The Awful Truth

Adrenalectomy through the Nurse's Eye

			Perioperative care of the laparoscopic adrenalectomy patient  OR Nurse 2013, November 2010 Expires: 12/31/2013

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Perioperative care of the laparoscopic adrenalectomy patient

Jennifer Dziuba-Pallotta BSN, RN, CNOR Vivian Akontoh-Kufour RN, CNOR Ravi Munver MD, FACS OR Nurse 2013 November 2010   Volume 4  Number 6  Pages 22 - 29

Laparoscopic adrenalectomy is the standard of care for removal of the adrenal gland. The advantages of a laparoscopic approach include decreased postoperative pain, shorter hospital stay, and improved cosmetic results. The perioperative nurse plays an integral role in the preoperative, intraoperative, and postoperative phases of surgery, and is crucial in facilitating positive patient outcomes. Figure. No caption available. Case study A healthy 37-year-old woman sought medical attention from her primary care provider for a chief complaint of frequent headaches. After a medical examination, she was diagnosed with hypertension and was prescribed oral antihypertensive medication. Four months later, the hypertension persisted and was poorly controlled despite multiple oral medications. Serum lab results revealed hypokalemia. The patient underwent a computed topography (CT) scan of the abdomen and pelvis, which revealed a 3-cm right adrenal mass. Further serum and urine chemistries confirmed the adrenal mass was a functional aldosterone-producing adrenal adenoma. The patient was referred to a urologist with expertise in laparoscopic surgery and scheduled to undergo a right laparoscopic adrenalectomy to treat her hypertension and hypokalemia. Introduction The adrenal glands are small retroperitoneal organs that are an integral component of the endocrine system. These organs secrete hormones essential for the body to regulate electrolytes, manage fluid balance, maintain normal BP, as well as help control the body's response to stress. They also play an important role in sexual development. There are several types of tumors that affect the function of the adrenal glands. Since the initial report on the laparoscopic approach for adrenalectomy in 1992, laparoscopic adrenalectomy has gradually become the standard of care for most conditions requiring surgical removal of the adrenal gland.1 Review of anatomy and physiology The adrenal glands are retroperitoneal organs located at the superior aspect of the kidneys bilaterally. The adrenal glands receive their blood supply from branches of the inferior phrenic artery, renal artery, and the aorta (see Location of the adrenal glands). Each adrenal gland consists of two independently functioning components, the adrenal medulla and the adrenal cortex. The adrenal medulla is located in the center of the gland and secretes catecholamines (epinephrine and norepinephrine). The adrenal cortex surrounds the medulla and is responsible for producing mineralocorticoids, glucocorticoids, and adrenal androgen hormones. The products secreted by the adrenal glands are influenced by pituitary gland activity. Indications for surgery Laparoscopic adrenalectomy is indicated for hypersecretory benign adrenal tumors or selected primary malignant adrenal tumors. Although the exact size of a nonsecreting adrenal tumor prompting surgical intervention remains controversial, most authorities agree that lesions greater than 4 to 5 cm should be removed due to the increased likelihood of malignancy. Smaller lesions are more often benign and can be followed radiographically.2 Functional adrenal adenomas that secrete hormones such as aldosterone and cortisol are among the most common indications for surgical excision of the adrenal gland. These benign tumors are considered optimal for laparoscopic excision due to their location and small size. Aldosteronomas secrete aldosterone and are characterized by severe-to-moderate hypertension as well as hypokalemia.3 The hypertension resulting from this tumor may not respond to medical intervention and therefore often requires surgical removal. Figure. Location of the adrenal glands A cortisol-producing adenoma is responsible for 30% of all Cushing syndrome cases. The majority of these tumors are benign; however, 15% are found to be malignant. Another adrenal tumor, pheochromocytoma, is a rare catecholamine-secreting tumor, which is benign in 90% of cases.4Due to the excessive amount of epinephrine and norepinephrine these tumors secrete, these patients are at higher risk for intraoperative cardiovascular complications such as severe hypertension and dysrhythmias. When surgically removing a pheochromocytoma, early ligation of the adrenal vein is crucial to prevent