What are the operative steps for an adrenalectomy in an infant?

Operative Steps for Adrenalectomy in an Infant

Minimally invasive surgery (MIS) should be performed for adrenalectomy in infants when feasible, with the transperitoneal laparoscopic approach being the preferred method for most pediatric adrenal lesions. 1, 2, 3

Preoperative Considerations

Hormonal Evaluation

• Complete hormonal evaluation is mandatory before surgical intervention to prevent perioperative complications:
  • 1-mg overnight dexamethasone suppression test for cortisol excess
  • Plasma or 24-hour urinary metanephrines for pheochromocytoma
  • Aldosterone-to-renin ratio for primary aldosteronism in cases with hypertension or hypokalemia 4

Perioperative Glucocorticoid Management

• For infants with adrenal insufficiency or on exogenous glucocorticoids:
  • Continue regular doses of hydrocortisone until surgery
  • Administer IV hydrocortisone (2 mg/kg) at induction
  • Postoperatively, administer 2 mg/kg hydrocortisone every 4 hours IV/IM for major surgery
  • Consider hydrocortisone infusion if there is evidence of instability 1

Fasting Guidelines

• No infant with adrenal insufficiency should be fasted for more than 6 hours
• Check blood glucose hourly if pre-operative fasting exceeds 4 hours
• Continue glucose monitoring hourly after surgery until enteral intake is resumed 1

Surgical Technique

Patient Positioning

• Position the infant in lateral decubitus position with the affected side up for transperitoneal approach
• Secure the infant to the operating table with appropriate padding of pressure points
• Place a roll under the flank to increase the space between costal margin and iliac crest 2, 3

Port Placement

• For transperitoneal approach (most commonly used in 94.2% of pediatric cases):
  • Place 3-4 ports based on infant size
  • Primary camera port (5mm) at umbilicus or periumbilical location
  • Working ports (3-5mm) placed under direct vision
  • Additional port may be needed for retraction 2, 3, 5

Right Adrenalectomy Steps

1. Mobilize the right lobe of liver and retract it upward
2. Incise the peritoneal reflection along the inferior vena cava
3. Identify the right adrenal vein early and ligate with clips or vessel sealing device
4. Dissect the gland from surrounding structures (kidney, liver, diaphragm)
5. Carefully separate the gland from the inferior vena cava
6. Complete the dissection with meticulous hemostasis 6, 2, 3

Left Adrenalectomy Steps

1. Mobilize the splenic flexure of colon
2. Reflect the spleen and pancreatic tail medially
3. Identify the left adrenal vein draining into the renal vein and ligate
4. Dissect the gland from surrounding structures (kidney, spleen, pancreas)
5. Complete the dissection with careful attention to hemostasis 6, 2, 3

Specimen Retrieval

• Place the specimen in an endoscopic retrieval bag
• Extract through slightly enlarged port site
• For larger specimens, consider a small muscle-splitting incision 2, 3

Special Considerations

Size Limitations

• Tumor size is not necessarily a contraindication to laparoscopic approach in infants
• Studies report successful laparoscopic removal of adrenal masses up to 8cm in children 3
• Consider open approach for tumors >6cm with suspected malignancy 1, 4

Conversion Criteria

• Be prepared to convert to open procedure if:
  • Tumor adherence to surrounding organs is encountered
  • Adequate exposure cannot be maintained
  • Significant bleeding occurs
  • Malignancy with local invasion is discovered intraoperatively 2, 3

Partial Adrenalectomy

• Consider organ-sparing adrenalectomy for small, benign lesions
• Particularly important for bilateral adrenal disease to preserve adrenal function
• Can help avoid lifelong steroid replacement 7

Postoperative Management

• Monitor vital signs closely in the immediate postoperative period
• Check blood glucose hourly until enteral intake is resumed
• When enteral intake is established, administer double the normal dose of hydrocortisone for 48 hours for infants with adrenal insufficiency
• Reduce to standard hydrocortisone doses once stability is achieved 1
• For functional tumors, perform appropriate hormonal work-up to confirm resolution of hyperfunction 1

Outcomes and Follow-up

• Expected hospital stay: 2-5 days for uncomplicated cases
• Low risk of significant blood loss or complications (reported complication rate of 3.1% in pediatric cases)
• For benign lesions <4cm, no further follow-up imaging is required
• For malignant lesions, follow-up should be based on tumor-specific protocols 4, 2, 3