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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Welcome. Today, on the Med Cast we’re examining retroperitoneoscopic adrenalectomy. And my guest is Dr. Brenessa Lindeman. She’s an endocrine surgeon in surgical oncology at UAB Medicine. Dr. Lindeman, what an interesting topic in my research. This is really fascinating. Please explain a little bit about retroperitoneoscopic adrenalectomy, this approach. Tell us a little about it.

Brenessa Lindeman, MD (Guest): Absolutely. And thank you for having me today. I have to say that adrenalectomies are one of the most interesting operations that I do because there are a variety of different approaches but of those that I offer, that being an open approach to adrenalectomy, a laparoscopic transabdominal approach to adrenalectomy and this retroperitoneoscopic adrenalectomy. The retroperitoneal approach is by far my favorite for reasons that I will explain.

What it involves is the most direct approach to the adrenal glands possible that rather than trying to go across the abdominal cavity and move other organs out of the way to reach the adrenal gland that lives at the back of our abdominal space, just above the kidneys; we can actually approach it through the back in a more direct fashion and avoid all of the intraabdominal organs that exist.

Host: Dr. Lindeman thank you for that explanation. What is the evolution of it? Why was there a need? Tell us how those indications have evolved. As you said it’s the most direct route to the adrenal glands. How did this all come about?

Dr. Lindeman: Yes. So, when laparoscopic or a minimally invasive approach to surgery began in the early 1990s, it was recognized early on that adrenalectomy would be an operation that would greatly benefit from a minimally invasive approach. Because in order to reach the adrenal glands, way at the back of the abdomen; patients had to undergo very large incision which was associated with much morbidity and an extended recovery period.

And so, while many surgeons began investigating a transabdominal approach, interestingly, only about a year after the initial laparoscopic adrenalectomy was described; the first what was called endoscopic retroperitoneal adrenalectomy was described. Because for many patients, if they have had prior intraabdominal operations; it can be quite challenging to navigate the scar tissue that has formed or otherwise be able to access the adrenals using a transabdominal approach.

And another great indication for the retroperitoneoscopic approach is that the patient is placed in the prone position or in the face down position which allows easy access to both sides for patients that need to undergo a bilateral adrenalectomy within the same operative setting. With other approaches to adrenal surgery; the patient either has to have a very large open incision to access both adrenal glands or they would need to have one side completed and then the patient would have to be repositioned to the other side and basically an entirely separate operation begun in order to perform a bilateral adrenalectomy using a minimally invasive transabdominal approach.

Host: That is so interesting that you don’t have to transverse the peritoneal cavity or mobilize other surrounding organs including potential scar tissue. What an interesting approach. So, tell us about patient selection criteria and who is it indicated for. Can everybody have this or not so much?

Dr. Lindeman: Well there are certainly patients that are ideal candidates for this approach and others for whom it becomes quite challenging. The working space with the retroperitoneal approach is smaller when you compare it to the working space in the abdomen more generally. And so, we tend to consider patients with adrenal masses that are six centimeters or less in size. Sometimes we will approach adrenal masses that are a little larger than that in certain circumstances but that is typically the cut-off that is used.

Additionally, there are some facets of a patient’s body habitus that can make the approach more challenging. One study that I conducted with some fellow investigators examined the thickness of the patient’s back musculature and skin and subcutaneous tissue and if that distance was greater than 9 centimeters in size; then we identified that the operative time for those patients was significantly longer than when patients has less retroperitoneal subcutaneous tissue that was present.

And so, I try to use the imaging that patients have had preoperatively to very carefully select which patients would benefit most or be the ideal operative candidates for this approach.

Host: Then Doctor, what have trials comparing retroperitoneoscopic adrenalectomy with transabdominal laparoscopic adrenalectomy shown? When you are looking at the two techniques, how is the RP technique shown to be superior for the patient?

Dr. Lindeman: Yes, I’m glad you asked because there has been many studies that have compared the retroperitoneal adrenalectomy approach with the transabdominal laparoscopic approach and in all but one of these, the retroperitoneal approach was found to have superior outcomes to the transabdominal laparoscopic approach and in the most rigorous study that was conducted; a randomized single blind controlled trial; that one was published in 2014. It identified that the retroperitoneal approach to adrenalectomy was superior to the transabdominal laparoscopic approach in terms of operative time, blood loss, hospital lengths of stay, postoperative complications and it also found that patients that had the retroperitoneal adrenalectomy had a shorter time to taking food by mouth and also les postoperative pain.