a sudden increase in BP due to manipulation of the adrenal gland.5 Although pathologic evaluation is the standard for establishing a definitive diagnosis, radiographic imaging is essential in the evaluation of an adrenal mass. CT scans with and without intravenous contrast are vital in assessing adrenal lesions. Magnetic resonance imaging scans are also commonly obtained in the evaluation of adrenal masses. This imaging study can provide additional information such as identifying adipose tissue within lesions and improve the identification of invasion into surrounding structures.2 Laparoscopy vs. open surgery There are several advantages to the laparoscopic approach as compared to open surgery. The traditional open adrenalectomy requires a large flank or subcostal incision to obtain adequate exposure of the adrenal glands. A large surgical incision increases the risk of wound infection, results in significant postoperative pain, and prolongs recovery time.1The increased pain experienced with this type of incision may result in decreased mobility and impaired respiratory effort during the crucial postoperative period, leading to a higher risk of pneumonia as well as deep vein thrombosis. There's also a potential for increased blood loss with the open technique. Laparoscopic adrenalectomy is performed through several small keyhole size incisions (5 to 12 mm), and offers benefits of decreased postoperative pain, shorter hospital stay, quicker recovery time, and improved cosmetic results.1 In addition, because the adrenal vessels are dissected under high magnification on a high-definition (HD) screen, there's the potential for minimizing blood loss. Studies have also shown that the laparoscopic approach is associated with a significantly lower overall complication rate as compared to the open procedure.1 Preoperative nursing care A complete history and physical examination is mandatory in the evaluation of a patient with an adrenal mass. A complete endocrinologic evaluation should include measurement of serum electrolytes, serum hormone levels, and urine levels of steroid hormones and their metabolites. The particular diagnostic blood work ordered by the physician will depend on the observed clinical signs and symptoms as well as the patient's history and physical examination.2 When the patient arrives at the hospital on the day of surgery, the nurse should perform an initial preoperative assessment as per the institutional policy. A large-bore intravenous line should be inserted and electrolyte imbalances such as hypokalemia should be corrected preoperatively.3 At a minimum, the patient should be typed and screened because of the potential for blood loss during surgery. Bowel preparation isn't mandatory for the procedure; however, it can be helpful to decompress the bowel to facilitate the laparoscopic approach.1 Consent for the procedure must be signed and witnessed. The surgical site must be verified with the patient and clearly marked with a surgical marker by the attending surgeon before the patient is transported to the OR. This is a crucial step to ensure that during the intraoperative "time-out," the entire surgical team visualizes the site marked on the skin and agrees that the correct side has been selected.6 As with any surgical procedure, the RN should educate the patient as to what to expect during the intraoperative and postoperative phases. This discussion should include intravenous lines, arterial lines, sequential compression devices, an indwelling urinary drainage catheter, and other relevant issues. The RN should provide reassurance to the patient, encourage questions, and remain with the patient during the induction of anesthesia. Before the patient is brought to the OR, adequate positioning supplies need to be available and prepared including pillows, axillary roll, arm support device, padding materials, gel pad, and surgical tape (seeEssential supplies and equipment for laparoscopic adrenalectomy). Specialty equipment such as a laparoscopy insufflator, video tower, and appropriate thermal energy generators should be pretested. An experienced perioperative nurse knows that any laparoscopic procedure has the potential for elective or emergent open conversion due to bleeding, unanticipated organ injury, or failure to progress as in the case of excessive intra-abdominal adhesions. Appropriate instrumentation and supplies necessary for laparotomy should be readily available in the room, but may be kept unopened and uncounted unless their use is required. Upon arrival to the OR, the circulating nurse will interview and identify the patient. At least two patient identifiers are used, and may include: medical record number, name, and