V4-06: Laparoscopic adrenalectomy for large tumors: complications and their management
VideoIntroductions and Objectives
Laparoscopic adrenalectomy is the procedure of choice for most adrenal tumours. However, their proximity to major structures makes surgery prone to complications. Large tumors pose specific problems because of their size. We present some complications we encountered during these surgeries and discuss their management and prevention.
Operative videos of 3 patients who underwent laparoscopic adrenalectomy for tumors greater than 10 cm in size and had major intraoperative complications were reviewed. The clips highlighting occurrence of injury and its management were compiled for this video. The first patient, with a 12 cm right adrenal carcinoma, had a rent in the renal vein during dissection. This injury did not bleed and was not recognized during surgery. Bleeding was identified only when low-pressure inspection of the surgical bed was performed. The second patient, with a 14cm right adrenal carcinoma, had bleeding from an avulsed adrenal vein and the liver bed that required packing. The third patient underwent an en-masse left adrenalectomy and radical nephrectomy for an inflammatory malignant fibrous histiocytoma. The diaphragm was injured during dissection and, during its repair, the assistant injured the spleen during retraction. All injuries were managed with intracorporeal suturing.
All injuries were identified and managed intraoperatively. The key-steps to prevention would have been adequate mobilization of adjacent structures, precise identification of tissue planes and careful assistance. Low-pressure inspection for bleeding prevented missing an injury. One patient required intra-costal tube drainage that was removed on the 5th post-operative day. Another developed a collection in the operative area that required per-cutaneous drainage. There were no adverse outcomes in recovery.
Laparoscopic adrenalectomy for large adrenal tumours is feasible but is associated with a greater risk of injuries. Their prevention, identification and management require expertise, both of the surgeon and his assistants.