Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma

Adrenal Surgery for Cushing's Syndrome: An Update

Recent advances in the molecular pathogenesis and the natural history of Cushing's syndrome have improved the understanding of the management of this disease. The long-term efficacy of several cortisol-lowering medical treatments is currently under evaluation. However, adrenalectomy is a safe option for the treatment of patients affected by Cushing's syndrome. Unilateral adrenalectomy is the gold standard for treatment of adrenocortical adenomas associated with hypercortisolism. Bilateral adrenalectomy has been widely used in the past as definitive treatment of bilateral macronodular hyperplasia and persistent or recurrent Cushing's disease. The indication and the potential applications of this technique have been recently critically analyzed.

Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis

BACKGROUND

Adrenalectomy can be performed via open and various minimally invasive approaches. The aim of this systematic review was to summarize the current evidence on surgical techniques of adrenalectomy.

METHODS

Systematic literature searches (MEDLINE, EMBASE, Web of Science, Cochrane Library) were conducted to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing at least two surgical procedures for adrenalectomy. Statistical analyses were performed, and meta-analyses were conducted. Furthermore, an indirect comparison of RCTs and a network meta-analysis of CCTs were carried out for each outcome.

RESULTS

Twenty-six trials (1710 patients) were included. Postoperative complication rates did not show differences for open and minimally invasive techniques. Operation time was significantly shorter for open adrenalectomy than for the robotic approach (p < 0.001). No differences were found between laparoscopic and robotic approaches. Network meta-analysis showed open adrenalectomy to be the fastest technique. Blood loss was significantly reduced in the robotic arm compared with open and laparoscopic adrenalectomy (p = 0.01). Length of hospital stay (LOS) was significantly lower after conventional laparoscopy than open adrenalectomy in CCTs (p < 0.001). Furthermore, both retroperitoneoscopic (p < 0.001) and robotic access (p < 0.001) led to another significant reduction of LOS compared with conventional laparoscopy. This difference was not consistent in RCTs. Network meta-analysis revealed the lowest LOS after retroperitoneoscopic adrenalectomy.

CONCLUSION

Minimally invasive adrenalectomy is safe and should be preferred over open adrenalectomy due to shorter LOS, lower blood loss, and equivalent complication rates. The retroperitoneoscopic access features the shortest LOS and operating time. Further high-quality RCTs are warranted, especially to compare the posterior retroperitoneoscopic and the transperitoneal robotic approach.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database.

METHODS

Patient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups.

RESULTS

A total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group ($42,659 versus $33,748, p < 0.0001). There was a significant trend towards more adrenalectomies being performed robotic assisted by year. Only 22% of adrenalectomies were performed robotic-assisted in 2009 compared with 48% in 2012.

CONCLUSIONS

The overall benefit for RA remains small and higher total charges for RA may currently outweigh the benefits. These findings may change as more cases are performed robotically assisted and robotic technology improves.

Laparoscopic Adrenalectomy

Purpose

We investigated the following issues regarding laparoscopic adrenalectomy: techniques and advantages, indications in adrenal diseases, and the special case of pheochromocytoma.

Methods

Qualified literature reports were reviewed and integrated with results of our initial experience with laparoscopic adrenalectomy.

Results

Most authors prefer a transperitoneal approach, but some (including ourselves) use the retroperitoneal approach. Laparoscopic adrenalectomy is as effective and safe as traditional surgery, but the associated morbidity was found to be much lower in laparoscopic series. The need for conversion to open surgery does not exceed 5% of all cases. Practically all adrenal masses can be managed by laparoscopy. The only clinical situations where laparoscopy is not recommended as first choice are large adrenal masses (>6 cm) and gross cortical carcinoma, which are related conditions. Laparoscopy is also indicated in pheochromocytoma. No mortality and an elevated hypertension cure rate (75–100%) have been reported. Hypertension and plasma volume contraction must be normalized prior to surgery. Special attention should be paid to possible severe blood pressure variations during surgery. Partial adrenalectomy has been recently proposed for bilateral and familial pheochromocytoma in order to avoid lifelong mineral corticoid replacement therapy.

Conclusions

Laparoscopic adrenalectomy currently represents the first surgical choice for adrenal masses. Only large lesions that are suspected to be malignant should not be electively submitted to this procedure. Pheochromocytoma can be safely and effectively treated with laparoscopic surgery; special care for related symptoms is required.