date of birth.6 The informed consent should include the surgical procedure, correct side, correct site, date, surgeon signature, patient signature, and witness signature. Because anatomically there is a right and a left adrenal gland, it's imperative for the patient to confirm the correct laterality (right or left side) of the diseased gland. As per The Joint Commission, the operative site needs to be marked while the patient is awake and alert, and before sedative medication is administered.6 A thorough preoperative nursing assessment should include N.P.O. status, allergies, medical history, previous surgery, metal implants or jewelry, loose or removable teeth, and the presence of contact lenses. After the patient is secured to the OR table with a safety belt, antithrombotic stockings and knee- or thigh-high sequential compression devices are placed on the lower extremities, to prevent venous stasis and reduce the risk of deep vein thrombosis and pulmonary embolism.7Prophylactic I.V. antibiotics should be administered within 60 minutes of the initial skin incision.8 After the induction of general anesthesia, the patient is endotracheally intubated and an orogastric tube is placed to decompress the stomach. An arterial pressure line may be established for hemodynamic monitoring. An indwelling urinary drainage catheter is inserted by either the circulating nurse or surgeon to decompress the bladder. The anesthesia provider avoids administering nitrous oxide to prevent bowel distension, which may limit exposure of the adrenal gland.9 Intraoperative nursing care For the perioperative nurse, proper positioning is one of the key responsibilities to protect the safety and skin integrity of the patient under anesthesia. The patient is placed on a beanbag or the surgeon might prefer large gel rolls placed behind the patient's back to help support the patient in the lateral decubitus position. To maintain proper alignment and stability during positioning, the patient must be moved by at least four team members. A gel pad is placed on the beanbag to help relieve pressure from the dependent hip and torso. The patient is placed in a modified lateral decubitus position with the affected side elevated 45 degree to 60 degree over the kidney rest portion of the operating table. The table may be gently flexed to increase the area between the iliac crest and costal margin.3 Pillows are placed between the legs and the dependant leg is flexed at the hip and knee for stabilization and alignment. The opposite leg is placed straight. The dependent leg should be well padded to prevent pressure on the common peroneal nerve. The dependent arm is placed on a well-padded arm board and secured with 3-inch cloth tape. The opposite arm is placed on a padded arm support device above the head or on several folded blankets or pillows, which is then secured to the OR table. The arms should never be abducted more than 90 degrees to prevent brachial plexus nerve injury.10 An axillary roll is placed 2 to 3 finger breadths below the dependant axilla to relieve pressure from the brachial plexus and facilitate adequate chest expansion. The ankles, knees, dependant hip, and shoulders need to be adequately padded to avoid neuromuscular damage. The patient is secured to the table with the safety strap, which may be reinforced with 3-inch tape over the hips and across the shoulders (see Positioning for right laparoscopic adrenalectomy). After positioning, the patient should be assessed for proper spinal alignment, tissue perfusion, and skin integrity. Also, pressure points on the dependent side, especially the ear, acromion process, iliac crest, greater trochanter, lateral knee, and malleolus, should be well padded to reduce risk of injury.11 The patient will also be placed on a lower or upper body warming device. After the patient is draped and just before the surgical incision is made, any member of the surgical team may initiate the time-out. This procedure requires the entire perioperative team to verify: * Correct patient identity Figure. Trocar placement for right laparoscopic adrenalectomy * Correct side and site markings * Correct patient position * Accurate procedure consent form * Relevant images and results are properly displayed or available * Antibiotic administration * Safety precautions based on patient history or medication.7 After the time-out has been verified and the entire surgical team verifies the mark indicating the correct side and site, surgery may proceed. A Veress needle is commonly used to insufflate the peritoneum. Generally, two or three 5 mm x 100 mm trocars and one 12 mm x 100 mm trocar are sufficient for performing laparoscopic adrenalectomy (see