Laparoscopic Adrenalectomy in Children:
A Multicenter Experience
Shawn D. St. Peter, MD,1Patricia A. Valusek, MD,1Sarah Hill, MD,2Mark L. Wulkan, MD,2Sohail S. Shah, MD,3
Marcello Martinez Ferro, MD,4Pablo Laje, MD,5Peter A. Mattei, MD,5Kathleen D. Graziano, MD,6
Oliver J. Muensterer, MD,7Elizabeth M. Pontarelli, MD,8Nam X. Nguyen, MD,8Timothy D. Kane, MD,9
Faisal G. Qureshi, MD,9Casey M. Calkins, MD,10Charles M. Leys, MD,1 1
Joanne E. Baerg, MD,12and George W. Holcomb III, MD1
Introduction: Laparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy
for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic
small case series. Therefore, we conducted a large multicenter review of children who have undergone lapa-
Methods: After Institutional Review Board’s approval, a retrospective review was conducted on all patients who
have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included
unilateral adrenalectomy without concomitant procedures.
Results: About 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions,
59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2–63.5 minutes (range 43–406 minutes).
The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone
preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 gang-
lioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most
conversions were because of tumor adherence to surrounding organs, and tumor size was not different in
converted cases (P=.97). A blood transfusion was required in 2 cases. The only postoperative complication
was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels.
At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a
Conclusions: The laparoscopic approach can be applied for adrenalectomy in children for a wide variety of
conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for
significant blood loss or complications is low, and it should be considered the preferred approach for the
majority of adrenal lesions in children.
1Department of Surgery, Children’s Mercy Hospital, Kansas City, Missouri.
2Department of Surgery, Children’s Healthcare of Atlanta at Egleston, Atlanta, Georgia.
3Department of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
4Department of Surgery, Fundacion Hospitalaria Children’s Hospital of Buenos Aires, Buenos Aires, Argentina.
5Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.
6Department of Surgery, Phoenix Children’s Hospital, Phoenix, Arizona.
7Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
8Department of Surgery, Children’s Hospital of Los Angeles, Los Angeles, California.
9Department of Surgery, National Children’s Hospital, Washington, District of Columbia.
10Department of Surgery, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin.
11Department of Surgery, Riley Children’s Hospital, Indianapolis, Indiana.
12Department of Surgery, Loma Linda University Children’s Hospital, Loma Linda, California.
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 21, Number 7, 2011
ª Mary Ann Liebert, Inc.
as the standard approach for adrenalectomy for benign
lesions in adults. The published experience in children and
adolescents has been limited to sporadic small case series.
Therefore, we conducted a large multicenter review of chil-
dren who have undergone laparoscopic adrenalectomy.
aparoscopic adrenalectomy is now being recognized
After obtaining institutional review board approval, a ret-
rospective review was conducted on all patients who have
undergone laparoscopicadrenalectomy at12 institutions over
the past 10 years.
pathology, and outcomes were recorded. Pre- and postoper-
unilateral adrenalectomy without concomitant procedures.
Data are expressed as mean–standard deviation. Con-
two-tailed Student’s t-test. Discrete variables were analyzed
About 140 patients were identified of which 70 were males
(50%). Laterality included 76 (54.3%) left-sided lesions, 59
(42.1%) right, and 5 (3.6%) bilateral. Age, weight, lesion size,
and operative time are listed in Table 1. The mean operative
time for all cases including combination procedures and bi-
lateral adrenalectomy was 140.7–70 minutes (range 43–406
minutes). The meannumber ofports used was4.0(range3–6),
including an average of 3.8 for left-sided lesions, 4.1 for right-
sided lesions, and 5.4 for bilateral.
Most common pathology was neuroblastoma in 39 cases
(27.9%), of which 23 (59.0%) had undergone preoperative
chemotherapy. Display of pathology with mean lesion size
and conversion rates are listed in Table 2.
There were 13 conversions to an open operation (9.9%).
Most conversions were because of tumor adherence to sur-
rounding organs. There were no differences in patient or
tumor characteristics between the cases converted to open
and those completed laparoscopically (Table 3).
Abloodtransfusion wasutilized in 4cases, ofwhich 2 were
due to operative losses (1.4%) and the others appear have
been given empirically where 50 cc was given in 2 separate
cases with documented losses of 25 and 5mL. In the 2 cases
and 900mL prompting 300 and 600 cc transfusion in those
cases. The single case with large loss was because of left ad-
renal vein hemorrhage requiring conversion.
The only postoperative complication was renal infarction
after resection of a large neuroblastoma in an infant that re-
quired skeletonization of the renal vessels. At a median
follow-up of 18 months, there was only one local recurrence,
which was in a patient with a pheochromocytoma.
