title: Thoracoscopic transdiaphragmatic adrenalectomy: the initial experience.
abstract: OBJECTIVE
  We introduce the technique of thoracoscopic transdiaphragmatic adrenalectomy.
  
  
  METHODS
  Initially in 4 human cadavers bilateral thoracoscopic nephrectomy was performed to develop the technique of diaphragmatic incision, retroperitoneal control of renal artery and vein, circumferential mobilization of the kidney and adrenal gland, and suture repair of the diaphragm. Subsequently, 3 select patients underwent thoracoscopic transdiaphragmatic adrenalectomy (2 right side and 1 left side). All 3 patients had significant prior abdominal scarring after either partial or total radical nephrectomy, thereby precluding efficient transabdominal laparoscopic access to the adrenal gland. After double lumen endotracheal intubation, a 4 port transthoracic approach without pneumo-insufflation was performed with the patient in the prone position. The diaphragm was incised under real-time laparoscopic ultrasound guidance. The adrenal gland was visualized high in the retroperitoneum, the vasculature controlled, and the specimen entrapped and extracted intact through a thoracic port site. The diaphragm was suture repaired with freehand laparoscopic suturing and intracorporeal knot tying. A chest tube was inserted in the initial 2 patients.
  
  
  RESULTS
  There were no intraoperative or postoperative complications. Operating time was 4.5, 6.5 and 2.5 hours, and blood loss was 150, 500 and 50 cc, respectively. Mean narcotic analgesic requirement was 27 mg. morphine sulfate equivalent. Hospital stay was 2 days for all 3 patients. Pathology revealed metastatic renal cell carcinoma in 2 patients and myelolipoma in 1.
  
  
  CONCLUSIONS
  In select patients with significant concomitant intraperitoneal and retroperitoneal scarring from prior major abdominal or renal surgery laparoscopic adrenalectomy can be safely performed with the transthoracic transdiaphragmatic approach. We present our initial experience.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: I S
authors.initials: IS
authors.lastname: Gill
authors.forename: A M
authors.initials: AM
authors.lastname: Meraney
authors.forename: J C
authors.initials: JC
authors.lastname: Thomas
authors.forename: G T
authors.initials: GT
authors.lastname: Sung
authors.forename: A C
authors.initials: AC
authors.lastname: Novick
authors.forename: I
authors.initials: I
authors.lastname: Lieberman
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000000981:diagnostic imaging / Q000556:secondary / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods*; D000328:Adult; D006801:Humans; D007442:Intubation, Intratracheal; D007680:Kidney Neoplasms / Q000473:pathology; D008297:Male; D008875:Middle Aged; D013536:Suture Techniques; D013906:Thoracoscopy; D014057:Tomography, X-Ray Computed