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Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies

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Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies ORIGINAL ARTICLE Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies Anouk Scholten, MD; Robin M. Cisco, MD; Menno R. Vriens, MD, PhD; Wen T. Shen, MD; Quan-Yang Duh, MD Importance: Knowing the types and frequency of ad- Results: Variant venous anatomy was encountered in renal vein variants would help surgeons identify and con- 70 of 546 adrenalectomies (13%). Variants included no trol the adrenal vein during laparoscopic adrenalec- main adrenal vein identifiable (n=18), 1 main adrenal tomy. vein with additional small veins (n=11), 2 adrenal veins (n=20), more than 2 adrenal veins (n=14), and vari- Objectives: To establish the surgical anatomy of the main ants of the adrenal vein drainage to the inferior vena cava vein and its variants for laparoscopic adrenalectomy and and hepatic vein or of the inferior phrenic vein (n=7). to analyze the relationship between variant adrenal ve- Variants occurred more often on the right side than on nous anatomy and tumor size, pathologic diagnosis, and the left side (42 of 250 glands [17%] vs 28 of 296 glands operative outcomes. [9%], respectively; P=.02). Patients with variant anatomy compared with those with normal anatomy had larger Design, Setting, and Patients: In a retrospective re- tumors (mean, 5.1 vs 3.3 cm, respectively; PϽ.001), more view of patients at a tertiary referral hospital, 506 patients pheochromocytomas (24 of 70 [35%] vs 100 of 476 [21%], underwent 546 consecutive laparoscopic adrenalecto- respectively; P=.02), and more estimated blood loss mies between April 22, 1993, and October 21, 2011. Pa- (mean, 134 vs 67 mL, respectively; P=.01). For patients tients with variant adrenal venous anatomy were com- with variant anatomy vs those with normal anatomy, the pared with patients with normal adrenal venous anatomy regarding preoperative variables (patient and tumor char- rates of transfusion requirement (2 of 70 [3%] vs 10 of acteristics [size and location] and clinical diagnosis), in- 476 [2%], respectively; P=.69) and reoperation for bleed- traoperative variables (details on the main adrenal venous ing (1 of 70 [1%] vs 3 of 476 [1%]; P=.46) were similar drainage, any variant venous anatomy, duration of opera- between groups. tion, rate of conversion to hand-assisted or open proce- dure, and estimated blood loss), and postoperative vari- Conclusions and Relevance: Understanding variant ables (transfusion requirement, reoperation for bleeding, adrenal venous anatomy is important to avoid bleeding duration of hospital stay, and histologic diagnosis). during laparoscopic adrenalectomy, particularly in pa- tients with large tumors or pheochromocytomas. Sur- Intervention: Laparoscopic adrenalectomy. geons should anticipate a higher probability of adrenal vein variants when operating on pheochromocytomas and Main Outcomes and Measures: Prevalence of vari- larger adrenal tumors. ant adrenal venous anatomy and its relationship to tu- mor characteristics, pathologic diagnosis, and operative outcomes. JAMA Surg. 2013;148(4):378-383 APAROSCOPIC ADRENALEC- the left renal vein on the left (Figure 1 tomy has evolved to be- and Figure 2).4 Variations to this pat- come the procedure of tern have been documented in cadaver choice for most surgically studies,5-11 a clinical study,12 and a few case treated adrenal diseases.1-3 A reports.13,14 Lsafe laparoscopic adrenalectomy re- Author Affiliations: quires a thorough knowledge of the usual See Invited Critique Author Aff Department of Surgery, anatomy of the adrenal gland as well as its at end of article Departmen University of California, unusual anatomical variations. University San Francisco (Drs Scholten, The venous drainage from each adre- Anson and Caudwell5 studied the ve- San Francis Cisco, Shen, and Duh); and nal gland, described in standard anatomi- nous drainage of the adrenal glands in 450 Cisco, Shen Department of Surgery, Departmen University Medical Center cal texts, is usually via a single vein emp- cadavers. They confirmed the constancy University Utrecht, Utrecht, the tying directly into the inferior vena cava of conventional venous drainage anatomy, Utrecht, Ut Netherlands (Drs Scholten and on the right side, joining with the infe- with only 1 variant identified in 900 ad- Netherland Vriens). rior phrenic vein, and then draining into renals. Subsequent cadaver studies de- Vriens). JAMA SURG/ VOL 148 (NO. 4), APR 2013 WWW.JAMASURG.COM 378 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 MHV LHV IPV RHV LAV RAV LRV IVC RRV IVC Figure 2. Normal adrenal venous anatomy on the left side. IPV indicates inferior phrenic vein; IVC, inferior vena