Minimally invasive approaches to adrenal tumors: an up-to-date summary including patient position and port placement of laparoscopic, retroperitoneoscopic, robot-assisted, and single-site adrenalectomy

PURPOSE OF REVIEW

There are multiple minimal invasive approaches to remove the adrenal gland. The purpose of this review is to summarize the most up-to-date findings about laparoscopic, retroperitoneoscopic, robot-assisted, and single-site adrenalectomy, and to define the most common approaches to the adrenal gland.

RECENT FINDINGS

Laparoscopic adrenalectomy is the gold standard to remove adrenal tumors. New approaches are being explored to outperform the advantages of laparoscopic adrenalectomy.

SUMMARY

Retroperitoneoscopic adrenalectomy, when performed by skilled surgeons, offers an alternative to the conventional laparoscopic approach, with better outcome. The robot-assisted and single-site approaches still need further studies to fully identify their roles in adrenalectomy.

Laparoscopic Versus Open Adrenalectomy for Localized/Locally Advanced Primary Adrenocortical Carcinoma (ENSAT I-III) in Adults: Is Margin-Free Resection the Key Surgical Factor that Dictates Outcome? A Review of the Literature

BACKGROUND

The aim of this study was to review the current literature on the role of laparoscopic adrenalectomy (LA) in the treatment of primary adrenocortical carcinoma (ACC; European Network for the Study of Adrenal Tumors [ENSAT] I-III) in adults.

MATERIALS AND METHODS

Nonrandomized controlled trials published between January 1999 and February 2017 were identified by searching the Pubmed, EMBASE, Cochrane Library, and Google Scholar databases. Primary and secondary endpoints included surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, and period of follow-up), surgical outcomes (operative time, estimated blood loss, length of hospital stay, conversion rate to laparotomy, R0 resection, and surgical margin's status), and oncological outcomes (rate of recurrence, disease-free survival [DFS], and overall survival [OS] rates).

RESULTS

A total of 13 studies encompassing data on 1171 patients were included in the review. Compared with open approach, LA demonstrated lower tumor size, shorter operative time, lower intraoperative blood loss, shorter postoperative hospital stay, and equivalent local recurrence rates. No significant differences were observed between groups treated with an open or laparoscopic approach for the following criteria: R0 surgical resection status, tumor overall recurrence, and postoperative DFS and OS rates.

CONCLUSIONS

LA appears to be equivalent to open method for localized/locally advanced primary ACC (ENSAT I-III) in terms of R0 resection rate, overall recurrence, DFS, and OS, therefore suggesting that the extent of surgery with adequate tumor resection is the predominant endpoint, rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods exploring the long-term oncological outcomes are required to determine the benefits of the laparoscopic over the open approach in adrenocortical carcinoma.

Obesity does not affect peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy

Laparoscopic adrenalectomy is the gold standard procedure for most adrenal tumors. Obesity is considered as a risk factor for surgical complications. This study aimed to evaluate whether obesity affects peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy using body mass index (BMI). This retrospective study included 98 patients who underwent transabdominal laparoscopic adrenalectomy between January 2011 and December 2016. We divided the patients into 2 groups: non-obese group (BMI < 25 kg/m2) and obese group (BMI ≥ 25 kg/m2). We assessed perioperative outcomes and postoperative complications between the groups. A total of 98 patients were analyzed (70 without obesity and 28 with obesity). There were no significant differences between the non-obese and obese groups regarding operative time (111 vs 107 min; p = 0.795), blood loss (3.5 vs 3.5 ml; p = 0.740), rate of placement of additional trocars (14.3% vs 17.9%; p = 0.657), rate of open conversion (2.6% vs 3.6%; p = 0.853), and postoperative length of hospital stay (6 vs 5 days; p = 0.237). Furthermore, obesity was not a significant risk factor for postoperative complications (postoperative bleeding, wound infection, and pneumonia). There are no significant differences in peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy in patients with obesity compared with those without obesity. Transabdominal laparoscopic adrenalectomy is feasible and safe for patients with obesity.

Factors related to improved clinical outcomes associated with adrenalectomy for metachronous adrenal metastases from solid primary carcinomas

BACKGROUND

Surgery for metachronous adrenal metastases from solid primary carcinoma has increased with the development of technical skills. Here we analyzed the postoperative clinical outcomes of patients who underwent adrenalectomy for metachronous adrenal metastases from solid primary carcinomas.

METHODS

Patients who underwent adrenalectomy for metachronous adrenal metastases after initial treatment of primary carcinoma at Asan Medical Center from 2000 to 2010 were included. Clinicopathological parameters were analyzed to evaluate prognostic outcomes.

