Nghiên cứu đặc điểm bệnh lý, chỉ định và kết quả phẫu thuật nội soi u tuyến thượng thận phát hiện tình cờ tt tieng anh

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INTRODUCTION
Adrenal incidentalomas (AIs) are tumors in the adrenal glands that are
discovered by accident by imaging diagnosis (ultrasound, computed
tomography, magnetic resonance) because other conditions, with no clinical
symptoms related to adrenal gland disease. The rate of AIs is about 1.0 - 8.7%
of the population. Regarding the treatment of randomized benign adrenal
adenomas, most authors agree on surgery for patients with hormone-secreting
tumors, and tumors ≥ 6 cm. For tumors with no increased hormone secretion
indicated. Surgery or follow-up is controversial.
Laparoscopic adrenalectomy (LA) to remove adrenal adenoma first
performed by Gagner in 1992. LS has great advantages such as: allowing easy
access and dissection in remote areas such as adrenal glands, aesthetics,
postoperative pain relief, short hospital stay time, patients can soon return to
normal activities, reducing the rate of prolapse bulging the abdominal wall after
surgery. In Vietnam, the studies of Nguyen Duc Tien, On Quang Phong, Do
Truong Thanh conclude that laparoscopic adrenalectomy and laparoscopic single
incison surgery to remove adrenal glands are safe, feasible and with good results.
However, there has been no in-depth analysis of AIs by chance, and there is no
agreement on surgical indications for tumor resection. The big question arises: if
you have no symptoms why remove it? On the other hand, many studies show
that asymptomatic adrenal adenomas can grow in size, switch to endocrine
activity, accompanied by an increased risk of malignancy, making surgery
difficult, etc. Thus, we carried out this research with two objectives:
1. Description of clinical and subclinical features of adrenal incidentalomas at
Viet Duc Friendship Hospital for the period 2015 – 2018.
2. Analysis indications and results of Laparoscopic adrenalectomy to treat adrenal
incidentalomas at Viet Duc Friendship Hospital for the period 2015 – 2018.

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THE NEW MAIN SCIENTIFIC CONTRIBUTION OF THE THESIS
- Reviews of the pathological features of adrenal incidentalomas include:
Clinical and subclinical characteristics (tumor imaging characteristics on
computed tomography or magnetic resonance, assess the ability of tumor
endocrine activity based on the adrenal hormone test).
- Analysis of laparoscopic adrenalectomy indications to treat adrenal
incidentalomas based on evidence of tumor progression, including: Switch to
endocrine activity, the risk of malignancy, the growth of tumor increases in
size, causing difficulties if not indicated for surgery early.
- From the achieved results, the dissertation contributes to affirm that
laparoscopic adrenalectomy is a feasible and safe method in the treatment of
adrenal incidentalomas with a low rate of complications and complications and
no recurrence was noted during long-distance follow-up.
STRUCTURE OF THE THESIS
This thesis consists of 124 pages: 2 pages of introduction, 34 pages of
literature review, 23 pages of research methods, 25 pages of research results, 37
pages of discussion, 2 pages of conclusion, 1 page of recommendation; 2
research works, 46 tables, 08 charts, 20 figures; 109 references, including 14 in
Vietnamese and 95 in foreign languages.


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Chapter 1
LITERATURE REVIEW
1.1.

Anatomy and physiology of the adrenal glands

1.1.1.

Anatomy

1.1.2.

Physiology of the adrenal glands

1.1.2.1. Adrenal cortex
Hormone secretion controls two types of organic metabolism, inorganic
metabolism and sexual steroids.
1.1.2.2. Adrenal marrow
Clinically synthesized three substances are: dopamine, epinephrine and
norepinephrine, which are called catecholamines.
1.2.

Adrenal incidentalomas

Adrenal incidentalomas are tumor in the adrenal glands that are discovered
by accident by imaging diagnosis (ultrasound, computed tomography, magnetic
resonance) because other conditions, with no clinical symptoms related to
adrenal gland disease. The rate of AIs is about 1.0 - 8.7% of the population.
1.3.

Subclinical feature of adrenal incidentalomas

1.3.1.

Adrenocortical adenoma

Benign adrenocortical adenomas are the most common adrenal tumors
found in 4-6% of the population. About 6% of adrenal cortex tumors are
endocrine activity causing manifestations such as Cushing's syndrome, Conn's
syndrome, etc.
- Computed tomography: Typical benign adrenocortical adenomas often
have a well-defined, uniform density.
1.3.2.

Adrenal myeloma (Pheochromocytoma)

Studies on benign adrenal adenomas are found by chance showing that the
percentage of Pheochromocytoma is about 7-10%.