Host: Doctor, as complex as this is, can it be an outpatient procedure?

Dr. Lindeman: Absolutely. And when I’m counseling my own patients, I often tell them that it’s similar to having a laparoscopic cholecystectomy. And I believe that my patients that have a retroperitoneoscopic adrenalectomy actually have even less pain than patients that have had their gallbladder removed. There are some patients that require adrenalectomy for hormonally active tumors that can cause severe alterations in their blood pressure that will necessitate a need for overnight observation.

But I will tell you that in my own practice, the majority of my patients that undergo a retroperitoneoscopic adrenalectomy go home the same day or if their underlying adrenal condition warrants that overnight observation; they all go home the following day.

Host: That’s amazing. So, speak about the learning curve and what other providers might find interesting about your surgical technique and what are some technical considerations you’d like them to know about?

Dr. Lindeman: Absolutely. One of the interesting facets of the retroperitoneal approach to adrenalectomy that has been described is that it has a little bit steeper learning curve for surgeons that intend to add this to their armamentarium than does the transabdominal laparoscopic approach. And that simply relates to the familiarity of the surgeon with the anatomy that they are seeing. When I am training residents and fellows to utilize this approach; I will often flip the CT scan upside down so that they are looking at it in the same view that they will have within the operating room.

So, it requires the surgeon to be a little bit mentally flexible in their ability to manipulate the images and the views that they are seeing in their mind as they are first learning. But it’s been shown that once the surgeon reaches somewhere over 25 to 30 operations being performed this way; that their operative times greatly decrease, and they can perform this safely independently.

So, there are a few centers that offer this approach across the United States. And I am fortunate to have trained in a very high volume retroperitoneoscopic adrenalectomy center and I feel very excited to be able to bring this approach to UAB and to the patients in Alabama and across the southeastern United States.

Host: So, where do you see it going from here Dr. Lindeman? Tell us about some promising new therapies. If you were to look forward to the next ten years in the field; what do you see happening and changing?

Dr. Lindeman: Yes. I think that we will see an even further advance in terms of the technology that we are able to use. Currently, this operation is performed with three small ports that is the only part that the patient sees in terms of what’s left over following the procedure. But I think that we will be able to really advance in two ways.

One is that some patients, a small percentage, about 5% or so, after this approach, will experience a temporary abdominal wall laxity meaning that the muscles of the abdominal flank or the side of the abdomen lose a little bit of tone after surgery for a period of a couple of months and then this goes back to normal. That is caused from irritation to one of the nerves that lives in the area in which the ports are placed. And we are finding that we will have an increasing ability to identify where that nerve is using imaging modalities in order to prevent that complication in advance.

And the second advance that I see coming forward is that as our technology in minimally invasive surgical techniques continues to be refined; we will see probably robotic surgical techniques that can utilize one slightly larger port than what is used currently today, that is able to introduce multiple arms and to be able to accomplish this operation with an even smaller incision length than what we can today.

Host: How interesting. So, as a wrap up Doctor, tell other physicians what you’d like them to know about retroperitoneoscopic adrenalectomy and when you feel it’s important that they refer to the specialists at UAB Medicine.

Dr. Lindeman: Thank you. I would tell all of the providers listening out there that all patients that have an adrenal mass that is identified greater than a centimeter in size should continue to undergo a functional hormonal workup and then I would tell them that if they identify a patient that has a functional adrenal mass or any adrenal mass that’s larger than four centimeters in size; that patient should be evaluated by a high volume adrenal surgeon. Because that individual is going to be best positioned to provide the comprehensive and multidisciplinary care that these patients benefit from and will have been shown in multiple studies to be associated with a lower rate of complications.

And so, I’m very excited to be able to offer this retroperitoneoscopic adrenalectomy technique through which, I am able to offer outpatient adrenalectomy in a large majority of cases and offer this approach wherein patients have less pain, can eat and drink sooner and experience a lower rate of complications than patients even with the very well tolerated transabdominal laparoscopic approach.

Host: Wow, what an interesting segment. Thank you so much Dr. Lindeman. You really put me to the challenge today and I appreciated it and it is I hope for other providers, as interesting as it was for me. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, head on over to our website at www.uabmedicine.org/physician. If you, as a provider, found this podcast as informative as I did, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library because there are quite a few. Until next time, this is Melanie Cole.