Annals of the Royal College of Surgeons of England (1979) vol 6i ASPECTS OF TREATMENT*
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma E A Benson FRCS Consultant Surgeon, The General Infirmary at Leeds
Technique of transabdominal bilateral A case is made for the more general adoption adrenalectomy of the transabdominal approach to the adrenal POSITION ON TABLE glands as this has obvious advantages over The patient lies prone and it is an advantage bilateral loin incisions. to have the kidney bridge (accurately posifioned) elevated 3-4 in (7.5-10 cm). Introduction Bilateral adrenalectomy is an accepted method INCISION of palliation in metastatic breast cancer and Bilateral subcostal incisions joined in the midproduces a remission in 3070 of patients",2. line give excellent access (Fig. i). The anOestrogen receptor analysis of metastatic terior rectus sheath and rectus muscles are tissue promises to improve this in OR-posi- cut (using either scalpel or diathermy) in the tive patients to 6O7o%'6. In these cases surgeons line of the skin incision, and the oblique may now feel more encouraged to advise muscles are split laterally for about 2 in adrenalectomy than in the past, when the (5 cm) on each side. Once the abdomen has chance of a response has been essentially a been opened the falciform ligament is dimatter of clinical judgment7. vided and the costal margin retracted with a The adrenals may be removed either Goligher sternal retractor (Fig. 2). In thin through bilateral loin incisions or transabdominally. Although recent series have been reported89, surprisingly little attention has been directed to comparing the relative merits of these two approaches. It is the purpose of this communication to describe the transabdominal method as I use it and to indicate its superiority over the loin approach.
Summary
-2N be/ow Costa imargin
2 Goligher sternal-lifting retractor. (Adapted from an illustration provided by FIG. I Incision for transabdominal bilateral the manufacturers, Bio-Med Engineering Ltd, Liversedge, Heckmondwike, W Yorks.) adrenalectomy. The Editor would welcome any observations on this paper from readers. FIG.
*Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma
-I.VC. -BILE DUCT
Porietol Peritoneum
FIG. 3 See text. patients with a narrow costal angle a long midline or paramedian incision may be preferred and also gives good access. REMOVAL OF RIGHT ADRENAL GLAND
This is technically the more difficult of the two adrenalectomies. The general disposition of the retractors is not unlike that for cholecystectomy. The gallbladder is mobilised as far as the junction of the cystic and common hepatic ducts, a pack is placed over it, and a Kelly's retractor put in to lift the liver towards the patient's right shoulder. The hepatic flexure of the colon and the duodenum are then dragged down with a large abdominal flat. The right kidney is readily palpated in the depths of the wound and the peritoneum above and medial to its superior pole is opened with curved scissors using an incision running more or less parallel to the
I1\
453 right-hand border of the inferior vena cava (IVC) (Fig. 3). The inferolateral border of the right adrenal usually comes into view and is readily recognised from its colour and outline. It invariably lies above the superior pole of the right kidney, which is then retracted firmly down. It is important not to divide the attachment of the right adrenal to the kidney too soon as otherwise the gland tends to slip upwards and access then becomes more difficult. The right lateral border of the gland is mobilised by diathermy and cutting with scissors and drawn gently to the right with a sponge-holding forceps. It is important to be gentle as the gland may be soft and if handled too roughly will break up, producing irritating venous oozing. At this stage a Shucksmith's retractor is placed over the IVC to retract it gently towards the midline (Fig. 4). The right adrenal may then be grasped between the finger and thumb of the left hand and pulled laterally in order to gain access to the right adrenal vein. The operator works between the right-hand edge of the IVC and the medial border of the adrenal gland until the short right adrenal vein is identified (Fig. 4). This is normally quite easy to find but is notoriously short and rather fragile. The vein is clipped and divided between Haemoclips. Safe in the knowledge that torrential venous bleeding will not occur, the operator may then remove the right adrenal gland by a process of diathermy and cutting. A plug of haemostatic gauze is usually left in the right adrenal bed. REMOVAL OF LEFT ADRENAL GLAND
The stomach is retracted to the right, the left costal margin firmly retracted, and the sur-
RETRACTOR AND LV
RADRENAL-Afo:
D
SHORT VEIN BE
CLIPPED R. KIDNEY-
PANCREAS
Nl~
EFT KIDNEY ADRENAL LlENO-RENAI
SPLEEN
FIG. 4 See text.
FIG-
5 See text.
454
E A Benson
moved through a separate short right lower paramedian, midline, or Pfannenstiel's incision. WOUND CLOSURE
The wound is closed in layers with chromic catgut, using deep tension sutures above the posterior rectus sheath; abdominal drains are not necessary. We have not found wound dehiscence a problem.