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- Computed tomography: The density of Pheochromocytoma can be
homogeneous or heterogeneous, may contain intracellular fat or degenerative
cyst, leading to a decrease in pre-injection density.
1.3.3.

Ganglioneuroma

Ganglioneuroma are tumors originating from the sympathetic ganglia, about
10% localized in the adrenal gland location. On computed tomography images,
the lymphoma has a homogeneous solid structure, the size at diagnosis is
usually larger than 5 cm.
1.3.4.

Myelolipoma

Myeloma is a benign adrenal adenoma containing fat and hematopoietic
organization, a rare tumor with the rate of about 0.08 - 0.2%. Most tumors are
small and have no clinical symptoms, the size can vary from a few millimeters
to 30 centimeters.
1.3.5.

Other benign adrenal glands

1.4.

Treatment for benign Adrenal incidentalomas

1.4.1.

Medical monitoring and treatment

1.4.2.

Surgery

1.4.2.1. Open surgery
1.4.2.2. Laparoscopic surgery
The surgical methods of laparoscopic adrenalectomy include:
- Traditional laparoscopic surgery: Use 3 - 4 trocars placed in different
positions, with the conventional linear endoscope. There are 2 main approaches
including retroperitoneal LS and Laparoscopic surgery in the peritoneum.
- Laparoscopic adrenalectomy for a hole or an incision to remove an adrenal
tumor: Create an entry line (single slit) through which a dedicated gate is used

to bring one or more trocar in through the designated channels at the gate to
perform operations.
- Robot laparoscopic adrenalectomy.


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1.5.

Laparoscopic

adrenalectomy

indications

to

treat

adrenal incidentalomas
According to the Guidelines of the American Society of Endocrinology and
Endocrine Surgery (AACE / AAES) in 2009, adenoma of the adrenal cortex
with increased aldosteron secretion causing primary aldosteron secretion and
adrenal medullary tumors are indicated for surgery. Tumor of the adrenal cortex
with increased secretion of cortisol causes subclinical Cushing syndrome with
only surgical indication in a few cases. For tumors < 4 cm and inactive
function, visual and endocrine features of the tumor should be monitored. If the
tumor turns to endocrine activity or an increase of 0.5 cm in 6 months, an
increase of > l cm or visual properties suggest malignancy with surgical
indication. Glazer indicated surgery for solid tumors ≥ 3 - 4 cm in diameter.

Edgar D Research. Staren: Surgical indication is recommended for functional
or large (<6 cm) adrenal adenomas, tumors 3 to 6 cm in diameter in patients
under 50 years of age, and tumors with suspected visual characteristics.
malignant
In Vietnam, author Nguyen Duc Tien indicated LA for adrenal adenoma
cases discovered accidentally with a size of > 3 cm, including secretory and
non-secretive tumors. LS for large tumors of size ≤ 10cm, and cancer but no
invasive signs on preoperative imaging.
1.6.

Research

in

the

world

and

Vietnam

on

laparoscopic

adrenalectomy results to treat adrenal incidentalomas
1.6.1. World
Most studies have demonstrated that LA in the peritoneum to remove the
adrenal gland is a safe technique with rare rates of complications,

complications and postoperative mortality. The complication rate according to
the studies is 9%, ranging from 2.9% to 15.5%.


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In addition, many studies also indicate factors related to the rate of
complications, complications and open surgery for laparoscopic adrenal tumor
surgery including age, patient's BMI, history previous abdominal surgery,
tumor location, ... In general, the rate of open-switch surgery in laparoscopic
adrenalectomy is about 2% of cases, with ranges from 0% to 13%. The most
common causes of open surgery include damage to blood vessels or nearby
organs and technical difficulties. The death rate after laparoscopic
adrenalectomy ranged from 0% to 0.8%. The best causes of death include
massive bleeding, pancreatitis, pulmonary embolism, sepsis.
1.6.2. Vietnam
In Vietnam, laparoscopic adrenalectomy has been carried out for the first
time since August 1998 at Viet Duc Hospital. Since then, this method has been
widely applied in many major surgical centers in the country. Studies by Vu Le
Chuyen (2004), Nguyen Duc Tien (2006 - 2007), Tran Binh Giang, Do Truong
Thanh (2013) and On Quang Phong (2017) show that LS to treat adrenal
adenoma is Feasible, safe, good results.
Chapter 2
SUBJECTS AND METHODS
2.1. Subjects of the research
78 patients diagnosed with adrenal incidentalomas and treated with
laparoscopic adrenalectomy at Viet Duc Hospital, from October 2015 to the end
of October 2018. Tracking far to May 2019.
2.1.1 Selection criteria:
- Patient accidentally discovered adrenal adenoma based on one of imaging

probes such as ultrasound, computed tomography, magnetic resonance without
clinical symptoms of adrenal adenoma
- Patients indicated for laparoscopic adrenalectomyin the peritoneum


