L. I. Ruffolo1, M. F. Nessen1, C. P. Probst1, D. T. Ruan2, L. O. Schoeniger1, J. Moalem1 1University Of Rochester,Department Of Surgery,Rochester, NY, USA 2Tampa General Hospital,Department Of Surgery,Tampa, FL, USA
Introduction: Surgical excision of the adrenal gland has radically evolved since Charles Mayo first excised a pheochromocytoma in 1927. Although most adrenalectomies are presently undertaken laparoscopically, open adrenalectomy remains the gold standard for large tumors and those concerning for adrenocortical carcinoma (ACC).
Most reports describe the use of midline, subcostal, Mercedes Benz, or thoracoabdominal incisions for open adrenalectomy. We studied our experience with the Makuuchi incision (MI), a “J” or “L” shaped incision designed to optimize exposure and minimize denervation of the abdominal wall.
Methods: We retrospectively reviewed all operations scheduled as “open adrenalectomy” by a single surgeon between 2009 and 2017. Operations performed via non–MI were excluded. Patient demographics, intraoperative details, and postoperative complications were investigated. We compared surgical site infection (SSI) and hernia rates with published standards. The study was approved by the university IRB.
Results: Of 55 open operations identified, 41 were performed via MI (23 right, 17 left, 1 bilateral). Mean population statistics were as follow: Age 51, BMI 29.7, ASA class 3, tumor diameter 8 cm (range 3.1 to 26 cm), operative time 333 minutes. Thirteen (32%) required multivisceral resection, including, for example, an en-bloc resection of a 20cm pheochromocytoma along with a large hepatic wedge, nephrectomy, and an 8cm segment of vena cava (Fig 1). Six (15%) were for pheochromocytoma, 8 (20%) had ACC, 2 (5%) had oncocytic adrenocortical neoplasm of uncertain malignant potential, and 8 (20%) had non-adrenal pathology. Forty (98%) had R0 resection on pathology.
Seventeen patients (41%) had prior abdominal surgery. Twenty-two (51%) were previous or current smokers, and 9 (22%) had hypercortisolemia at surgery. Median length of stay was 6 days, with 80% of patients having LOS<10 days. As of last follow up, (median = 27 months), incisional hernia occurred in 5 (12%). SSI was documented in 3 (7%) patients, two patients with Cushing’s and one immunosuppressed. By comparison, published rates for midline incisions are 9-30%. Postoperative pain was well controlled with PCEA/PCA and POD 1 daily morphine equivalents equating to 0.5 mg of hydromorphone q2h.
Conclusion: The Makuuchi incision affords outstanding exposure of the adrenals and ligamentous attachments of the liver, spleen, and splenic flexure. Incisional hernia and SSI were favorable compared to published rates for midline or subcostal incisions, despite an obese population with a high incidence of hypercortisolism and immunosuppression. Postoperative pain was well controlled.