Trocar placement for right laparoscopic adrenalectomy). The first port is inserted at the umbilicus to accommodate the camera. Additional ports are placed at least 8 to 10 cm apart so that the surgeon's freedom of movement and operating space aren't restricted. With the laparoscopic approach, it's more difficult to dissect the adrenal gland because the surgeon doesn't have the ability to palpate the gland as in open surgery. Therefore, intraoperative ultrasonography can be used to aid in identifying the adrenal gland as necessary. The surgeon may utilize an atraumatic grasper, laparoscopic kittner, or suction irrigator in the nondominant hand and a dissecting instrument in the dominant hand. (See Common instrumentation for laparoscopic adrenalectomy). A variety of laparoscopic thermal energy devices are available. Ultrasonic shears are useful for colon mobilization and adrenal vein dissection. A laparoscopic bipolar vessel-sealing device has excellent hemostatic properties for performing the adrenal dissection. These devices have been shown to significantly decrease blood loss and operative time during adrenal dissection as compared to other thermal energy devices.12 An experienced circulating nurse and scrub person can often anticipate the surgeon's needs as they closely follow the steps of the procedure (see Surgical steps for laparoscopic adrenalectomy). The scrub person will stand on the opposite side of the primary surgeon to allow easy communication and facilitate instrument exchanges. Laparoscopic instruments are placed on a mayo stand with the handles facing the surgeon to expedite transfer to the surgeon's hands. During the procedure, the circulating nurse monitors the level of the CO2 tank and has reserve tanks available. Hemostatic agents must be readily available for the surgical team should bleeding occur. The circulating nurse must be prepared with additional trocars or a hand-access device if requested by the surgeon. The adrenal glands are highly vascular and lie adjacent to many vascular structures such as the inferior vena cava and aorta as well as vascular organs such as the liver and spleen. The perioperative nurse must be vigilant to potential intraoperative complications at all times such as bleeding and bowel injury. Emergent conversion to an open operation can occur at any time, and open surgical instruments and supplies should be readily available. Bleeding is the most common complication during and after laparoscopic adrenalectomy, accounting for 40% of complications.13The next most common complication is injury to surrounding organs such as the liver, spleen, colon, pancreas, and diaphragm, accounting for less than 5% of all complications.2 At the completion of the procedure, the specimen is grasped and placed into a laparoscopic specimen retrieval bag (see Intraoperative view of right adrenal gland (center), located under the elevated liver (top of photo). The specimen is removed by extending the 12-mm trocar incision as necessary. The CO2 pneumoperitoneum is evacuated before incision closure to decrease postoperative bowel irritation that may lead to delayed return of bowel function. The 12-mm trocar site may be closed with a fascial closure device, and the skin incisions are closed with subcuticular sutures or skin staples. Figure. Intraoperative view of right adrenal gland (center), located under the elevated liver (top of photo) Postoperative nursing care The patient is usually extubated in the OR before transport to the postanesthesia care unit (PACU). The orogastric tube is removed at the completion of the procedure. A chemistry screen and complete blood cell count are obtained in the PACU. Because the adrenal glands play an integral part in stress responses and BP regulation, close monitoring of BP is necessary via an arterial line or BP cuff.1 Postadrenalectomy patients require close monitoring of electrolytes, especially potassium. The PACU RN must also monitor the patient closely for signs of acute hemorrhage.2 The PACU nurse assesses the patient's level of pain and medicates the patient for pain as ordered. Typically, the patient won't require patient-controlled analgesia (PCA) as would be needed with an open adrenalectomy. Due to the small laparoscopic incisions, patients are prescribed pain medications at regular intervals on an as needed basis. Patients are encouraged to ambulate shortly following surgery. The urinary drainage catheter is removed on the first postoperative day. A clear-liquid diet is started on the first postoperative day, and the diet is advanced as tolerated. Serum cortisol levels are evaluated to assure that no element of adrenal insufficiency requires supplementation. A patient