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(Including those with LA switching open or adding trocar)
- The result of postoperative disease surgery is benign adrenal adenoma
- Full medical records, patients agree to participate in the study.
2.1.2 Exclusion standard
- The result of postoperative disease surgery is adrenal cancer or adrenal
metastasis
- Patients with severe medical disease, incapable of general anesthesia
- Patients with blood clotting disorders or existing systemic infections.
2.2. Research Methods
2.2.1 research design: Research, clinical intervention, no control.
2.2.2 Sample size and sample selection
The sample size is calculated according to the formula, the minimum
number of patients is 63.
2.2.3 Technical procedure of laparoscopic adrenalectomy
2.2.3.1. Indicated for surgery
We recommend LA to remove adrenal adenoma according to the Guidelines
of Jung-Min Lee (2017), K. Lorenz (2019), AACE / AAES (2009):
+ Tumors that works with endocrine functions
+ Tumors that are ≥ 4 cm on diagnostic imaging.
+ Tumors that change size, morphology during tracking.
+ Tumors that are < 4cm (Think of Pheochromocytoma) based on
MRI or computed tomography
2.2.3.2. Prepare the patient

2.2.3.3. Prepare surgical tools and facilities
2.2.3.4. Indifference method, patient posture and surgical team position
2.2.3.5. Surgical techniques
- Step 1: Open the posterior abdominal wall peritoneum, exposing the
adrenal gland and the main adrenal vein


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- Step 2: Anatomy, control of the main adrenal vein
- Step 3: Clamp the middle and upper adrenal artery
- Step 4: Control of the lower adrenal artery
- Step 5: Check the area of dissection and hemostasis, drainage
- Step 6: Remove the specimen, release CO2 gas, close the trocar holes
2.2.4 The research criteria
2.2.4.1. Targets for goal 1: Clinical and subclinical characteristics
- Clinical characteristics
+ Age, sex, reason to visit
+ History of internal medicine, surgery history of the abdomen
- Clinical characteristics
+ Characteristics of disease anatomy
+ Image diagnosis: Abdominal ultrasound, computed tomography or
magnetic resonance imaging, endocrine activity characteristics of the tumor,
+ Biochemical tests for Adrenal Hormone
2.2.4.2. Targets for goal 2: Analysis indications and results of laparoscopic
adrenalectomy to treat adrenal incidentalomas
- Analysis indications of laparoscopic adrenalectomy to treat AIs
- Results in surgery:
+ Surgical methods: Traditional LA/ Single incision laparoscopic
+ Add trocar / open surgery.

+ Method of handling main adrenal vein, hemodynamic change in surgery
+ Methods of handling tumors, complications and complications
- Early results
+ Mean time, draining, pain after surgery
+ Early complications, time in hospital after surgery
+ Evaluate early results: according to 4 levels: Good, fair, average, poor
- Far Result Reviewed at the end of the study (May 2019):


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+ Number of patients re-examined, long-distance follow-up time (months)
+ Clinical symptoms (if any)
+ Diagnostic imaging results (ultrasound, computed tomography or MRI)
upon re-examination
+ Biochemistry test results for adrenal hormones
+ Complications far away, recurrence tumors
2.2.5 Data collection and processing
- Information is collected according to pre-designed research records
- The data are processed by medical statistical software SPSS 20.0.
2.2.6 Research ethics
- The research outline has been approved by the Outline Council - Hanoi
Medical University to ensure its science and feasibility.
- The patients participating in the study are carefully explained about the
treatment methods and voluntarily participate in the study.
- Patient information is confidential, only for research purposes.
Chapter 3
RESEARCH RESULTS
3.1.

Clinical, subclinical characteristics of Adrenal incidentalomas

3.1.1.

Clinical

- Year old: Average age of patients is 45.22 ± 13.39 (13 - 79 years)
Gender: female patients accounted for the majority with 64.1%.
Table 3.1. Reason for admission
Number of patients

Percentage

(n = 78)

(%)

Periodic health examination

37

47.4

Exam for another disease

26

33.4

Follow-up by appointment

15

19.2

Reason for admission


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due to the discovery of
adrenal adenoma in the past
- Medical history: 46 patients (59.0%) with combined medical disease
- History of abdominal surgery: 7 patients (9.1%) had a history of
abdominal surgery.
3.1.2.

