate learning curve, is requested,” they cautioned.

Among the study’s limitations, the investigators mentioned the lack of comparison with open surgery and the fact that all surgeries were performed by the same team.