RESULTS

A total of 30 patients with 19 hepatocellular carcinomas and 11 lung carcinomas were included. The mean age was 54.3 years. The mean time until adrenalectomy was 23 months. The size of the metastatic adrenal tumor and the disease status of the primary carcinoma at the time of adrenalectomy were associated with second recurrence after adrenalectomy (P < 0.05). There was no significant difference in disease-specific recurrence-free survival between patients who underwent open adrenalectomy and laparoscopic adrenalectomy (P = 0.646).

CONCLUSIONS

Surgical treatment should be recommended for metachronous adrenal metastases in patients with no evidence of primary carcinoma and/or in those having metastatic adrenal tumors ≤4.4 cm. This approach may increase the recurrence-free interval related to second recurrence. Further, laparoscopic adrenalectomy appears sufficient for the treatment of such patients.

Right adrenal gland pseudocyst masquerading as a large symptomatic hepatic cyst: Single incision laparoscopic (SILS) resection and a review of current literature

Adrenal pseudocysts are rare entities, which are usually asymptomatic. Large symptomatic adrenal pseudocysts may cause compressive symptoms. The etiology of these cysts is unknown, although the cyst wall is all lined by fibrous tissue, without any epithelial or endothelial lining. We report a case of a 26-year-old lady who presented with a symptomatic right adrenal pseudocyst measuring 7.6 cm in size. Magnetic resonance imaging confirmed the presence of a right retroperitoneal cystic lesion which was hyperintense on T2 sequencing. An attempted single incision transumbilical laparoscopic surgery (SILS) was performed to excise the right adrenal pseudocyst. However, due to the retro-hepatic nature of the lesion and as the medial wall of the cyst was adherent to the inferior vena cava, an additional 5 mm port was inserted to facilitate retraction of the liver. The post-operative period was uneventful. She was successfully discharged from the hospital as a day surgery patient. The final pathology showed an adrenal pseudocyst.

Laparoscopic adrenalectomy using the lateral retroperitoneal approach: Is it a safe and feasible treatment option for pheochromocytomas larger than 6 cm?

OBJECTIVES

To evaluate the surgical feasibility of laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of large pheochromocytomas, and to identify the preoperative risk factors for intraoperative hypertension.

METHODS

We retrospectively reviewed 51 patients who underwent laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of pheochromocytomas. Patient characteristics and perioperative outcomes were analyzed and compared between the two study groups based on tumor size: group A (n = 27, ≤6 cm) and group B (n = 24, ˃6 cm).

RESULTS

There was no significant difference in preoperative characteristics between the two groups except for tumor size (P = 0.001) and urinary metanephrine (P = 0.011). Group B patients required longer operating time (P = 0.008), had a greater estimated blood loss (P = 0.001) and hemoglobin change (P = 0.002). However, no significant differences were observed in perioperative complications and mortality. Multivariate analysis showed that symptomatic pheochromocytomas (P = 0.004) and tumor size (P = 0.007) were significant risk factors for intraoperative hypertension.

CONCLUSIONS

Laparoscopic adrenalectomy using the lateral retroperitoneal approach for pheochromocytomas can be regarded as a treatment option, even for tumors measuring >6 cm. Symptomatic pheochromocytomas and large tumor size seem to represent risk factors for intraoperative hypertension.

Retroperitoneal laparoscopic adrenalectomy with transient renal artery occlusion for large adrenal tumors (≥8 cm)

OBJECTIVES

To analyze our experience in retroperitoneal laparoscopic adrenalectomy (RLA) with transient renal artery occlusion for large adrenal tumors (≥8 cm) and to explore the safety and feasibility of this surgical procedure.

METHODS

A retrospective cohort study was conducted with a surgical data review of 18 patients with large adrenal tumors who underwent RLA with transient renal artery occlusion in our hospital.

RESULTS

Eighteen patients were treated by RLA with transient occlusion of the renal artery, and none were converted to open adrenalectomy. The renal artery occlusion time, operative time, estimated blood loss, perirenal drainage time, postoperative hospital stay, and postoperative drainage were 7.6 ± 1.0 min, 176.3 ± 49.7 min, 247.2 ± 274.1 mL, 4.1 ± 1.02 days, 6.3 ± 1.4 days, and 73.6 ± 47.9 mL, respectively. No severe complications occurred, with the exception of hemodynamic instability in one patient with a pheochromocytoma and one transfusion during the operation. Only one case of adrenal crisis occurred postoperatively. Pathological examination revealed 9 cases of pheochromocytoma, 6 cases of adrenal myelolipoma, 1 case of adrenal ganglioneuroma, 1 case of hygromata, and 1 case of adrenal teratoma. No recurrence or evidence of metastasis was observed during the 7-to-30-month follow-up period.