cava; LAV, left adrenal vein; and LRV, left renal vein. Figure 1. Normal adrenal venous anatomy on the right side. IVC indicates inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RAV, right adrenal vein; RHV, right hepatic vein; and RRV, right renal vein. roscopic adrenalectomy performed by a single surgeon at the University of California, San Francisco and the San Francisco Veterans Affairs Medical Center between April 22, 1993, and scribed more variations in the adrenal veins, mainly on October 21, 2011. the right side.6-11 These cadaver studies reported the With the exception of 19 cases performed via a retroperi- anatomy of nondiseased adrenal glands. Adrenal pathol- toneal approach, all operations were performed via the lateral ogy, possibly through angiogenesis or vasodilation of pre- transperitoneal approach. existing small collateral vessels, may increase both the Adrenal vascular anatomy was routinely recorded prospec- variation of venous drainage and the number of peri- tively by the attending surgeon in the operative findings part adrenal vessels. Parnaby et al12 studied the venous anatomy of the detailed operative report. Only patients with such a re- encountered in 162 laparoscopic adrenalectomies for ad- port describing the venous anatomy were included. We re- viewed these operative notes to assess variant adrenal venous renal pathology. They found variant venous anatomy in anatomy. Sufficient information was available for 506 pa- 5 adrenal glands: 4 in patients with pheochromocytoma tients. Forty of these patients underwent bilateral adrenalec- and 1 in a patient with adrenal cortical cancer. In addi- tomy, yielding a total of 546 procedures evaluable for adrenal tion, MacGillivray et al13 reported confluence of the right venous anatomy. adrenal vein with the accessory right hepatic vein in a Preoperative data included patient and tumor characteris- patient with hyperaldosteronism, and Stack et al14 de- tics (size and location) and clinical diagnosis. Intraoperative scribed an anomalous left adrenal vein draining directly data included the details on the main adrenal venous drain- into the inferior vena cava in a patient with hyperaldo- age, any variant venous anatomy, duration of operation, rate steronism. of conversion to hand-assisted or open procedure, and esti- The ability to anticipate variant adrenal venous mated blood loss. Postoperative data included transfusion re- quirement, reoperation for bleeding, duration of hospital stay, anatomy is important to prevent excessive bleeding from and histologic diagnosis. the adrenal and accessory veins during laparoscopic ad- Patients with variant adrenal venous anatomy were com- renalectomy. We therefore studied 546 consecutive lapa- pared with patients with normal adrenal venous anatomy re- roscopic adrenalectomies to establish details of the pri- garding the various preoperative, intraoperative, and postop- mary venous drainage and any variant venous anatomy. erative variables. Comparison of binary variables was by ␹2 test. In addition, we compared patients with variant adrenal Comparison of continuous values was by unpaired t test. De- venous anatomy with patients with normal adrenal ve- scriptive statistics were calculated for all variables. Statistical nous anatomy. significance was shown at PϽ.05. METHODS RESULTS With approval of the University of California, San Francisco In 70 (13%) of the 546 evaluable procedures (250 [46%] Institutional Review Board, we retrospectively reviewed the rec- right-sided procedures and 296 [54%] left-sided proce- ords of all patients (n=523) who underwent consecutive lapa- dures), there was a variant adrenal venous anatomy JAMA SURG/ VOL 148 (NO. 4), APR 2013 WWW.JAMASURG.COM 379 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 1. Variant Adrenal Venous Anatomy by Number Patients, No. Variant (n = 63) No central adrenal vein identified 18 With multiple small veins 7 1 Central adrenal vein with 11 multiple small veins 2 Adrenal veins 20 With multiple small veins 2 Ͼ2 Adrenal veins 14 With multiple small veins 1 1 Central adrenal vein with Draining into multiple accessory veins right hepatic vein Table 2. Variant Adrenal Venous Anatomy by Location Figure 3. Variant adrenal venous anatomy on the right side. Variant Side (n=7) Left Central adrenal vein, 2 branches (n = 1) Central adrenal vein draining into left renal vein, branch to inferior phrenic vein (n = 1) Central adrenal vein, inferior phrenic vein draining separately into left renal vein (n = 2) Right Central adrenal vein draining into right hepatic vein (n = 1) Central adrenal vein draining into right hepatic vein, multiple small veins draining into inferior vena cava (n = 1) Central adrenal vein draining into inferior vena cava, accessory adrenal vein draining
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