Subclinical
Table 3.2. Characteristics of disease anatomy
Pathology

Number of patients

Percentage(%)

Adrenocortical adenoma

52

66.7

Schwannoma

2

2.6

Pheochromocytoma

15

19.2

Myelolipoma

1

1.3

Ganglioneuroma

6

7.7

Lymphanginoma

1

1.3

1

1.3

Pheochromocytoma +
Phải;Ganglioneuroma
46.15%
Trái; 53.85%

Comment: The majority of adrenocortical tumors with 52 cases (66.7%)
Pheochromocytoma accounts for 19.2%
- Abdominal ultrasound: 12 cases
(15.4%) did not detect tumors with ultrasound. The average tumor size
according to ultrasound was 3.4 ± 1.98 cm
Chart 3.1. Distribution of the tumor location according to computed tomography
Comment: Left adrenal adenoma majority with 53.8%
- Tumor size according to computed tomography or magnetic resonance:
Average 3.63 ± 1.88 cm
- Tests for Adrenal Hormone: The percentage of patients with increased blood
cortiol accounted for the most with 29.5%, blood adrenalin increased in 8.9% of
cases.


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- Inhibitory therapy (NPUC): 23 patients (29.5%) with increased Cortisol
assay, we tested NPUC with low dose 1 mg dexamethasone overnight. Of
these, 19 were positive (82.6%).
- Comment: 69.2% of tumors are endocrine inactive. 30.8% of tumors are

endocrine activity, of which 24.4% show subclinical Cushing syndrome, 6.4%
of tumors have increased secretion of Catecholamin
- Pathology and endocrine activity: 19/52 patients (36.5%) functional
adrenocortical adenoma with symptoms of subclinical Cushing syndrome. 5/15
(33.3%) Pheochromocytoma increased secretion of Catecholamin
3.2.

Analysis indications and results of laparoscopic adrenalectomy to
treat adrenal incidentalomas

3.2.1. Analysis indicated for surgery
Table 3.3. Indications of laparoscopic adrenalectomy
Number of

Percentage

patients (n = 78)

(%)

Active endocrine tumors

24

30.8

Tumors ≥ 4 cm (inactive endocrine)

34

43.6

Tumors resize

15

19.2

5

6.4

Indications

Tumors think of Pheochromocytoma
on computed tomography or
magnetic resonance
Comment: Indications of laparoscopic adrenalectomy due to tumor > 4 cm
(inactive endocrine) accounts for 43.6%
24 cases (30.8%) of surgery due to active endocrine tumors
- Indications of laparoscopic adrenalectomy according to tumor size: The
average tumor size was 3.68 ± 0.21.
3.2.2. The result of LA to treat Adrenal incidentalomas
3.2.2.1. Results in surgery


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- ASA anesthesia risk factor classification: The majority of patients with
ASA II classification score accounted for 64.1%

- Comment: 61 patients (78.2%) received traditional laparoscopic surgery
- The tumor size indicated for single incision LA (2.54 ± 0.3 cm) is smaller
than that of traditional LA (3.92 ± 0.25). The difference is statistically
significant with p <0.01
Table 3.4. Add trocar / open surgery
Number of

Percentage

patients (n = 78)

(%)

One more trocar

8

10.3

Add 2 trocar

1

1.3

Open surgery

2

2.6

Add trocar / open surgery

Comment: 10.3% must add 1 trocar, 2.6% switch to open surgery
Table 3.5. Method of handling the main adrenal vein
Method of handling the

Number of

Percentage

main adrenal vein

patients (n = 78)

(%)

Clip

8

10.3

Ligasure

53

67.9

Clip + Ligasure

15

19.2

Stitched

2

2.6

Comment: X stodgy main adrenal vein by 67.9% Ligasure accounts. 15
cases (19.2%) combined with clip clip and ligasure
- The larger the tumor size, the higher rate of main adrenal venous
hemostasis by clip or in combination with ligasure to stop bleeding. The
difference is statistically significant with p <0.05
- Comment: 6.4% changes in hemodynamics: 5.1% increase in BP and
1.3% increase in rapid pulse


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- Hemodynamic changes in surgery according to tumor anatomy: There
were 5 cases of hemodynamic change when clamping the main adrenal vein.
- Change in hemodynamic in surgery according to the endocrine activity
100% of inactive endocrine tumors have no changes in hemodynamic in
surgery. 2/5 cases (40%) of tumors with increased secretion of catecholamine
have increased blood pressure
- Method of treating tumors: 96.1% of cases have surgery to remove the
entire adrenal gland

- Method of treating tumors according to tumors size: Indications for the
complete adrenalectomy for tumors larger than the tumor selective group (p <0.05)
Table 3.6. Accidents in surgery
Number of

Percentage

patients (n = 78)

(%)

Bleed

11

14.1

Damage to the left kidney stem

1

1.3

Damage to the spleen

2

2.6

Total

14

17.9

Accidents in surgery

Comment: 14 cases with complications in surgery, accounting for 17.9%
- Accidents in surgery by tumor size: The larger the tumor size, the higher the
rate of complications. The difference is statistically significant with p <0.01.
Because there are 2 cases of open surgery, so it is not included in the rate
of drainage, the time of surgery as well as the results after surgery.
- There are 22 cases (28.9%) requiring intra-abdominal drainage
- Surgical time: The average vibration was 80.39 ± 27.72 minutes (35 170). There was no statistically significant difference in surgery time between
the single incision surgery group and the traditional LS group (p> 0.05).
3.2.2.2. Early results
- Mid time: Average 1.95 ± 0.65 days.