CONCLUSION

RLA with transient renal artery occlusion is a feasible, effective, and safe treatment for large adrenal tumors (≥8 cm).

Application of Three-Dimensional Visualization Technology in Laparoscopic Surgery for Pheochromocytoma/Paraganglioma: A Single-Center Experience

OBJECTIVE

To compare the feasibility of three-dimensional visualization technology (3DVT) with that of routine computed tomography (CT) examination during planning of laparoscopic surgery for pheochromocytoma (PHEO) and paraganglioma (PGL) and the effects on operative and postoperative outcomes.

PATIENTS AND METHODS

The clinical data for 36 patients who underwent laparoscopic surgery for PHEO/PGL in our department from January 2016 to April 2017 were analyzed retrospectively. Fourteen patients underwent laparoscopic surgery for PHEO/PGL after preoperative 3DVT-based assessment and 22 after conventional CT examination. The demographic parameters, surgical procedures used, and perioperative outcomes were compared between the two groups. Data were entered into a Microsoft Excel worksheet and analyzed using SPSS version 24.0.

RESULTS

No significant differences were found between the groups with regard to age, gender, body mass index, tumor size, surgical approach, estimated blood loss, mean length of hospital stay, number of hypertensive and hypotensive episodes during surgery, peak blood pressure (BP) values during tumor handling, and minimum values after tumor excision. However, the operating time was significantly shorter and the fluctuations in BP were significantly lower in the 3DVT group.

CONCLUSIONS

3DVT is a feasible and useful preoperative assessment method in patients undergoing laparoscopic surgery for PHEO/PGL. This imaging technique accurately shows the relationship between the tumor and peripheral structures and aids the surgeon's understanding of the anatomic structure in the operative area and in surgical planning.

Endocrine-specific NIR fluorophores for adrenal gland targeting

The adrenal glands (AGs) are relatively small yet require definitive identification during their resection, or more commonly their avoidance. To enable image-guided surgery involving the AGs, we have developed novel near-infrared (NIR) fluorophores that target the AGs after a single intravenous injection, which provided dual-NIR image-guided resection or avoidance of the AGs during both open and minimally-invasive surgery.

Randomized trial of low versus high carbon dioxide insufflation pressures in posterior retroperitoneoscopic adrenalectomy

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy has gained widespread acceptance for the removal of benign adrenal tumors. Higher insufflation pressures using carbon dioxide (CO₂) are required, although the ideal starting pressure is unclear. This prospective, randomized, single-blinded, study aims to compare physiologic differences with 2 different CO₂ insufflation pressures during posterior retroperitoneoscopic adrenalectomy.

METHODS

Participants were randomly assigned to a starting insufflation pressure of 20 mm Hg (low pressure) or 25 mm Hg (high pressure). The primary outcome measure was partial pressure of arterial CO₂ at 60 minutes. Secondary outcomes included end-tidal CO₂, arterial pH, blood pressure, and peak airway pressure. Breaches of protocol to change insufflation pressure were permitted if required and were recorded.

RESULTS

A prospective randomized trial including 31 patients (low pressure: n = 16; high pressure: n = 15) was undertaken. At 60 minutes, the high pressure group had greater mean partial pressure of arterial CO₂ (64 vs 50 mm Hg, P = .003) and end-tidal CO₂ (54 vs 45 mm Hg, P = .008) and a lesser pH (7.21 vs 7.29, P = .0005). There were no significant differences in base excess, peak airway pressure, operative time, or duration of hospital stay. Clinically indicated protocol breaches were more common in the low pressure than the high pressure group (8 vs 3, P = .03).

CONCLUSION

In posterior retroperitoneoscopic adrenalectomy, greater insufflation pressures are associated with greater partial pressure of arterial CO₂ and end-tidal CO₂ and lesser pH at 60 minutes, be significant. Commencing with lesser CO₂ insufflation pressures decreases intraoperative acidosis.

Single center experience with laparoscopic adrenalectomy on a large clinical series

BACKGROUND

Laparoscopic adrenalectomy is considered the gold standard technique for the treatment of benign small and medium size adrenal masses (<6 cm), due to low morbidity rate, short hospitalization and patient rapid recovery. The aim of our study is to analyse the feasibility and efficiency of this surgical approach in a broad spectrum of adrenal gland pathologies.

METHODS

Pre-operative, intra-operative and post-operative data from 126 patients undergone laparoscopic adrenalectomy between January 2003 and December 2015 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in case of pheochromocytoma while spironolactone and potassium were employed to treat Conn's disease. Laparoscopic adrenalectomies were all performed by the same surgeon (CG). First 30 procedures were considered as learning curve adrenalectomies.

