Sub-total Retroperitoneoscopic Adrenalectomy for a Conn’s Adenoma.
K. Elliott , M. Fazel, J. Todd1, K. Steer2, F. Palazzo
Imperial Centre for Endocrinology, Dept of Thyroid and Endocrine Surgery & Endocrinology1, Hammersmith Hospital and Dept Endocrinology Northwick Park Hospital2
Mrs WO, A 37 year old woman with a 5 year history of hypertension and hypokalaemia was diagnosed with Conn’s syndrome at a neighbouring hospital. She required 8 SandoK potassium supplements per day, Nifedipine, Labetolol and Spironolactone to control her blood pressure and maintain normokalaemia. She had an aldosterone-renin ratio of greater than 3000. An MRI scan failed to detect an adrenal lesion, however venous sampling provided evidence of predominant right-sided secretion of aldosterone (aldosterone-cortisol ratio: right 15.3 vs. left 1.8). Surgery was planned and a routine pre-operative adrenal protocol CT demonstrated a well demarcated 1cm nodule within the medial limb of the right adrenal gland consistent with a hypersecreting adenoma. The patient expressly requested that if possible not all the adrenal gland be removed. The patient underwent a right retroperitoneoscopic exploration that confirmed the radiological findings. A subtotal retroperitoneoscopic adrenalectomy was performed. Her post-operative progress was uncomplicated, pain was minimal and managed with simple analgesia, and she returned directly to the ward. The day following surgery her blood pressure remained stable and potassium was 3.3mmol/L; she was discharged home within 23 hours of her operation on no potassium supplements and Nifedipine alone. The histology revealed a well-circumscribed, benign adrenocortical adenoma, completely excised with a 14mm margin. Follow up in clinic 2 weeks later revealed good healing of the port sites, a stable blood pressure of 134/78 and a potassium of 4.3mmol/L.
Discussion: Retroperitoneoscopic adrenalectomy is an established alternative minimal access approach to laparoscopic adrenalectomy that is associated with a shorter operating time1 limited pain and early discharge. It also allows excellent visualization of the retro-caval adrenal gland permitting a partial or subtotal/cortex sparing adrenalectomy when required. The use of partial adrenalectomy in well localized, aldosterone-secreting adrenal tumours is well documented2,3 and appears not to be associated with any medium term adverse consequences when the diagnosis of an adenoma is unequivocal.