From OncoLog, May 2008, Vol. 53, No. 5

A Reverse Approach to Adrenal Gland Resection

by Joe Munch

For more than a decade, using transperitoneal laparoscopy to treat patients with benign adrenal neoplasms has been the norm. However, surgical endocrinologists at M. D. Anderson are finding that for some of these patients, a different approach may be warranted. Today, these surgeons are using retroperitoneoscopic posterior adrenalectomy (RPA), a procedure that has become commonplace in Germany (where it was initially developed) but is seldom employed in the United States, to resect adrenal glands containing benign tumors and small metastases.

Since its introduction in 1992, laparoscopic adrenalectomy has become the standard of care for patients with benign adrenal disease. Traditional transperitoneal laparoscopic adrenalectomy is performed with the patient in a supine position; surgeons must navigate through the patient’s abdomen to approach the adrenal glands anteriorly, carefully moving organs aside to access the retroperitoneum. In contrast, RPA is performed while the patient is in a face-down “jackknife” position, and the adrenal glands are accessed through the lower back. This provides quick, direct access without disturbing the intraabdominal organs. Not only does RPA have all the usual advantages of laparoscopic surgery—including minimal blood loss, shorter hospital stay, less pain, and quicker recovery—but because it allows more direct access to the adrenal glands, RPA also provides a superior field of view.

Who benefits?

While RPA is not indicated for patients with primary adrenal cancer—these tumors are often too large and have invaded too much of the surrounding tissue to be removed laparoscopically—the procedure can lessen the impact on recovery for patients with benign disease or small metastatic tumors.

According to Nancy D. Perrier, M.D., an associate professor in and chief of the Section of Endocrine Tumor Surgery in the Department of Surgical Oncology, patients who particularly benefit from RPA include:

• Patients with prior abdominal surgery. Scarring and adhesions caused by prior abdominal surgery create a “nonfriendly” abdomen in which tissues have fused together, making it difficult to access the adrenal glands from an anterior approach.
• Patients who need a bilateral adrenalectomy. Traditionally, bilateral adrenalectomy requires either a large, open operation or two completely separate laparoscopic surgeries. “This would involve turning the patient in the middle of a case, which is very tricky when a patient is intubated and asleep,” Dr. Perrier said. “To unprep, undrape, reposition the patient, then re-prep and re-drape can add an hour and a half to the anesthesia time.”
• Patients with Cushing syndrome caused by a benign adrenal adenoma. The syndrome, which is characterized by high levels of cortisol in the blood, prevents normal wound healing. In these cases, the most direct and minimally invasive operation is best, since it requires the least amount of tissue healing.
• Patients with metastatic cancer in the adrenal glands. These patients need to receive chemotherapy or radiation therapy. A traditional, anterior adrenalectomy in such patients, who often have had multiple prior abdominal operations, would likely require a long recovery period. RPA, with its shorter recovery period, may allow the rest of their treatment to proceed more quickly.

The use of RPA is not limited to patients with these conditions; in fact, Dr. Perrier said, the approach may be used to resect other types of tumors in the same region. However, RPA is not indicated for large tumors because the modest operating space afforded by RPA makes manipulation of large tumors difficult. RPA is also not appropriate for very obese patients; even in the prone position, the retroperitoneum in these patients becomes compressed, and sufficient operative space cannot be created.

A precipitous learning curve

Yet despite the benefits RPA offers and despite the fact that RPA has been around for more than a decade now, few U.S. surgeons have embraced the procedure. Many of those who attempted to do so, Dr. Perrier said, abandoned the procedure after only a few cases.

“There is a learning curve, and it is steep,” Dr. Perrier said.

RPA is a technically challenging procedure. Not the least of these challenges is approaching the adrenal glands from an entirely unfamiliar direction. Surgeons are trained to navigate human anatomy head-on; in a conventional laparoscopic adrenalectomy, for instance, surgeons approach the adrenal glands anteriorly, guided in part by familiar anatomical “landmarks” within the abdomen—the liver, the spleen, the pancreas, and so on. But to perform an RPA, surgeons must completely reorient themselves.

“It would be like asking you to drive home backward,” Dr. Perrier said. “You’ve never driven backward before. You’ve always driven forward, right? If you just randomly try to do it, it’s very frustrating and very difficult.” The trick to performing a successful RPA, Dr. Perrier said, is knowing the right steps.

“There are certain absolutes to this operation,” Dr. Perrier said. “For instance, getting the patient in the right position makes or breaks the operation. Getting into the right surgical plane, knowing the tricks for retracting and exposing the adrenal vein, dissecting the adrenal gland medially off the kidney—if you don’t know how to do these things, you won’t be able to do the operation. It’s too technically demanding.”

Training at the source

To gain the technical expertise necessary to perform a successful RPA, Dr. Perrier and her colleagues went straight to the source. Martin K. Walz, M.D., a professor at the Department of Surgery and Center for Minimally Invasive Surgery at the Kliniken Essen-Mitte, Essen, Germany, developed the procedure not long after laparoscopic adrenalectomy was first described.

“He really single-handedly designed this operation,” Dr. Perrier said.

In 2005, Dr. Perrier was teaching a course on parathyroid surgery at the European Institute of TeleSurgery when she first observed Dr. Walz perform several RPAs.

“I saw Martin do these surgeries, and I was so impressed,” Dr. Perrier said. “It was really mind-boggling to see him do these operations, to see the technical ease of him doing it—it was just mesmerizing. I came back and said, ‘We have got to learn how to do this.’ ”

So, later that year, Dr. Perrier, along with Jeffrey E. Lee, M.D., and Douglas Evans, M.D., professors in the Department of Surgical Oncology, traveled to Essen, Germany, where they observed Dr. Walz perform seven RPAs in a matter of 6 hours and noted the critical aspects of the procedure. The team members returned to M. D. Anderson, and, bolstered by their observational experience, performed their first RPA in November 2005. The following spring, Dr. Walz (who had by that time performed the procedure more than 600 times) came to M. D. Anderson and observed the surgeons as they performed RPAs. His input proved exceedingly valuable and helped Drs. Perrier, Lee, and Evans succeed where other surgeons had failed. Since then, the team has done more than 70 RPAs.

“For me, now, there is no doubt that doing this operation is easier than for me to do an anterior operation,” Dr. Perrier said, “but it wasn’t that way at the beginning.”

For more information, call Dr. Perrier at 713-794-1345 or Dr. Evans at 713-794-4324.

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