Act as Urológicas Españolas.

2011;35(2):119–122
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CASUISTRY

Partial laparoscopic adrenalectomy in primary

hyperaldosteronism
O.A. Castilloa,b,c, *, M. Díaza, L. Arellanoc

a
Depart ament o de Urología, Clínica Indisa, Sant iago, Chile
b
Facult ad de Medicina, Universidad Andrés Bello, Sant iago, Chile
c
Facult ad de Medicina, Universidad de Chile, Sant iago, Chile

Received November 12, 2010; accept ed November 23, 2010

KEYWORDS Abstract
Hyperaldost eronism; Int roduct ion: Primary hyperaldost eronism is one of t he few pot ent ially curable causes
Conn’s Syndrome; of secondary art erial hypert ension. One of t he most import ant variant s is t he adenoma of
Laparoscopy; t he adrenal cort ex t hat produces aldost erona (Conn’s Syndrome). The t reat ment
Part ial Adrenalect omy of choice in t his subgroup of pat ient s was t he removal of t he lesion. A first series of
aldost eronoma-carrying pat ient s subj ect ed t o part ial laparoscopic adrenalect omy is
present ed.
Mat erials and met hod: We examined t he case select ion and met hods applied t o
hypert ensive pat ient s subj ect ed t o part ial laparoscopic adrenalect omy bet ween
November 2001 and March 2004 due t o primary hyperaldost eronism. They all present ed
an imaging st udy (CT scan) compat ible wit h a t umour of t he adrenal cort ex; in t wo
pat ient s t he lesion was bilat eral. One pat ient had a hist ory of incident al adrenalect omy
during an open colecist ect omy performed some years previously.
Result s: We operat ed on 16 pat ient s, 13 of t hem women and 3 men, wit h a mean age of
55.4 years. We performed 18 laparoscopic adrenalect omies: 17 conservat ive operat ions
and one t ot al adrenalect omy of a 4.3 cm t umour in a pat ient wit h bilat eral lesion. The
mean durat ion of t he operat ions was 70.9 minut es, wit h a mean bleeding rat e of 30 ml.
There were no complicat ions or t he need t o resort t o open surgery. Post operat ive hospit al
st ay was 2.8 days. In all t he cases, t he hypert ension improved t ot ally or part ially.
Concl usi on: Alt hough small, t he series conf irmed t hat part ial laparoscopic
suprarenalect omy can be performed wit h good result s and wit h t he advant ages of
minimally invasive surgery.
© 2010 AEU. Published by Elsevier España, S.L. All right s reserved.

*Corresponding aut hor.

E-mail: oct avio.cast illo@indisa.cl (O.A. Cast illo).

0210-4806/ $ - see front mat t er © 2010 AEU. Published by Elsevier España, S.L. All right s reserved.
120 O.A. Cast illo et al

Adrenalectomía parcial laparoscópica en hiperaldosteronismo primario

PALABRAS CLAVE
Hiperaldost eronismo; Resumen
Síndrome de Conn; Int roducción: El hiperaldost eronismo primario es una de las pocas causas pot encialment e
Laparoscopía; curables de hipert ensión art erial secundaria. Una de las variant es más import ant es la
Adrenalect omía parcial const it uye el adenoma de la cort eza suprarrenal product or de aldost erona (Síndrome de
Conn). El t rat amient o de elección en est e subgrupo de pacient es es la ext irpación de la
lesión. Se present a una serie inicial de pacient es port adores de aldost eronoma somet i-
dos a adrenalect omía parcial por vía laparoscópica.
Mat erial y mét odo: Se revisó la casuíst ica de pacient es hipert ensos somet idos a adre-
nalect omía parcial laparoscópica ent re noviembre del 2001 y marzo del 2004, debido a
hiperaldost eronismo primario. Todos present aron est udio de imagen (t omografía com-
put ada) compat ible con t umor de la cort eza suprarrenal, y en 2 pacient es la lesión fue
bilat eral. Un pacient e t enía ant ecedent e de adrenalect omía incident al durant e colecis-
t ect omía abiert a efect uada años ant es.
Result ados: Se operaron 16 pacient es, 13 muj eres y 3 hombres, con una edad media de
55,4 años. Se efect uaron 18 adrenalect omías laparoscópicas: 17 cirugías conservadoras
y una adrenalect omía t ot al en un t umor de 4,3 cm en una pacient e con lesión bilat eral.
El t iempo operat orio medio fue 70,9 minut os, con un sangrado promedio de 30 ml. No
hubo complicaciones ni necesidad de conversión a cirugía abiert a. La est ancia hospit a-
laria post operat oria fue 2,8 días. En t odos los casos hubo mej oría t ot al o parcial de la
hipert ensión.
Conclusión: La serie, aunque pequeña, confirma que la suprarrenalect omía parcial por
vía laparoscópica es reproducible, con buenos result ados y con los beneficios de la ciru-
gía mínimament e invasiva.
© 2010 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.

