LAPAROSCOPIC SURGERY FOR ADRENAL TUMORS: results from 450 operations

C. Aggeli, A. Nixon, I. Perysinakis, A. Diamantopoulos, A. Koronaios, G.N. Zografos

Department of SurgeryAthens General Hospital ‘ G. Gennimatas’, Greece

EAES CONGRESS, AMSTERDAM JUNE 16-18, 2016

ADRENAL SURGERYThird Department of Surgery, Athens General Hospital

“G. Gennimatas” January 1998 – December 2015

450 Resection of adrenal tumors ( 439 patients)

361 Laparoscopic procedure

50 Open approach from the start

37 Conversion of laparoscopic approach to open

450 ProceduresJanuary 1998 – December 2015

ADRENAL SURGERYThird Department of Surgery, Athens General Hospital “G. Gennimatas” January 1998 – December 2015

121 Adenoma (72 autonomous cortizol+/- aldosterone)29 Potentially malignant tumors ( 24 medulla, 5 cortical)63 Cushing’ syndrome 11 Cushing’ disease65 Pheochromocytoma (5 ectopic, 4 ΜΕΝ ΙΙΑ)35 Malignant tumors6 Malignant pheochromocytoma1 Recurrent malignant pheochromocytoma13 Metastatic Ca (lung., colon, kidney )24 Primary cortical Ca 1 Αngiosarcoma66 Conn’ s syndrome12 Μyelolipoma11 Cysts, Cystic tumors3 Ganglioneuroma 1 hematoma 2 swannoma 1 Αngiolipoma

•Mean age: 53,6 years

PATIENT POSITIONING

65 Pheochromocytomas Hypervascular tumors, need laparoscopic

experience

G.N. Zografos, G. Piaditis et al. Laparoscopic resection of pheochromocytoma with delayed vein ligation

Surg Laparosc Endosc Percut Tech 2011;21(2):116

LAPAROSCOPIC ADRENALECTOMY IN CUSHING’S SYNDROME ( 63 +11 Cushing’s disease)

72 SUBCLINICAL CUSHING

LARGE ADRENAL TUMORS

• 121/450( 8 to 23 cm)

• 71 tumors 8 – 14 cm laparoscopically

• Tumors > 15cm can not be resected laparoscopically

• 3 Hand – assisted technique

Bresadola V et al Applicability of laparoscopic approach to the resection of large adrenal tumors: a retrospective cohort study of 200 patients Surg Endosc 2015; 5Zografos GN et al. Laparoscopic resection of large adrenal ganglioneuromaJ Surg Lap Soc 2007;11(4):487-492.

LAPAROSCOPIC SURGERY FOR MALIGNANT AND POTENTIALLY MALIGNANT

TUMORS

• Primary malignancy: 5/23 laparoscopic ( 1 pheo, 4 cortical)

• Potentially malignant: 25 laparoscopic ( 5/6 cortical, 2 paragagglioma, 18/23 pheochromocytoma)

• Solitary adrenal metastasis: 7 laparoscopic, 5 conversion, 6 open from the start

37 CONVERSION TO OPEN

• 12 Malignant tumors ( oncologic safety), • 9 large tumors• 16 previous surgery, in learning curve

ADRENAL SPARING SURGERY

• Bilateral benign pheochromocytoma inΜΕΝ ΙΙ ( 4 cases)

• Conn’ s syndrome (5/66)

Adrenal mass

CT, MRI Laboratory screen

Biochemically active Biochemically inactive

<12-14cm >12-14cm <4cm >12-14 cm

OpenAdrenalectomy Serial CT

<

OpenAdrenalectomy

LapAdrenalectomy

>4 cm,<12-14cm<4cm, <50yo

Laparoscopicadrenalectomy

Primary Malignancy cautious approachPossible invasion early conversion

CONCLUSION

Laparoscopic surgery is indicated in all benign adrenal tumors

Large tumors 8-14 cm necessitate laparoscopic experience

Solitary adrenal metastasis can be safely resected laparoscopically

G. Zografos et al . Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma. J.S.L.S 2007;11(2):261-265

CONCLUSIONS

• Primary adrenal tumors suspicious of malignancy < 10 cm must be approached by laparoscopy in specialized centres.

• Malignant tumors or potentially malignant tumors > 10 cm, with or without peri-adrenal invasion must be operated by open technique from the start

Ζografos G.N et al Laparoscopic surgery for malignant adrenal tumors Journal Surgical Oncology 2009;13(2):196-202Zografos G.N. et al Laparoscopic surgery for potentially malignant adrenal tumors: an

unresolved issue. Hormones 2015