6 See text. geon's left hand inserted to draw the spleen gently towards the midline. The lienorenal ligament is divided with scissors well back on the kidney (Fig. 5) to reduce the risk of splenic damage. This ligament requires to be divided completely from the splenic flexure of the colon to the short gastric vessels at the oesophageal hiatus as this enables the spleen and tail of pancreas to be stripped forwards and retained under a gauze swab without tearing the splenic capsule. The left kidney is easily identified and a search should then be made in the fat on the medial aspect of its superior pole for the left adrenal gland (Fig. 6). Once identified it is an easy matter to define its boundaries by a combination of diathermy and dissection, and the gland may then be drawn up towards the operator from its bed by applying sponge-holding forceps. The left adrenal vein is considerably longer than the right and may be either ligated in continuity and divided or divided between Haemoclips. Again a plug of haemostatic gauze is used to occupy the left adrenal bed, and the spleen and pancreas are allowed to fall back over it. FIG.
BILATERAL OOPHORECTOMY If the ovaries are relatively easily accessible through the upper incision (and in our experience this is so in three-quarters of the cases) they are removed after clamping, dividing, and transfixing the ovarian pedicles with catgut. If not readily accessible the ovaries are re-
Advantages over the bilateral loin approach i) The abdominal viscera may be fully assessed for metastases and tissue removed for biopsy and also for oestrogen receptor analysis. 2) The patient is not turned-a risk in women with extensive spinal secondaries when the lumbar approach is used'0. 3) The anaesthetist (or surgeon) is not given the chance between sides to decide that the patient is too unfit for the operation to proceed! It is our contention that both adrenals should be removed at the one operation; we do not approve of staged adrenalectomy. To find that a woman with metastatic disease who has undergone unilateral adrenalectomy is then too unwell to undergo contralateral surgery is a serious iatrogenic mishap. 4) There is no need for rib resection with this method and no risk of transgressing the pleural space via the diaphragm. 5) Exposure of both adrenals is better and a safer approach, to the right adrenal vein in particular, is possible from the front. 6) Other conditions such as gallstones may be dealt with if deemed necessary. 7) The operation, on average, takes about Il h to perform and is not, therefore, appreciably more prolonged than the bilateral loin
approach. 8) The patient's postoperative progress is smoother and she is certainly easier to nurse. Postoperative pain is not a major feature with
this incision and the absence of drains (particularly possible chest drains) is appreciated. 9) Aird", while admitting that right adrenalectomy may be difficult from the front, also claims that total removal of all adrenal tissue is more easily assured from the front than from the loin approach. i o) Oophorectomy can often be accomplished through the same incision. A separate
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma
455
incision is required when the loin approach References is used. I Fracchia, A A, Randall, H T, and Farrow, J H (I967) Surgery, Gynecology and Obstetrics, 125, i I) The only possible contraindication to 747. the transabdominal approach is the presence M J, Byron, R L, Yonemoto, R H, of gross hepatomegaly and ascites, when 2 Silverstein, Riihimaki, D I, and Schuster, G (1975) Surgery, access to the adrenals may be difficult owing 77, 825. to the large liver and possibly also to peritoneal 3 Jensen, E V, Smith, S, Polley, T Z, Block, G E, and De Sombre, E R (I974) International conmetastases on the posterior abdominal wall. ference, Florence. It is, however, questionable whether adrenalectomy should even be contemplated in such 4 McGuire, W L (I975) Cancer, 36, 638. 5 Walt, A J, Singhakowinta, A, Brooks, S C, and cases. Cortez, A (0976) Surgery, 80, 5o6. I 2) The only argument in favour of the 6 Sharma, R K, and Criss, W E (1978) in Progress loin approach is that it avoids transgressing in Cancer Research and Therapy, vol. 9, p. I98. New York, Raven Press. the peritoneal cavity and, according to Dao10, is thus associated with 'a lower morbidity', 7 Leaper, D J (I976) British Journal of Surgery, 759. although this is not defined any more speci- 8 63, Pressman, P I (1976) Surgery, Gynecology and fically. The loin approach is also said to be Obstetrics, 142, 743. quicker, but this has certainly not been our 9 Dao, T L (1978) International Journal of Radiation Oncology-Biology-Physics, 4, 473. experience. io Aird, I, and Helman, P (I955) British Medical I am grateful to Mrs J Elwine for typing the manuscript and to Mr E Grayshon Lumby in the Department of Medical Illustration, Leeds University, for the illustrations.
ii
Journal, 2, 708. Aird, I (I957) A Companion in Surgical Studies, 2nd edn, p. I0o6. Edinburgh and London, Livingstone.
