Adrenal Gland Tümörlerinde Cerrahi Tedavi
Özet
Cerrahi adrenalektomi, benign ve malign adrenal tümörlerin tedavisinde özel eğitim almış cerrahlar tarafından yüksek volümlü merkezlerde gerçekleştirilmesi gereken, düşük komplikasyon riski taşıyan zorlu bir prosedürdür. Operasyonlar transabdominal, retroperitoneal veya nadiren transtorasik yaklaşımlarla; açık ya da minimal invaziv cerrahi (MİC) teknikleri kullanılarak yapılabilmektedir. Operatif yaklaşımın seçimi cerrahın tecrübesine, tümörün boyutuna, malignite şüphesine ve hastanın anatomik özelliklerine göre belirlenir. MİC, iyi huylu fonksiyonel veya fonksiyonel olmayan kitlelerin çıkarılmasında daha az kan kaybı ve daha hızlı iyileşme avantajlarıyla altın standart kabul edilirken; laparoskopik transabdominal yaklaşım büyük tümörlerde (>8 cm) ve obez hastalarda, posterior retroperitoneoskopik adrenalektomi (RPA) ise üst karın cerrahisi öyküsü olanlarda ve bilateral tümörlerde tercih edilmektedir. Adrenokortikal karsinom (ACC) gibi bilinen veya şüphelenilen malignitelerde ve 6 cm'den büyük invaziv feokromositomalarda, çevre dokuların en blok rezeksiyonuna ve vasküler kontrole olanak tanıyan açık transabdominal yaklaşım önerilmektedir. Robot yardımlı cerrahi ise özellikle sınırlı retroperitoneal alanda çalışan RPA için avantaj sağlamakta ve benzer klinik sonuçlar sunmaktadır. Ameliyat öncesinde antibiyotik, venöz tromboemboli ve antiemetik profilaksisi uygulanırken; ameliyat sonrasında hastaların takibi ve ağrı yönetimi cerrahi yaklaşıma göre 1 ila 5 gün arasında hastanede yatış süresiyle planlanmaktadır.
Surgical adrenalectomy is a challenging procedure that should be performed by specially trained surgeons in high-volume centers for benign and malignant adrenal tumors, carrying a low risk of complications. Operations can be performed via transabdominal, retroperitoneal, or rarely transthoracic approaches, utilizing either open or minimally invasive surgery (MIS) techniques. The choice of operative approach is determined by the surgeon's experience, tumor size, suspicion of malignancy, and patient's anatomical characteristics. While MIS is considered the gold standard for removing benign functional or non-functional masses due to its advantages of less blood loss and faster recovery, the laparoscopic transabdominal approach is preferred in large tumors (>8 cm) and obese patients, and posterior retroperitoneoscopic adrenalectomy (RPA) is preferred in those with a history of upper abdominal surgery and bilateral tumors. In known or suspected malignancies such as adrenocortical carcinoma (ACC) and invasive pheochromocytomas larger than 6 cm, an open transabdominal approach is recommended to allow for en bloc resection of surrounding tissues and vascular control. Robot-assisted surgery provides an advantage especially for RPA working in the limited retroperitoneal space and offers similar clinical outcomes. Preoperatively, antibiotic, venous thromboembolism, and antiemetic prophylaxis are administered, while postoperative follow-up and pain management are planned with a hospital stay ranging from 1 to 5 days depending on the surgical approach.
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