Introduction
Primary hyperaldost eronism is one of t he few pot ent ially
curable causes of art erial hypert ension. 1-4 According t o
t radit ional lit erat ure, t his condit ion causes hypert ension in
1%of diagnosed pat ient s; however, recent st udies have shown
t hat a direct ed invest igat ion may est ablish t he diagnosis of
hyperaldost eronism in up t o 10%of hypert ensive pat ient s. 2 In
t his subgroup of pat ient s, it is est imat ed t hat bet ween 20%-
30%correspond t o idiopat hic hyperaldost eronism, frequent ly
classified as primary hypert ension. The rest , i.e., close t o
70% are carriers of hyperaldost eronism associat ed wit h t he
presence of a funct ioning nodule of t he suprarenal cort ex
(aldost eronoma), described by Conn in 1955.
The t reat ment of choice in t hese pat ient s is resect ion of
t he lesion, which in t he maj orit y of t hem, is t he definit ive

Table 1 Characteristics of the patients

Case Age Sex Side Operat ion Surgical Time (hours) Hospit al St ay (days) Bleeding (ml) Size (cm)

1 66 M Left Tumourect omy 120 10 50 1.5

2 59 F Right Excission 70 2 20 4.3
Left Tumourect omy 25 2 0 2.3
3 44 F Left Tumourect omy 75 1 10 2
4 49 F Right Tumourect omy 70 1 100 2.2
5 53 F Right Tumourect omy 50 2 50 2.2
6 63 M Right Tumourect omy 60 3 50 4
Left Tumourect omy 75 3 0 6
7 70 F Left Tumourect omy 120 2 50 1.8
8 44 F Left Tumourect omy 60 2 0 1.2
9 51 F Right Tumourect omy 55 3 0 2
10 40 F Right Tumourect omy 45 2 0 3.7
11 52 F Left Tumourect omy 40 2 0 1.2
12 46 F Left Tumourect omy 60 2 100 3
13 33 F Left Tumourect omy 60 1 0 2
14 44 F Right Tumourect omy 90 4 20 3
15 54 F Right Tumourect omy 60 3 30 2
16 67 F Right Tumourect omy 50 2 0 1.4
M: male, F: female.
Part ial laparoscopic adrenalect omy in primary hyperaldost eronism
t reat ment of t heir hypert ension. The exist ence of a
malignant lesion in t hese cases is ext remely rare, so much
so t hat surgery may be aimed at resect ioning only t he lesion
and conserving t he healt hy gland. This is also t he case in
bilat eral pheochromocyt omas or in t he cont ext of genet ic
anomalies (Von Hippel-Lindau disease, Mult iple Endocrine
Neoplasia t ype 2). 1 In t he last few years, laparoscopy has
become t he choice in suprarenal gland surgery, proving t o
be safe, efficacious and reproducible wit h very sat isfact ory
post operat ive evolut ion. 5 We present an init ial experience
of laparoscopic part ial adrenalect omy in Conn’s syndrome.
Materials and method
Bet ween June 1993 and August 2010, we performed
316 laparoscopic adrenalect omies at our cent re.
Sixt een biochemically-confirmed pat ient s wit h primary
hyperaldost eronism were select ed f or conservat ive
surgery. In all of t hem, t he CAT scan clearly showed a
well-delimit ed suprarenal gland. Two pat ient s present ed
bilat eral lesions and anot her had a hist ory of an incident al
right adrenalect omy, performed several years before in
t he course of an open cholecyst ect omy. The hist ological
st udy of t he adrenal lesion in t his pat ient showed a 10 cm
haemorrhagic pseudocyst . We have already described t he
surgical t echnique employed for laparoscopic access t o t he
suprarenal gland. 5
Briefly, it consist s of t he use of general anaest het ic,
wit h nasogast ric cat het er and uret hrovesical cat het er,
placed aft er inducing anaest hesia and removing t hem
in t he recovery room. We posit ioned t he pat ient in full
lat eral decubit us and init iat ed pneumoperit oneum using a
Veress needle in t he subcost al posit ion, put t ing t he t rocars
in place. We dissect ed t he suprarenal gland, ident ifying
t he gland and wit hout clipping t he vein. The parenchymal
sect ion can be performed wit h an ult rasonic scalpel
(Ult rasicion ®, Et hicon-Endosurgery) or also by monopolar