Based on size, there were 23 lesions >6cm. The mean op-
erative time was 172 minutes for the large lesions compared
with 123 minutes for those <6cm (P=.003). The conversion
rate was 17.4% for the larger lesion compared with 7.7% for
the smaller lesions (P=.23).
There have been multiple small case series of laparoscopic
adrenalectomy published in the pediatric literature, including
20 of the patients herein who were previously described in
single center series.1–4As is often the concern with advanced
techniques, a publication bias develops with a few surgeons
publishing results that may not translate to the practicing
community. This large multicenter series represents the ex-
perience approximately 50 surgeons to provide a generaliz-
able view of the contemporary experience in children. The
10% conversion rate in this series establishes a benchmark for
consulting families on likelihood of completing the operation
preparation is the confirmation of previous reports that the
risk for requiring a blood transfusion is low (<2%). Ad-
Table 1. Patient and Operative Details
Greatest tumor dimension (cm)
Operating time (minutes)
Table 2. Distribution of Pathology
Table 3. Comparison of Patient
Characteristics Between Converted Cases
and Those Completed Laparoscopically
Body mass index
648 ST. PETER ET AL.
ditionally, this series documents the full spectrum of pathol-
ogy that has been approached laparoscopically in children.
Several questions about laparoscopic adrenalectomy in
children have been posed by authors over the course of the
current published experience. The issues include the size limit
for the patients, the size limits for the adrenal mass, and the
role of laparoscopy for malignancy.
Some authors have suggestedthattherearenoage orweight
limits.5Our series confirms this suggestion as there were 7 pa-
old and 3.4 kg. In this case, a neuroblastoma tucked behind the
were no technical issues as the dissection proceeded without
overwhelming difficulty. This suggests that it is reasonable to
begin the operation laparoscopically if the surgeon is comfort-
able with this operation independent of patient size.
Another debate in the literature is maximum size of lesion
that should be approached laparoscopically. A 6cm limit was
initially posed in the adult literature based on risk of malig-
nancy.6This was subsequently challenged by several series
documenting laparoscopic resection of adrenal masses over
6cmwhen not limited by invasion.7–13Specificallycomparing
laparoscopic results with lesion over versus under 6cm in a
large adult series, operative times were comparable but the
conversion rate was higher with larger lesions. We found
significantly greater operative times with lesions >6cm, and
while the conversion rate was 10% higher with the larger le-
sions, this difference was not significant. Our series makes a
strong argument for approaching larger lesion lesions lapar-
oscopically when the lesion is otherwise circumscribed and
not infiltrating surrounding structures.
low rate of adrenocortical carcinoma.8When malignancy is
discovered, several authors have found that the risk of local
recurrence is also low.10–13In children, the concerns and rules
for malignancy are different. As opposed to the adult popula-
tion, the most common adrenal malignancy in children, neu-
roblastoma,is alsothe most
adrenalectomy. Neuroblastoma biologically differs from adult
lesions in its propensity to respond to chemotherapy by dis-
appearing ordifferentiating suchthatthe principlesof resection
do not follow standard oncologic principles. These lesions
should be resected to the extent feasible without injury to sur-
rounding organs, which makes it reasonable to approach some
of these laparoscopically, knowing resection to negative mar-
gins is not necessary. A separate question for neuroblastoma is
whether these can be approached laparoscopically after re-
sponse to chemotherapy. The concern is that tumor is often
initially infiltrating around multiple central vessels, making it
unresectable, which prompts the preoperative chemotherapy.
When the lesion has a dramatic response to become a single
suprarenal lesion, the surgeon does not know how much of the
former tumor will be scar, making it difficult to identify dis-
section planes. This series answers the question with an affir-
approached laparoscopically. There were 24 such cases per-
formed in this series with a conversion rate of 12.5%, which is
comparable to the entire series, and less than the 20% conver-
sion rate seen in the neuroblastomas approach before therapy.
The International Pediatric Endoscopic Group published
guidelines for the surgical treatment of adrenal masses in
children, stating that although there were no absolute con-
traindications, cases should be carefully selected.14Our data
suggest that lesions without involvement of surrounding
structures can be approached laparoscopically regardless of
the size of the lesion, size of patient, or suspected pathology.
No competing financial interests exist.
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Address correspondence to:
Shawn D. St. Peter, MD
Department of Surgery
Children’s Mercy Hospital
2401 Gillham Road
Kansas City, MO 64108
MULTICENTER LAPAROSCOPIC ADRENALECTOMY IN CHILDREN649
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