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma E A Benson FRCS Consultant Surgeon, The General Infirmary at Leeds
Technique of transabdominal bilateral A case is made for the more general adoption adrenalectomy of the transabdominal approach to the adrenal POSITION ON TABLE glands as this has obvious advantages over The patient lies prone and it is an advantage bilateral loin incisions. to have the kidney bridge (accurately posifioned) elevated 3-4 in (7.5-10 cm). Introduction Bilateral adrenalectomy is an accepted method INCISION of palliation in metastatic breast cancer and Bilateral subcostal incisions joined in the midproduces a remission in 3070 of patients",2. line give excellent access (Fig. i). The anOestrogen receptor analysis of metastatic terior rectus sheath and rectus muscles are tissue promises to improve this in OR-posi- cut (using either scalpel or diathermy) in the tive patients to 6O7o%'6. In these cases surgeons line of the skin incision, and the oblique may now feel more encouraged to advise muscles are split laterally for about 2 in adrenalectomy than in the past, when the (5 cm) on each side. Once the abdomen has chance of a response has been essentially a been opened the falciform ligament is dimatter of clinical judgment7. vided and the costal margin retracted with a The adrenals may be removed either Goligher sternal retractor (Fig. 2). In thin through bilateral loin incisions or transabdominally. Although recent series have been reported89, surprisingly little attention has been directed to comparing the relative merits of these two approaches. It is the purpose of this communication to describe the transabdominal method as I use it and to indicate its superiority over the loin approach.
Summary
-2N be/ow Costa imargin
2 Goligher sternal-lifting retractor. (Adapted from an illustration provided by FIG. I Incision for transabdominal bilateral the manufacturers, Bio-Med Engineering Ltd, Liversedge, Heckmondwike, W Yorks.) adrenalectomy. The Editor would welcome any observations on this paper from readers. FIG.
*Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma
-I.VC. -BILE DUCT
Porietol Peritoneum
FIG. 3 See text. patients with a narrow costal angle a long midline or paramedian incision may be preferred and also gives good access. REMOVAL OF RIGHT ADRENAL GLAND
This is technically the more difficult of the two adrenalectomies. The general disposition of the retractors is not unlike that for cholecystectomy. The gallbladder is mobilised as far as the junction of the cystic and common hepatic ducts, a pack is placed over it, and a Kelly's retractor put in to lift the liver towards the patient's right shoulder. The hepatic flexure of the colon and the duodenum are then dragged down with a large abdominal flat. The right kidney is readily palpated in the depths of the wound and the peritoneum above and medial to its superior pole is opened with curved scissors using an incision running more or less parallel to the
I1\
453 right-hand border of the inferior vena cava (IVC) (Fig. 3). The inferolateral border of the right adrenal usually comes into view and is readily recognised from its colour and outline. It invariably lies above the superior pole of the right kidney, which is then retracted firmly down. It is important not to divide the attachment of the right adrenal to the kidney too soon as otherwise the gland tends to slip upwards and access then becomes more difficult. The right lateral border of the gland is mobilised by diathermy and cutting with scissors and drawn gently to the right with a sponge-holding forceps. It is important to be gentle as the gland may be soft and if handled too roughly will break up, producing irritating venous oozing. At this stage a Shucksmith's retractor is placed over the IVC to retract it gently towards the midline (Fig. 4). The right adrenal may then be grasped between the finger and thumb of the left hand and pulled laterally in order to gain access to the right adrenal vein. The operator works between the right-hand edge of the IVC and the medial border of the adrenal gland until the short right adrenal vein is identified (Fig. 4). This is normally quite easy to find but is notoriously short and rather fragile. The vein is clipped and divided between Haemoclips. Safe in the knowledge that torrential venous bleeding will not occur, the operator may then remove the right adrenal gland by a process of diathermy and cutting. A plug of haemostatic gauze is usually left in the right adrenal bed. REMOVAL OF LEFT ADRENAL GLAND
The stomach is retracted to the right, the left costal margin firmly retracted, and the sur-
RETRACTOR AND LV
RADRENAL-Afo:
D
SHORT VEIN BE
CLIPPED R. KIDNEY-
PANCREAS
Nl~
EFT KIDNEY ADRENAL LlENO-RENAI
SPLEEN
FIG. 4 See text.
FIG-
5 See text.
454
E A Benson
moved through a separate short right lower paramedian, midline, or Pfannenstiel's incision. WOUND CLOSURE
The wound is closed in layers with chromic catgut, using deep tension sutures above the posterior rectus sheath; abdominal drains are not necessary. We have not found wound dehiscence a problem.
