Laparoscopic single site adrenalectomy using a conventional laparoscope and instrumentation.

Abstract

We present a case of Laparoendoscopic Single Site Surgery (LESS) left adrenalectomy performed with a conventional laparoscope and instruments.
A 45-year-old male was diagnosed with hyperaldosteronism. Computed tomography detected a left adrenal nodule. Bilateral adrenal vein sampling was consistent with a left-sided source for hyperaldosteronism.
Total operative time for LESS left adrenalectomy was 120 minutes. The surgery was performed with conventional instruments, a standard 5-mm laparoscope, and a SILS port, with no additional incisions or trocars needed. No complications occurred, and the patient reported an uneventful recovery.
LESS adrenalectomy is a feasible procedure. Although articulating instruments and laparoscopes may offer advantages, LESS adrenalectomy can be done without these.

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Laparoscopic Single Site Adrenalectomy Using a
Conventional Laparoscope and Instrumentation
Modesto J Colon, MD, Patrick LeMasters, MD, Phillipa Newell, MD, Celia Divino, MD,
Kaare J. Weber, MD, Edward H. Chin, MD
ABSTRACT
Background and Objectives: We present a case of Lapa-
roendoscopic Single Site Surgery (LESS) left adrenalec-
tomy performed with a conventional laparoscope and
instruments.
Methods: A 45-year-old male was diagnosed with hyper-
aldosteronism. Computed tomography detected a left ad-
renal nodule. Bilateral adrenal vein sampling was consis-
tent with a left-sided source for hyperaldosteronism.
Results: Total operative time for LESS left adrenalectomy
was 120 minutes. The surgery was performed with con-
ventional instruments, a standard 5-mm laparoscope, and
a SILS port, with no additional incisions or trocars needed.
No complications occurred, and the patient reported an
uneventful recovery.
Conclusions: LESS adrenalectomy is a feasible proce-
dure. Although articulating instruments and laparoscopes
may offer advantages, LESS adrenalectomy can be done
without these.
Key Words: Laparoscopic adrenalectomy, Laparoendo-
scopic single site surgery (LESS), Single site surgery.
INTRODUCTION
In recent years, laparoendoscopic single site surgery
(LESS) has become an accepted advance in minimally
invasive surgery. This has stimulated the development of
roticulating instruments, multi-trocar ports, flexible lapa-
roscopes, and intracorporeal retractors, leading to the
perception that specialized equipment is necessary to per-
form LESS procedures, especially for more difficult oper-
ations. We present a case report of LESS adrenalectomy
performed with a conventional laparoscope and instru-
ments.
CASE REPORT
A 45-year-old man with diabetes mellitus and hyperten-
sion was diagnosed with hyperaldosteronism. Computed
tomography detected a small left adrenal nodule (Figure 1).
Bilateral adrenal vein sampling was consistent with a
left-sided source for hyperaldosteronism, and the patient
was referred for left adrenalectomy. The patient’s body
mass index (BMI) was 26kg/m2, and he had no prior
surgical history. He was considered an appropriate can-
didate for minimally invasive adrenalectomy, and specif-
ically LESS adrenalectomy.
Procedure
The patient was placed in a right lateral decubitus posi-
tion. A 2.5-cm vertical incision was made within the um-
bilical ring, through which a SILS (Covidien, Norwalk CT)
port was inserted. A standard 5-mm, 30-degree laparo-
scope was used throughout the procedure in addition to
standard 5-mm instruments. Visualization of the left upper
quadrant from the umbilical location was adequate. Posi-
tioning in a steep reverse Trendelenburg and full lateral
tilt was essential to provide exposure and retraction of the
left colon and small bowel.
A Harmonic scalpel was used to mobilize the splenic
flexure, splenic attachments, and the pancreatic tail. The
left renal vein was exposed, followed by dissection of the
adrenal vein (Figure 2). The vein was secured using
locking, polymer clips, and then divided. Once the adre-
nal gland was completely separated from the upper pole
of the kidney and retroperitoneum, it was removed within
Department of Surgery, Mount Sinai School of Medicine, New York, New York,
USA (all authors).
Modesto J. Colon attests to full access of all information in the study and takes
responsibility for the integrity of the data.
Address correspondence to: Edward H. Chin, MD, FACS, Assistant Professor of
Surgery, The Mount Sinai School of Medicine, 5 E. 98th St, Box 1259, New York,
New York 10029, USA. Telephone: (212) 241-2115, Fax: (212) 241-5979, E-mail:
Edward.chin@mountsinai.org
DOI: 10.4293/108680811X13071180407195
© 2011 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2011)15:236–238
236
CASE REPORT

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a specimen retrieval bag. Total surgery time was 120
minutes. The patient had an uneventful postoperative
course, and was well recovered several weeks later.
DISCUSSION
Laparoscopic adrenalectomy was first described in 1992
by Gagner et al1and has become the preferred treatment
option for benign adrenal disorders.2,3Significant benefits
have been demonstrated for decreased morbidity, length
of stay, and recovery compared with open adrenalec-
tomy.3–6
Since the introduction of LESS, increasingly difficult pro-
cedures are being performed by single-incision laparos-
copy. After gaining substantial experience with LESS ap-
pendectomy, cholecystectomy, and splenectomy, we
embarked on LESS left adrenalectomy. Our prior success
with LESS splenectomy, which involves an identical op-
erative field, technical steps, and exposure, made LESS left
adrenalectomy seem feasible. An umbilical location for
the laparoscope is quite different from the location used in
standard laparoscopic adrenalectomy. While the view is
improved by a subcostal location for the laparoscope, the
umbilical view is still adequate for adrenalectomy. A su-
praumbilical placement of the SILS port would improve
upon the angle of view, but certainly compromise the
ultimate cosmetic outcome. Because our patient was quite
short in stature at 5?3”, this was not an issue, but for taller
patients, the umbilical view may not be adequate.
Cindolo et al7reported their initial experience with single-
port laparoscopic adrenalectomy, which required an ad-
ditional port for retraction, and was performed using ar-
ticulatinginstruments. In
Trendelenburg positioning and full lateral tilt were essen-
tial to keep the left colon and bowel out of the field.
Patients with significant obesity may require an additional
port to retract the viscera, but we did not require one.
our case, steepreverse
LESS adrenalectomy was also reported by Jeong et al8who
used articulating instruments, a flexible laparoscope, and
a multi-trocar port. This specialized equipment is not
accessible to many surgeons, and we sought a technique
where additional instrumentation was kept to a minimum
compared to instrumentation used with conventional
laparoscopic adrenalectomy.5
Our operative time was comparable to published results
of LESS adrenalectomy, suggesting that the absence of
articulating instruments and laparoscopes was not a sig-
nificant disadvantage. Our operative time also compares
favorably to that in large series of conventional laparo-
scopic adrenalectomy.5
An additional port would likely be required for liver retrac-
tion during LESS right adrenalectomy.7Intracorporeal retrac-
tors are now in development and likely will eliminate the
need for an additional port to provide liver retraction.
CONCLUSION
LESS adrenalectomy can be performed without articulat-
ing instruments or flexible laparoscopes.
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Figure 1. Adrenal mass.
Figure 2. Exposure of adrenal and renal veins.
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