RESULTS

One hundred twenty-six patients were included in the study. Functioning tumors were diagnosed in 84 patients, 27 patients were affected by pheochromocytomas, 29 by Conn's disease, 28 by Cushing disease. Surgery mean operative time was 137.33 min (range 100-180) during the learning curve adrenalectomies and 96.5 min (range 75-110) in subsequent procedures. Mean blood loss was respectively 160.2 ml (range 60-280) and 90.5 ml (range 50-200) in the first 30 procedures and the subsequent ones. Only one conversion to open surgery occurred. No post-operative major complications were observed, while minor complications occurred in 8 patients (0,79%). In 83 out of 84 functioning neoplasms, laparoscopic adrenalectomy was effective in normalization of endocrine profile.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe and feasible procedure, even for functioning masses and pheochromocytomas. A multidisciplinary team including endocrinologists, endocrine surgeons and anaesthesiologists, is recommended in the management of adrenal pathology, and adrenal surgery should be performed in referral high volume centers. A thirty-procedures learning curve is recommended to improve surgical outcomes.

Is there any role for minimally invasive surgery in NET?

Neuroendocrine tumors (NET) represent the variability of almost benign lesions either secreting hormones occurring as a single lesion up to malignant lesions with metastatic potential. Treatment of NET is usually performed by surgical resection. Due to the rarity of NET, surgical treatment is mainly based on the experience and recommendations of experts and less on the basis of prospective randomized studies. In addition, the development and establishment of new surgical procedures is made more difficult by their rarity. The development of laparoscopic-assisted surgery has significantly improved the treatment of many diseases. Due to the well-known advantages of laparoscopic surgery, this method has also been increasingly used to treat NET. However, due to limited comparative data, the assumed superiority of laparoscopic surgery in the area NET remains often unclear or not yet proven. This review focuses on the present usage of laparoscopic techniques in the area of NET. Relating to the current literature, this review presents the evidence of various laparoscopic procedures for treatment of adrenal, pancreatic and intestine NET as well as extraadrenal pheochromocytoma and neuroendocrine liver metastases. Further, this review focuses on recent new developments of minimally invasive surgery in the area of NET. Here, robotic-assisted surgery and single-port surgery are promising approaches.

Innovation in endocrine surgery: robotic versus laparoscopic adrenalectomy. Meta-analysis and systematic literature review

Several studies in the last years demonstrated the better surgical outcome of laparoscopic approach to adrenal gland. Laparoscopic surgery is more difficult to learn and requires different psychomotor skills than open surgery, especially with regard to complex maneuvers requiring precision and dexterity. The development of robotic platform with three-dimensional vision and increased degrees of freedom of the surgical instruments has the aim to overcome these problems. We performed a systematic literature review with meta-analysis to evaluate preoperative data and surgical outcomes of robotic adrenalectomy compared with laparoscopic technique. In September 2016 we performed a systematic literature review using the Pubmed, Scopus and ISI web of knowledge database with search term “robotic adrenalectomy”. We identified 13 studies with eligible criteria that compared surgical outcomes. This present systematic review with meta-analysis includes 798 patients: 379 underwent to robotic adrenalectomy (cases group) and 419 to laparoscopic adrenalectomy (controls group). There were no significant differences between the two groups of patients respect to age, gender, laterality and tumor size. BMI instead was significant lower in the robotic group. In this group we found also patients with higher incidence of previous abdominal surgery. The results from operative time demonstrated lower operative time for laparoscopic group but there were no significant differences with robotic group. Robotic adrenalectomy showed a significant lower blood loss. Robotic adrenalectomy is a safe and feasible technique with reduced blood loss and shorter hospital stay than laparoscopic adrenalectomy. Laparoscopic approach seems to be a more rapid technique when comparing to robotic technique, although recent studies demonstrate a significant operative time reduction in robotic group with the learning curve improvement and the development of new surgical technology.

Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses

OBJECTIVE

To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD).

METHODS

A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied.

RESULTS

TLPD involved longer operative time (weighted mean difference [WMD]: 116.85 min; 95% confidence interval [CI] 54.53-179.17) and significantly shorter postoperative hospital stay (WMD: -3.68 days; 95% CI -4.65 to -2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types.

CONCLUSIONS

Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

Laparoscopic Surgery in Urologic Oncology

Background

Techniques in genitourinary oncologic surgery have evolved over the past several years, shifting from traditional open approaches toward minimally invasive routes by laparoscopy.

