Laparoscopic adrenalectomy is considered the gold standard for the surgical management of adrenal pathology. It is the recommended treatment for both benign and malignant bilateral adrenal tumors [1]. Bilateral adrenal masses are a relatively rare occurrence, and their diagnosis requires careful consideration of a broad range of possibilities, distinct from unilateral cases [2]. These masses are more frequently associated with malignancy and tumor susceptibility syndromes. This article presents a case of bilateral adrenal masses in a patient with medullary thyroid carcinoma (MTC), which was managed with simultaneous bilateral laparoscopic adrenalectomy followed by delayed total thyroidectomy.

A 35-year-old male presented with a three-year history of intermittent abdominal pain, along with headaches and vomiting for the past four months. He had been diagnosed with hypertension four months earlier. Physical examination revealed a midline neck swelling that moved with deglutition but not with tongue protrusion.

Investigations, including blood tests and imaging, were ordered, along with fine needle aspiration cytology (FNAC) of the neck swelling. A triple-phase CT scan of the abdomen revealed bilateral adrenal adenomas. FNAC of the thyroid mass was suggestive of medullary thyroid carcinoma (MTC). Further laboratory tests showed significantly elevated 24-hour urinary metanephrines (12097.5 µg/24h), normetanephrines (1042.5 µg/24h), VMA (99.82 mg/24h), epinephrine (199.5 µg/24h), and norepinephrine (1267.5 µg/24h).

Based on these findings, a diagnosis of Multiple Endocrine Neoplasia Type 2A (MEN2A) was established. This was supported by the presence of MTC, pheochromocytoma (indicated by elevated catecholamine levels), and adrenal adenomas. The patient was started on alpha-blockers to control his hypertension, followed by beta-blockers after adequate alpha blockade was achieved.

The patient was scheduled for simultaneous bilateral laparoscopic adrenalectomy, followed by total thyroidectomy. once he became normotensive. Bilateral laparoscopic adrenalectomy was successfully performed using five ports. The surgery lasted approximately four hours with minimal blood loss of around 100 mL.

Surgical Technique

The procedure was performed under general anaesthesia. The patient was positioned in supine position. Five trocars (3 x 5 mm and 2 x 10 mm) were placed. The liver was lifted in the right hypochondrium to provide adequate access. The dissection continued until the vena cava and right renal vein were identified. After locating the right adrenal vein, it was ligated using Liga clips (Fig-1). The tumor mass was then dissected using Ligasure, revealing a direct relationship with the vena cava and renal vein (Fig-2). On the left side, the spleen is carefully dissected and mobilized to provide adequate access to the left adrenal gland. The left renal adrenal vein, which is longer than the right, is identified and carefully isolated. The ligation of the vein (Fig-3) and dissection of the adrenal gland on the left side (Fig-4)was done in a similar manner, following the same technique as on the right side. The tumor masses were extracted through an access port and placed in a specimen collection bag. Finally, the abdominal cavity is thoroughly irrigated, and the surgical site is checked for hemostasis. The cavity is then closed in layers, ensuring that all incisions are properly secured. The remaining ports are closed, and the patient is monitored for any immediate postoperative complications.

Histopathological examination of the adrenal tissue confirmed the presence of a malignant adrenal neoplasm, with tumor cells showing positivity for synaptophysin, supporting the diagnosis of pheochromocytoma.

A total thyroidectomy is planned after achieving normotension, as part of the treatment for MTC. Genetic testing for RET mutations is recommended for family screening. Regular follow-up is advised to monitor blood pressure, thyroid function, and the potential recurrence of MTC.

Fig-1: Clipped right adrenal vein

Fig-2: Right adrenal gland

Fig-3: Clipped right adrenal vein

Fig-4: Left adrenal gland

Laparoscopic surgery for adrenal tumors was first reported by Gagner et al. in 1992 [3]. It has since become the preferred surgical approach for adrenalectomy in cases like pheochromocytoma, adrenal tumors, and other adrenal pathologies, as the minimally invasive approach offers several advantages over traditional open surgery [4]. These benefits include smaller incisions, minimal blood loss, reduced infection risk, decreased postoperative pain, and faster recovery [4,5].

Although laparoscopic adrenalectomy is the treatment of choice for pheochromocytoma, there is limited experience in the literature regarding simultaneous bilateral laparoscopic adrenalectomy. A study by Castillo et al. published their experience with bilateral laparoscopic adrenalectomy in 44 patients, of which 20 patients underwent simultaneous bilateral adrenalectomy, and the remaining 2 underwent staged procedures. There was only one complication, a renal-vein injury, and the authors concluded that the procedure was technically feasible and could be performed with minimal bleeding and within a reasonable surgical time [1].

Several surgical techniques have been described for bilateral laparoscopic adrenalectomy, including anterior transperitoneal, lateral transperitoneal, retroperitoneal, and posterior retroperitoneal approaches [6]. The choice of surgical approach is often influenced by the surgeon's experience and preference. Chuan-Yu S et al. recommends the retroperitoneal approach, as it avoids interference with abdominal organs [4], while Yadav et al. preferred the transperitoneal laparoscopic approach for better identification of anatomical landmarks [6]. However, there is currently a lack of randomized controlled trials to determine the superiority of one approach over another.

Simultaneous bilateral laparoscopic adrenalectomy is a safe, time-efficient, minimally invasive procedure that offers multiple benefits, including minimal scarring, shorter hospital stays, fewer complications, and faster recovery.

1. Castillo OA, Vitagliano G, Cortes O, Kerkebe M, Pinto I, Arellano L. Bilateral laparoscopic adrenalectomy. J Endourol. 2007 Sep;21(9):1053-8. doi: 10.1089/end.2006.0182. PMID: 17941786.
2. Mohan DR, Shah R, Itani M, Awali M, Jasim S. Bilateral Adrenal Tumors: A Visual Case Series. AACE Clin Case Rep. 2024 Nov 27;11(1):79-86. doi: 10.1016/j.aace.2024.11.006. PMID: 39896942; PMCID: PMC11784626.
3. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. The New England Journal of Medicine. 1992;327(14):p. 1033. doi: 10.1056/NEJM199210013271417.
4. Chuan-Yu S, Yat-Faat H, Wei-Hong D, Yuan-Cheng G, Qing-Feng H, Ke X, Bin G, Guo-Wei X. Laparoscopic adrenalectomy for adrenal tumors. Int J Endocrinol. 2014;2014:241854. doi: 10.1155/2014/241854.
5. Mikhail AA, Tolhurst SR, Orvieto MA. Open versus laparoscopic simultaneous bilateral adrenalectomy. Urology 2006;67:693-96.
6. Tullavardhana T. Laparoscopic Adrenalectomy: Surgical Technique. World J Lap Surg 2010; 3 (2):91-97.
7. Yadav K, Bakshi G, Prakash G, Tamhankar A, Verma K. Simultaneous bilateral laparoscopic adrenalectomy for pheochromocytoma in multiple endocrine neoplasia (MEN) syndrome: Case report with review literature. Int J Surg Case Rep. 2014;5(8):487-90. doi: 10.1016/j.ijscr.2014.03.007.