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- Time to draw leads: average 2.86 ± 0.83 days.
- Postoperative pain time: The average was 2.14 ± 0.83 days. Postoperative
pain time of the single incision surgery group (1.47 ± 0.51 days) was shorter
than that of the traditional laparoscopic group (2.34 ± 0.80 days), the difference
was statistically significant. millet with p <0.01
Table 3.7. Early complications
Number of

Percentage

patients (n = 76)

(%)

Incision infection

3

3.9

Acute adrenal insufficiency

1

1.3

Total

4

5.2

Early complications

Comment: 4 patients (5.2%) developed early complications.
- Duration of hospital stay after surgery: average 5.17 ± 1.35 days (3 - 9).
- Evaluate early results: Good 94.8%, fair 3.9%, average 1.3%, poor 0%
3.2.2.3. Results are far away
- At the end of the study, 70/76 patients were examined again, accounting

for 92.1%. 7 patients (7.9%) were not examined again due to loss of contact.
- Long distance tracking time: Average is 24.03 ± 12.04 months (7 - 42).
Table 3.8. Clinical symptoms
Number of

Percentage

patients (n = 70)

(%)

Not

49

70.0

Hypertension

19

27.1

Headache, tiring

2

2.9

Clinical symptoms

Comment: The majority of patients re-examined have no clinical symptoms,
accounting for 70.0%. There were 19 patients with hypertension (27.1%).


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All patients re-examined underwent biochemical tests, electrolytes, diagnostic
imaging (including ultrasound and computed tomography of the abdomen):
+ No case of abnormal change on adrenal hormone and electrolyte assay
+ Ultrasound and computer tomography did not detect tumor recurrence or
metastasis.
- No patient died at the time of re-examination.
Chapter 4
DISCUSSION
4.1.

Clinical and subclinical features of incidentally detected benign
adrenal adenoma

4.1.1.

Clinical
4.1.1.1.

Age and gender characteristics

Average age of patients in the study is 45.22 ± 13.39 years (13 - 79 years).
Similar studies by Do Truong Thanh, Kwak, Vidal, Wang ranged from 43.3 to
47.2 years old. The percentage of female patients is the majority with 64.1%.

4.1.1.2.

Reason for admission

Most patients discovered adrenal adenoma during periodic health
examination, accounting for 47.4%. There were 26 patients (33.4%) who came
to see a doctor because of other diseases and 19.2% had previously discovered
adrenal adenoma but had not been treated. Mantero F. showed that the most
frequent reasons for visiting these patients were abdominal pain and
nonspecific symptoms, accounting for 36%.
4.1.1.3.

History of medical disease

The study has 46 patients with combined internal medicine, accounting for
59.0%. In which, most of them were simple hypertension with 47.4%, 6
patients (7.7%) had hypertension + diabetes, 1 patient (1.3%) only diabetes, 1
disease. Human (1.3%) hepatitis B + asthma, 1 patient (1.3%) basedow.


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4.1.1.4.

History of abdominal surgery

We have 7 patients (9.1%) with a history of abdominal surgery.
4.1.2.

Subclinical

4.1.2.1. Tumor anatomical features
In our study, adrenocortical tumors accounted for the majority with 52 cases
(66.7%), Pheochromocytoma 19.2%, Ganglioneuroma 7.7%, Schwannoma
2.6%, Myelolipoma 1.3%, Lymphanginoma 1.3% and mixed adrenal myeloma
(Pheochromocytoma + Ganglioneuroma) 1.3%. The research of Laparoscopic
surgery for benign adrenal adenoma found by chance also recorded that
adrenocortical tumor accounted for the highest percentage (from 49 - 69%),
Pheochromocytoma 11-23%, while Ganglioneuroma, Lymphangioma and
Myelopipoma account for a low rate of 0-15%.
4.1.2.2. Abdominal ultrasound
Our study has 12 cases (15.4%) of ultrasound can not detect tumors.
Equivalent to author On Quang Phong 18.1% did not detect tumors on
ultrasound, also according to this study, the sensitivity of ultrasound is 80.77%.
4.1.2.3. Computer tomography or magnetic resonance imaging (MRI)
The study found that the left adrenal adenoma accounted for the majority
with 53.8%, the right adrenal adenoma 46.2% and there was no case of bilateral
adenoma. The results are equivalent to author Minal J. Sangwaiya with the
left / right ratio of 1.94. In our study, the average size of adrenal adenoma on
computed tomography (or magnetic resonance) image is 3.63 ± 1.88 cm,
common tumor size is 2 - <4 cm, accounting for 41.0%. Research by Vincent
Amodru: tumors 4 to 6 cm in 66 patients (81.5%) and tumors> 6 cm in 15
patients (18.5%)
4.1.2.4. Characteristics of endocrine activity
The study found that most tumors were endocrine inactive, accounting for
69.2%, 30.8% of tumors with endocrine activity, of which 24.4% showed