Methods

We reviewed the literature on laparoscopic surgery for genitourinary cancer, with emphasis on contemporary indications, complications, and oncologic outcome of laparoscopic surgery for urologic malignancies.

Results

All urologic oncology procedures have been performed laparoscopically. Laparoscopic radical nephrectomy is becoming the preferred approach for managing kidney cancer. The initial experience with nephroureterectomy is encouraging. Laparoscopic radical prostatectomy is rapidly becoming the standard in Europe and is the procedure of choice in many centers in the United States.

Conclusions

When following the open oncologic principles for the surgical treatment of malignancies, laparoscopy offers similar oncologic clinical outcomes, less morbidity, improved operative precision, and reduced convalescence time.

Laparoscopic Liver Resection of Right Posterior Segments for Hepatocellular Carcinoma on Cirrhosis

BACKGROUND

Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver malignancies. Liver resection with laparoscopic approach was first adopted for tumors located in the peripheral portion of the anterolateral segments of the liver, but recent experiences in literature modified the attitude toward that approach. We herein report our technique and outcomes of LLR for hepatocellular carcinoma (HCC) located in the right-posterior segments of the liver (VI and VII).

MATERIALS AND METHODS

We retrospectively reviewed our prospectively maintained database, comparing peri- and postoperative outcomes of patients who underwent laparoscopic (13 patients) or open (51 patients) resections for HCC localized in the right-posterior segments between 2000 and 2014.

RESULTS

The two populations were homogeneous, showing no statistically significant differences in terms of gender, age, body mass index, and cirrhosis prevalence. Alpha-fetoprotein levels were higher in the open group (P = .04) and etiology of cirrhosis varied in a statistically significant manner (P = .01). The laparoscopic group showed an improved perioperative outcome with statistically significant less postoperative morbidity (P = .01) and less in-hospital stay (P = .0001). No differences were found in terms of blood loss or operative time, but any Pringle maneuver was needed (P = .04).

CONCLUSIONS

Patients affected by HCC localized in the right-posterior segments of the liver can be safely treated with laparoscopic approach. However, this kind of procedure can be challenging and should be performed in tertiary referral hospitals to provide the patient the best care, with the integration of different specialties.

Patients criteria determining difficulty of the laparoscopic lateral transperitoneal adrenalectomy. A retrospective cohort study

BACKGROUND

Identification of patients in whom adrenalectomy may be more difficult, can help in decision making in borderline and doubtful cases. The aim of the study was to determine patients criteria influencing difficulty of laparoscopic lateral transperitoneal adrenalectomy (LTA).

MATERIAL AND METHODS

The study enrolled 275 patients who underwent LTA. We analyzed the impact of gender, age, history of previous abdominal surgery, body mass index, risk of anesthesia measured as ASA scale, size, localization (left/right), and histological type of the tumor on parameters reflecting the level of difficulty of the procedure: operative time, intraoperative blood loss, conversion rate and intraoperative complications rate.

RESULTS

Multivariate logistic regression showed that following factors were associated with longer operative time: gender, tumor size and malignant lesions. In another model it was shown that age, size of the tumor and malignancy were associated with more excessive blood loss. Moreover, it was shown, that tumor size predictive factor for conversion. Univariate analysis showed a relation with malignancy, but multivariate analysis revealed no significance.

CONCLUSIONS

Patient age, gender, size and histological type of the tumor are criteria influencing parameters reflecting the level of difficulty. This criteria could be considered as predictors of the difficulty of LTA. Surgery in case of patients with combination of this risk factors should be handled by surgeon with sufficient experience to minimalize the risk of adverse events.

Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review

Aim

We described the use of a hand-port assisted laparoscopic adrenalectomy for excising a large 10 cm vascular left adrenal pheochromocytoma. The useful technical tips and important pitfalls to avoid for a successful outcome are discussed in this article.

Introduction

A 64-year-old man who was investigated for microalbuminuria was found to have a 10-cm left adrenal mass. Blood investigation and imaging confirmed it to be a pheochromocytoma.

Case report

Initial mobilization of the adrenal mass was performed laparoscopically using two 5-mm ports in the epigastric. While dissecting the inferomedial pedicle, the aberrant adrenal vessel was injured and resulted in torrential bleeding. A gelport for hand assistance was inserted as a salvage approach for hemostasis.

Conclusion

Hand-port assisted laparoscopic adrenalectomy is a very practical and easy-to-adopt technique that preserves the minimally invasive surgical advantages in patients with large adrenal masses.