6 See text. geon's left hand inserted to draw the spleen gently towards the midline. The lienorenal ligament is divided with scissors well back on the kidney (Fig. 5) to reduce the risk of splenic damage. This ligament requires to be divided completely from the splenic flexure of the colon to the short gastric vessels at the oesophageal hiatus as this enables the spleen and tail of pancreas to be stripped forwards and retained under a gauze swab without tearing the splenic capsule. The left kidney is easily identified and a search should then be made in the fat on the medial aspect of its superior pole for the left adrenal gland (Fig. 6). Once identified it is an easy matter to define its boundaries by a combination of diathermy and dissection, and the gland may then be drawn up towards the operator from its bed by applying sponge-holding forceps. The left adrenal vein is considerably longer than the right and may be either ligated in continuity and divided or divided between Haemoclips. Again a plug of haemostatic gauze is used to occupy the left adrenal bed, and the spleen and pancreas are allowed to fall back over it. FIG.
BILATERAL OOPHORECTOMY If the ovaries are relatively easily accessible through the upper incision (and in our experience this is so in three-quarters of the cases) they are removed after clamping, dividing, and transfixing the ovarian pedicles with catgut. If not readily accessible the ovaries are re-
Advantages over the bilateral loin approach i) The abdominal viscera may be fully assessed for metastases and tissue removed for biopsy and also for oestrogen receptor analysis. 2) The patient is not turned-a risk in women with extensive spinal secondaries when the lumbar approach is used'0. 3) The anaesthetist (or surgeon) is not given the chance between sides to decide that the patient is too unfit for the operation to proceed! It is our contention that both adrenals should be removed at the one operation; we do not approve of staged adrenalectomy. To find that a woman with metastatic disease who has undergone unilateral adrenalectomy is then too unwell to undergo contralateral surgery is a serious iatrogenic mishap. 4) There is no need for rib resection with this method and no risk of transgressing the pleural space via the diaphragm. 5) Exposure of both adrenals is better and a safer approach, to the right adrenal vein in particular, is possible from the front. 6) Other conditions such as gallstones may be dealt with if deemed necessary. 7) The operation, on average, takes about Il h to perform and is not, therefore, appreciably more prolonged than the bilateral loin
approach. 8) The patient's postoperative progress is smoother and she is certainly easier to nurse. Postoperative pain is not a major feature with
this incision and the absence of drains (particularly possible chest drains) is appreciated. 9) Aird", while admitting that right adrenalectomy may be difficult from the front, also claims that total removal of all adrenal tissue is more easily assured from the front than from the loin approach. i o) Oophorectomy can often be accomplished through the same incision. A separate
Transabdominal bilateral adrenalectomy for metastatic breast carcinoma
455
incision is required when the loin approach References is used. I Fracchia, A A, Randall, H T, and Farrow, J H (I967) Surgery, Gynecology and Obstetrics, 125, i I) The only possible contraindication to 747. the transabdominal approach is the presence M J, Byron, R L, Yonemoto, R H, of gross hepatomegaly and ascites, when 2 Silverstein, Riihimaki, D I, and Schuster, G (1975) Surgery, access to the adrenals may be difficult owing 77, 825. to the large liver and possibly also to peritoneal 3 Jensen, E V, Smith, S, Polley, T Z, Block, G E, and De Sombre, E R (I974) International conmetastases on the posterior abdominal wall. ference, Florence. It is, however, questionable whether adrenalectomy should even be contemplated in such 4 McGuire, W L (I975) Cancer, 36, 638. 5 Walt, A J, Singhakowinta, A, Brooks, S C, and cases. Cortez, A (0976) Surgery, 80, 5o6. I 2) The only argument in favour of the 6 Sharma, R K, and Criss, W E (1978) in Progress loin approach is that it avoids transgressing in Cancer Research and Therapy, vol. 9, p. I98. New York, Raven Press. the peritoneal cavity and, according to Dao10, is thus associated with 'a lower morbidity', 7 Leaper, D J (I976) British Journal of Surgery, 759. although this is not defined any more speci- 8 63, Pressman, P I (1976) Surgery, Gynecology and fically. The loin approach is also said to be Obstetrics, 142, 743. quicker, but this has certainly not been our 9 Dao, T L (1978) International Journal of Radiation Oncology-Biology-Physics, 4, 473. experience. io Aird, I, and Helman, P (I955) British Medical I am grateful to Mrs J Elwine for typing the manuscript and to Mr E Grayshon Lumby in the Department of Medical Illustration, Leeds University, for the illustrations.
ii
Journal, 2, 708. Aird, I (I957) A Companion in Surgical Studies, 2nd edn, p. I0o6. Edinburgh and London, Livingstone.