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symptoms of subclinical Cushing's syndrome, 6.4% increased Catecholamin
secretion. Yoon Young Cho's research: 13.8% of fully functional tumors, 9.9%
have subclinical Cushing syndrome. Many other studies also show that about
80% of adrenal adenomas are found to be ineffective, 5% have subclinical
Cushing syndrome, 1% increase Aldosterone secretion.
19/52 patients (36.5%) functional adrenocortical adenoma with symptoms
of subclinical Cushing syndrome, 5-20 % higher than Terzolo M's study.
4.2. Analysis indications and results of laparoscopic adrenalectomy to
treat adrenal incidentalomas
4.2.1.

Analysis indications of LA to treat adrenal incidentalomas

Minimal invasive surgery is indicated for adrenal adrenal tumors that are
incidentally detected based on tumor size and signs of malignancy suggestive
of imaging. In terms of size, the rule of 6 cm is accepted, for adrenal adenomas
<6 cm in diameter and without signs of malignancy, LA is recommended.
Many studies have shown: There is a positive correlation between tumor size
and the risk of malignancy.
There is much debate about the optimal approach for large adrenal tumors
(≥ 4 cm). Barzon's study found that the rate of malignancy was very low for
tumors < 4 cm and can reach as high as 50% for tumors > 6 cm. Recently, the
Mayo Clinic group with 705 patients with adrenal adenoma greater than 4 cm,
malignancy rate up to 31%.
For inactive endocrine adrenal tumors, according to the American
Association of Endocrinology and Surgery (AACE / AAES) in 2009, surgery
must be indicated in all inactive adrenal tumors ≥ 6 cm, since the risk of
malignancy is approximately 25%.
According to the guidelines of the German Endocrine Surgery Association
2019, LA should be indicated for inactive adrenal gland tumors < 6cm in

diameter, without suspicion of malignancy. Consider adrenalectomy in case of


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visual findings with suspected malignancy, Pheochromocytoma or adrenal
tumor with endocrine activity. In Vietnam, Nguyen Duc Tien indicated LA for
all adrenal adenomas with endocrine activity. For adrenal incidentalomas,
surgery is indicated when the size is > 3 cm.
Similar to the above studies, we indicated LA for tumor size averaging 3.68 ±
0.21 cm (0.8 - 9.6), mostly due to tumor > 4 cm (inactive endocrine) 43.6%. 24
cases (30.8%) surgery due to active endocrine tumors 15 patients (19.2%) had
changes in tumor size and morphology during the average follow-up time of 26 ±
8.97 months (12 - 36). The guidelines of the German Society for Endocrine
Surgery and the American Society of Endocrinology and Surgery indicate that
surgery should be indicated for suspected pheochromocytoma and/ or
paraganglioma based on imaging and laboratory diagnosis. Hormone. The
authors believe that pheochromocytoma and paraganglioma, if not treated early,
can turn into active endocrine tumors causing uncontrolled catecholamine
increases, leading to cardiovascular disease and increased mortality. In addition
to the growth and malignant potential of these tumors is also one of the reasons
that surgery is needed as soon as it is discovered. Likewise, we have 6.4% of
patients with a tumor < 4 cm inactive but with computerized tomography
characteristics of Pheochromocytoma that are indicated for successful LA
without occurring What complications and complications?
4.2.2. Results of laparoscopic adrenalectomy to treat
adrenal incidentalomas
4.2.2.1. Results in surgery
Surgical methods
In the study, 61 patients (78.2%) applied traditional LA 17 patients (21.8%)

had single incision laparoscopic surgery. Laparoscopic adrenalectomy can be
performed through the peritoneum or posterior cavity, depending on the habits