Clinical significance: We advocate the use of hand-assisted laparoscopic adrenalectomy technique for complex pheochromocytoma as an alternative for surgeons with vast experience in laparoscopic adrenalectomy.

How to cite this article

Lee DJK, Tan YP, Singaporewalla RM. Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review. World J Endoc Surg 2017;9(1):27-31.

Lateral retroperitoneoscopic adrenalectomy for complicated adrenal tumor larger than 5 centimeters

BACKGROUND

The role of lateral retroperitoneoscopic adrenalectomy (LRA) for complicated tumor with large diameter remains controversial, this study aimed to evaluate the effectiveness of this procedure on the management of tumor larger than 5cm in diameter.

METHODS

A retrospective comparison was conducted of 67 patients with large complicated adrenal tumor (>5cm). 41 patients received LRA, and 26 received open adrenalectomy (OA) in our hospital between January 2011 and June 2015. Basic characteristics regarding mean age, gender, body mass index (BMI), tumor size, tumor side, previous abdominal surgery, resection method, pathology were preferentially analyzed. Operative indicators regarding operation time, estimated blood loss (EBL), conversion to ICU, complications, post-operative hospitalization, duration of drain, time to first oral intake and ambulation were compared between groups.

RESULTS

There were no significant differences between the two groups in the basic characteristics. The mean operation time for LRA was shorter than OA (98.7±32.3 min vs 152.7±72.3 min, P = 0.001). EBL was 31.9±20.0 ml for LRA and 590.0±1181.1 ml for OA (P = 0.03). There was no complication in LRA group and one patient in OA group had complications, but this difference was not significant (P = NS). The post-operative hospitalization in LRA was 7.4±2.8 days, and shorter than 9.8±2.7 days in OA group (P = 0.00). The time to first oral intake and ambulation for LRA was shorter than OA (first oral intake, 1.9±0.8 days vs 3.1±1.3 days, P = 0.00; time to ambulation, 2.6±1.4 days vs 4.2±1.6 days, P = 0.00). While the difference between groups were not significant in terms of ICU conversion (3/41 vs 4/26, P = NS) and duration of drain (3.9±2.2 days vs 4.7±1.9 days, P = NS).

CONCLUSION

Our study shows that LRA can be performed safely and effectively for complicated adrenal tumors larger than 5 cm in diameter, but it remains technically demanding.

European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma

BACKGROUND

Radical surgery provides the best chance of cure for adrenocortical carcinoma (ACC), but perioperative surgical care for these patients is yet to be standardized.

METHODS

A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, and were discussed until consensus was reached within the group.

RESULTS

Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged.

CONCLUSION

The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC.

Comparative outcomes of lateral transperitoneal adrenalectomy versus posterior retroperitoneoscopic adrenalectomy in consecutive patients: A single surgeon's experience

BACKGROUND

Among several minimally invasive adrenalectomy techniques, lateral transperitoneal adrenalectomy (LTA) is the procedure of choice for benign adrenal tumors; however, posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative that is increasing in popularity. This study compared the outcomes of these two approaches.

METHODS

Since a single surgeon started adrenalectomy, LTA had been performed exclusively until PRA was adopted and became the standard treatment. Therefore, the consecutive patients were allocated into two groups according to the date of surgery: the first group received LTA and the second group received PRA.

RESULTS

LTA was performed in 29 patients and PRA in 19 patients. There was no difference in sex, age, body mass index, clinical diagnosis, and tumor size between the LTA and the PRA group. The PRA group showed less blood loss (117.0 mL vs. 58.5 mL, p = 0.035) and tended to have a shorter operating time (92.2 minutes vs. 78.1 minutes, p = 0.054) and less pain score on postoperative Day 1 (3.8 vs. 3.0, p = 0.095) and Day 2 (3.2 vs. 2.5, p = 0.051). The mean operation time was significantly shorter for patients in the PRA group undergoing right adrenalectomy (109.2 minutes vs. 80.5 minutes, p = 0.009), but those undergoing left adrenalectomy had a similar operating time to the LTA group (83.2 minutes vs. 74.8 minutes, p = 0.380).

CONCLUSION

PRA is a good alternative operative technique for an endocrine surgeon who is experienced in the transperitoneal approach.

Transperitoneal laparoscopic adrenalectomy: a review and single-center experience

Background: Laparoscopic adrenalectomy (LA) is the preferred approach to adrenal gland tumors.

Objective: To evaluate the perioperative and functional outcomes of transperitoneal LA.

Methods: We retrospectively reviewed data of all consecutive patients who underwent transperitoneal LA at our institution between April 2000 and December 2011.