undergoing a unilateral adrenalectomy may require temporary replacement of glucocorticoids. If bilateral adrenalectomy is performed, the patient will be placed on cortisol replacement permanently. Most patients are discharged on the first postoperative day.3 Follow-up with the surgeon is usually a few days to a week after surgery. Patients can generally return to unrestricted activity approximately 4 weeks after surgery. Toward positive outcomes Laparoscopic adrenalectomy is currently the standard of care for surgical removal of the adrenal gland. Perioperative nurses are integral team members that must demonstrate attention to detail and critical-thinking skills in order to facilitate positive patient outcomes. Essential supplies and equipment for laparoscopic adrenalectomy * Beanbag and gel pad (or) gel roll * Axillary roll * Support * Pillows * Padding materials * Safety strap * 3-inch cloth tape * Sequential compression devices * Ultrasound machine * Laparoscopy insufflator and video tower * Thermal energy devices - ultrasonic shears generator - bipolar vessel-sealing device generator - monopolar cautery generator Common instrumentation for laparoscopic adrenalectomy * Veress needle * 5 or 10 mm, 0 and 30 laparoscopic scope * 5 and 12 mm trocars * Laparoscopic ultrasonic shears * Laparoscopic vessel-sealing device * Laparoscopic shears * Laparoscopic right angle dissector * Laparoscopic grasping forceps * Laparoscopic ultrasound probe * Polymer or titanium hemostatic clips (5 and 10 mm) * Suction-irrigation device * Laparoscopic retrieval bag * Laparoscopic peanut Surgical steps for laparoscopic adrenalectomy Left laparoscopic adrenalectomy Step 1 Mobilization of colon, tail of the pancreas, and spleen Step 2 Exposure of renal vein and adrenal vein Step 3 Ligation and division of adrenal vein Step 4 Dissection of adrenal gland borders (inferior, medial, superior, and lateral) with ligation and division of adrenal arteries and accessory veins Step 5 Retrieval of adrenal gland Right laparoscopic adrenalectomy Step 1 Mobilization of liver Step 2 Exposure of inferior vena cava and adrenal vein Step 3 Ligation and division of adrenal vein Step 4 Dissection of adrenal gland borders (inferior, medial, superior, and lateral) with ligation and division of adrenal arteries and accessory veins Step 5 Retrieval of adrenal gland REFERENCES 1. Zacharias M, Haese A, Jurczok A, Stolzenburg JU, Fornara P. Transperitoneal laparoscopic adrenalectomy: outline of the preoperative management, surgical approach, and outcome. Eur Urol. 2006;49(3):448-459. [Context Link] 2. Kesler S, Disick G, Munver R. Laparoscopic adrenalectomy. In: Nakada SY, Hedican SP, eds. Essential Urologic Laparoscopy the Complete Guide. 2nd ed. New York, NY: Humana Press; 2010:253-266. [Context Link] 3. Brunt LM. Minimal access adrenal surgery. Surg Endosc. 2006;20(3):351-361. [Context Link] 4. Hanberg A. Management of clients with adrenal and pituitary disorders. In: Black JM, Hawks, JH, eds. Medical Surgical Nursing. 8th ed. St. Louis, MO: Saunders Elsevier; 2009:1040-1054. [Context Link] 5. Nagle GM. Gentourinary surgery. In: Rothrock JC, ed. Alexander's Care of the Patient in Surgery. St. Louis, MO: Mosby; 2007:467-551. [Context Link] 6. The Joint Commission. Accreditation program: hospital national patient safety goals. 2010.http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-8858-0D5FAA4322F2. [Context Link] 7. Phillips N. Perianesthesia and procedural patient care. In: Berry and Kohn's Operating Room Technique. 11th ed. St. Louis, MO: Mosby; 2007:612-613. [Context Link] 8. SCIP Project information. Medqic. http://www.medqic/contentserver.[Context Link] 9. Phillips N. Anesthesia: techniques and agents. In: Berry and Kohn's Operating Room Technique. 11th ed. St. Louis, MO: Mosby; 2007:422-423. [Context Link] 10. Heizenroth PA. Positioning the patient for surgery. In: Rothrock JC, ed. Alexander's Care of the Patient in Surgery. 13th ed. St. Louis, MO: Mosby; 2007:155. [Context Link] 11. O'Connell MP. Positioning impact on the surgical patient. Nurse Clin North Am. 2006; 41(2):173-192. [Context Link] 12. Munver R, Lombardo S, Ilbeigi P. et al. Advances in the minimally invasive treatment of benign and malignant adrenal lesions: laparoscopic adrenalectomy using a novel vessel-sealing system-a combined experience. J Urol. 2006, 175(4); 347. [Context Link] 13. Grumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab. 2006; 20(3):483-499. [Context Link]

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Beyond pituitary surgery: Radiosurgery vs. Adrenalectomy vs Medical Treatment when Cushing’s disease persists or recurs

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