19

of the surgeon. All of the cases in our study performed LS to remove the
adrenal glands.
Add trocar / open surgery
The study had 8 cases (10.3%) to add 1 trocar, 1 case (1.3%) add 2 trocar.
According to Coste T., tumor size is one of the important factors affecting
surgical results. The author found that, for tumor with size > 4.5 cm is a risk
factor that increases the rate of complications in surgery, cyst damage, thereby
increasing the rate of adding trocar or changing open surgery, increasing
complications after surgery as well as surgery time.
In addition, we have 2 cases requiring open surgery, accounting for 2.6%. In
general, the rate of open-switch surgery in laparoscopic adrenalectomy is about
2% of cases, with ranges from 0% to 13%. We share a statement with the
authors: The most likely causes of open surgery include damage to blood
vessels or neighboring organs and technical difficulties, in addition to diagnosis
of large Pheochromocytoma or endocrine activity is also a factor in the increase
in rates. additional rate trocar or open surgery.
Handling method and hemodynamic change when clamping and
resection of the main adrenal vein
The authors stated: In laparoscopic adrenalectomy, due to its direct involvement
with other major tumor markers, the control of the main adrenal vein should be
very cautious. In our study, 67.9% of cases of primary adrenal vein treatment with
Ligasure, 10.3% clip clip alone and 19.2% combination clip and ligasure; 2.6% of
the main adrenal vein forced stitch is 2 cases of open surgery.
Research results show that the majority of patients have no changes in

hemodynamic in surgery, accounting for 93.6%. There were 5 cases (6.4%) of
hemodynamic changes with major adrenal venous clamping including 4
patients (5.1%) with malignant hypertension (ranging from 200 - 210/100
mmHg) and 1 patient (1.3%) rapid pulse oscillation> 110 times / min. Mainly


20

group of adrenocortical adenoma (3 patients) and Pheochromocytoma (2
patients). According to Table 3.24, 100% of tumors that are endocrine inactive
have no changes in hemodynamic in surgery. 2/5 cases (40%) of the tumor
increases secretion of catecholamin with increased blood pressure in surgery.
Treatment method for tumors
In our study, 96.1% of all cases had laparoscopic total adrenalectomy. Only
3.9% selectively cut tumors. Assign to cut the entire gland for tumors larger
than the selective tumor group 3.72 ± 0.22 cm compared with 1.88 ± 0.27 (p
<0.05). The rate of tumor selective resection in Wen Quang Phong's study is
2.5%. Do Truong Thanh performed total adrenalectomy in 88.2% of patients,
only 11.8% selected tumors.
Accidents in surgery
Our study met 14 cases with complications in surgery, accounting for
17.9%. In which, 11 cases were mainly bleeding (14.1%), 1 case damaged the
left kidney stem (1.3%) and 2 cases damaged the spleen (2.6%). Among our
bleeding complications, mainly due to bleeding in the adrenal gland or when
dissecting tumors sticking to the liver or spleen causing bleeding, in which 6
cases 1 trocar must be added to support electrolysis. blood. 1 case of bleeding
due to the tumor sticking to the diaphragm leg, renal vessel bundle and
abdominal aorta must open surgery (described above). Also 1 case of bleeding
due to damage of polar veins on the adrenal glands to add 1 trocar to clip clip
combined with ligasure to stop bleeding.

Coste T. (2017) recorded 81 complications during surgery, accounting for
15.6%, bleeding was the most frequent occurrence with 33.3%.
Drainage set
In the study, 22 patients (28.9%) had to have intra-abdominal drainage,
mainly due to bleeding complications or large tumors to remove adhesion, we


21

actively placed drainage to prevent and monitor complications. postoperative
blood or outbreak.
Surgical time
The average surgical time in the study was 80.39 ± 27.72 minutes, the
shortest 35 and the longest 170 minutes. The lower of Le Dinh Khanh is 151.46
± 54.44 minutes (90 - 260) and Do Truong Thanh is 86.2 minutes.
Surgical time of the single incision laparoscopic group is 88.82 ± 26.31
minutes (50 - 135), the traditional LA group is 79.66 ± 31.96 minutes (35 170). However, the difference was not statistically significant (p> 0.05).
The authors have the same assessment, the time of surgery depends on many
factors such as: Experience of surgeon, patient condition (fat, thin), location,
size and properties of tumor,… Besides, the authors also said that for tumors
with endocrine activity, surgery time is often longer due to difficulties in
surgery and resuscitation, tumors release hormones during surgery.
4.2.2.2. Early results
Middle time
The study found that the mean mean time was 1.95 ± 0.65 days, the shortest
1 day, the longest 4 days. The recovery time of postoperative gastrointestinal
circulation in Coste T.'s study was 2.71 ± 1.2 days (1–9).
Postoperative pain time
Our average postoperative pain time was 2.14 ± 0.83 days, this shortest 1,
and the longest 6 days. The cases of pain after surgery lasted 4-6 days due to

complications of infection of the wound, the patient showed fever, pain and
drainage of the wound.
Early complications
The study had 4 patients (5.2%) with complications early after surgery, of
which 3 cases (3.9%) wound infection and 1 acute adrenal insufficiency