or bipolar coagulat ion. We ext ract ed t he t umour using a
polyet hylene bag t hrough one of t he incisions.
Results
We operat ed 16 pat ient s, 13 women and 3 men, wit h
a mean age of 55.4 (range 44-70) years. In t ot al, we
performed sevent een part ial adrenalect omies and one t ot al
adrenalect omy. We performed t he t ot al adrenalect omy
in a pat ient wit h bilat eral lesion, on whom we performed
conservat ive surgery of a 2.3 cm left lesion and right t ot al
adrenalect omy of a 4.4 cm lesion. The mean durat ion of
t he surgical procedure was 70.9 min. per operat ion (range
25-120), wit h a mean bleeding rat e of 30 (range 0-100) ml.
The mean hospit al st ay was 2.8 (range 1-10) days (t able 1).
The mean size of t he 17 suprarenal lesions on which
conservat ive surgery was performed was 2.9 cm, wit h a
range of 1.2 cm t o 4 cm diamet er t he largest , measured
in t he anat omopat hological st udy. There was no conversion
t o open surgery nor int ra or post operat ive complicat ions.
There was no mort alit y in t he series. There was no clinical
evidence of adrenal insufficiency and in all t he pat ient s
121
wit h bilat eral surgery, t he post operat ive st udy wit h cort isol
measurement conf irmed t he presence of f unct ioning
adrenal cort ical t issue. As regards t he hypert ension, 14
of 16 pat ient s (87.5%) fully recovered and t he remaining
t wo significant ly reduced t heir need for hypert ension
medicat ion.
Discussion
The part ial adrenalect omy is described principally for cases
of bilat eral pheochromocyt oma or associat ed wit h Von
Hippel-Lindau disease, in which case full resect ion result s
in adrenal insufficiency wit h all t he inconveniences t hat
t his ent ails. 6 Access difficult ies wit h t radit ional surgical
t echniques and t he handling of a fragile and bleeding
organ make conservat ive surgery part icularly complex. The
laparoscopic t echnique offers very good exposure of t he
gland, wit h minimum manipulat ion and excellent visibilit y. 5-8
Because it is a lesion of t he cort ex, aldost eronoma is
generally peripheral and t his has cert ain advant ages over
pheochromocyt oma, which is more cent ral, making it more
accessible and easier t o resect ion wit h t his t echnique. 5
In our series, we used t he t ransperit oneal t echnique in
all t he cases. Some series of part ial adrenalect omies
due t o aldost eronoma have been performed by means of
ret roperit oneal laparoscopy wit h good result s, alt hough
t his case st udy is limit ed. 10, 11
It is import ant t hat t he inst rument used for t he dissect ion
does not damage t he t issue surrounding t he t umour t o
guarant ee t he vit alit y of t he remaining parenchyma.
The t echnique was init ially described wit h bipolar and
fibrin coagulat ion, closing t he defect wit h sut ures. It can
also be performed wit h mechanical sut ures (Endo-GIA),
however less precisely. 5,8 In our experience, sect ioning wit h
monopolar coagulat ion scissors or hook is equally effect ive,
alt hough t he ult rasonic scalpel offers t he advant age of a
cleaner surgical field.
The cont rol of t he post -surgical cort ical endocrine
funct ion wit h gammagraphy wit h marked aldost erol and
wit h cort isol drugs prior t o st imulat ion wit h ACTH5,11,12 has
been described. None of our pat ient s clinically developed
adrenal insufficiency. The cont rol was performed wit h AM
and PM cort isol measurement , which was normal, t herefore
no addit ional t est s were carried out .
The experience arising from our series is quit e limit ed,
however, it reaffirms laparoscopy as t he approach of choice
in surgery of t he adrenal gland, also wit h t his indicat ion.
Conlict of interest
The aut hors declare not t o have any conflict of int erest .
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