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(1.3%). The rate of early complications in the study of Coste T. was 15.6%,
Hirano D et al was 22.2%.
Postoperative hospital stay
The average postoperative hospital stay in the study was 5.17 ± 1.35 days (the
shortest 3 days, the longest 9 days). The duration of hospital stay after surgery
between the traditional LS group (5.05 ± 1.36 days) and the single incision
surgery (5.29 ± 1.16 days) did not have a statistically significant difference.
millet (p> 0.05). Other studies noted the postoperative hospital stay of the
traditional LS group from 3.1 ± 1.2 to 6.9 ± 1.75 days. Meanwhile, the single
incision surgery group had hospital stay ranged from 2.4 ± 0.70 to 6 ± 2.22 days.
Evaluate early results
The study found that the majority of patients achieved good results,
accounting for 94.8%. There are 3.9% of patients with fairly good results are
patients with complications of surgical wound infection. 1.3% on average were
patients with postoperative adrenal insufficiency and the poor result was 0%
4.2.2.3. Results are far away
At this time, 70/76 patients were re-examined, accounting for 92.1%. 7
patients (7.9%) were not examined again due to loss of contact, including 1
foreign patient. We recorded average follow-up time since post-surgery to be
24.03 ± 12.04 months, shortest 7 months, longest 42 months.
The results showed that the majority of patients (70.0%) had no clinical

manifestations at the time of re-examination, accounting for 70.0%. There were
19 patients with hypertension, these were all patients over 40 years old, had a
history of hypertension before and during follow-up there was no exacerbation
of hypertension. hypertension in these patients was due to a cause other than
adrenal cancer


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The results of our subclinical test on follow-up examination showed no
abnormal changes in the adrenal hormone and electrolyte assay, no recurrence
or death up to the time of follow-up.
We share a statement with the authors: Accidentally discovered benign
adrenal adenoma is a safe and effective method, especially for tumors that are
large or have endocrine activity.
CONCLUSION
1. Clinical and subclinical features of Adrenal incidentalomas
The average age of patients was 45.22 ± 13.39, with the majority female
with 64.1%. 47.4% accidentally discovered adrenal adenoma during periodic
health examination, 33.4% discovered by accident because of other diseases.
The majority of adrenocorticoma with 66.7%, Pheochromocytoma 19.2%,
Ganglioneuroma 7.7%, Schwannoma 2.6%, adipoma Myelolipoma 1.3%,
Lymphanginoma 1.3% and Pheochromocytoma + Ganglioneuroma) 1.3%.
Computerized tomography results: Left adrenal adenoma accounts for 53.8%.
The average tumor size was 3.63 ± 1.88 cm. 30.8% of tumors increased
secretory activity, of which 24.4% showed subclinical Cushing syndrome, 6.4%
increased catecholamin secretion.
2.

Analysis

indications

and

results

of

laparoscopic

adrenalectomy to treat AIs
Indications for surgery: 43.6% due to tumor ≥ 4 cm (inactive secretion),
30.8% due to active tumor secretion, 19.2% due to the tumor's change in size
during follow-up and 6.4% due to tumor of Pheochromocytome on
computerized tomography images.
Surgical results
Laparoscopic adrenalectomy is a feasible, safe method in the treatment of
adrenal incidentalomas: with 78.2% applied traditional LA and 21.8% single


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incision surgery; rate of open surgery is low (2.6%); 6.4% had changes in
hemodynamic in surgery (5.1% increased blood pressure and 1.3% rapid
pulse); the rate of complications was 17.9%, mainly bleeding (14.1%); The rate
of postoperative variable is low at 5.2%. Evaluate early results: Good 94.8%,
fair 3.9%, average 1.3%, less than 0%. 92.1% of patients followed up long
distances for a mean of 24.03 ± 12.04 months, not recorded any case with
distant complications, recurrence or death. Tests for Adrenal Hormone and

Electrolytes both returned to normal.
RECOMMENDATION
For adrenal incidentalomas <4 cm in diameter, it is necessary to have tests to
assess the tumor's secretory activity. If the tumor is inactive, it is advisable to plan
to monitor the changes in the nature, size and endocrine activity of the tumor.
Indication of laparoscopic adrenalectomy for adrenal incidentalomas with
size ≥ 4 cm, secretory active tumors, suspected tumors of Pheochromocytoma
on computerized tomography or magnetic resonance imaging, tumors or move
to moderated activity during follow-up.
Laparoscopic adrenalectomy for adrenal incidentalomas is a complicated
surgery requiring the coordination of many specialties: endocrine, resuscitation
and experienced surgeon should therefore be performed in major surgical centers.