Results: Two hundred two patients with mean age of 46 years were included in the study. There were 109 left, 89 right, and 4 bilateral tumors. Preoperative diagnosis included 126 aldosterone-producing adenomas (APA), 33 patients with Cushing syndrome, 19 pheochromocytomas, 20 nonfunctional tumors, and 4 adrenal metastases. Mean tumor size was 3.3 cm (range 0.4-22 cm). Mean operative time was 109 min and estimated blood loss 90 mL for unilateral adrenalectomy; and 195 min and 300 mL for bilateral adrenalectomy. Four patients with pheochromocytoma required transfusion and 2 required conversion to an open approach. Seven intraoperative complications and 18 30-day postoperative complications occurred. These included 5 major complications (Clavien-Dindo grade 3-5). Ninety-seven percent of APA patients had normal serum potassium levels after surgery. Among the patients with functioning endocrine tumors, complete resolution rate from secondary hypertension was significantly higher in the pheochromocytoma group compared with those with APA or Cushing syndrome (82% vs. 48% vs. 68% respectively, p = 0.02). Mean follow up was 35.2 months.

Conclusion: LA is the treatment of choice for most adrenal gland tumors with excellent outcomes and low complication rates. There was a high chance for complete resolution of secondary hypertension after surgery for pheochromocytoma.

Laparoscopic versus robotic adrenalectomy: A comprehensive meta-analysis

BACKGROUND

The benefit of robotic adrenalectomy (RA) compared to laparoscopic adrenalectomy (LA) is still debatable. The purpose of this paper was to systematically review and synthesize all available evidence comparing RA to LA so as to evaluate which procedure provides superior clinical outcomes.

METHODS

A systematic literature search of PubMed and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 31, 2016). Data on perioperative variables were extracted by three independent reviewers. Data were pooled using a random-effects model.

RESULTS

Twenty-seven studies were included in this review (13 comparative and 14 non-comparative). Overall, 1162 patients underwent adrenalectomy (747 treated with RA and 415 with LA). There was no significant difference between the robotic and the laparoscopic groups for intraoperative complications (OR: 1.20; 95%CI, 0.33-4.38), postoperative complications (OR: 0.69; 95% CI, 0.36-1.31), mortality (OR: 0.42; 95%CI, 0.07-2.72), conversion to laparotomy (OR: 0.51; 95%CI, 0.21-1.23), conversion to laparotomy or laparoscopy (OR: 0.73; 95%CI, 0.32-1.69) and blood loss (WMD: -9.78; 95%, -22.10 to 2.53). For patients treated with RA, there was a significantly shorter hospital stay (WMD: -0.40; 95% CI, -0.64 to -0.17) and a significantly longer operating time (WMD: 15.60; 95%CI, 2.12 to 29.08).

CONCLUSIONS

Robotic adrenalectomy is a safe and feasible procedure with similar clinical outcomes as the laparoscopic approach in selected patient populations. High quality RCTs as well as uniform and detailed reporting of outcomes are needed to determine the role and cost-effectiveness of robotic adrenal surgery in the years to come.

Laparoscopic left and right adrenalectomy from an anterior approach - is there any difference? Outcomes in 176 consecutive patients

Introduction

Traditionally, in open surgery, right adrenalectomy is considered technically more demanding than its left-sided counterpart. This belief is supposed to be attributable mainly to different anatomic characteristics of the adrenal veins. Whether this opinion is also correct for laparoscopic adrenalectomy remains elusive.

Aim

To compare the outcomes of left versus right laparoscopic adrenalectomy from an anterior approach.

Material and methods

Retrospective statistical analysis of a prospectively compiled database of consecutive patients undergoing laparoscopic adrenalectomy in a single center with focus on potential differences in the left- versus right-sided procedure in terms of demographic parameters, tumor size, operating time, occurrence of serious intraoperative complications, conversion, length of hospital stay and re-operation rate.

Results

One hundred seventy-six patients underwent elective laparoscopic adrenalectomy – 80 left-sided (45.45%) and 96 right-sided (54.55%). No significant difference was found between the groups in terms of age (54.09 ±11.2 vs. 56.27 ±11.6; p = 0.2), tumor size (3.39 ±1.86 vs. 3.26 ±1.66; p = 0.64), operating time (71.84 ±22.33 vs. 72.06 ±30.99; p = 0.95), occurrence of serious intraoperative complications (7.5% vs. 10.4%; p = 0.5), conversion (1.25% vs. 1.04%; p = 0.9), length of hospital stay (4.52 ±1.30 vs. 4.37 ±1.91; p = 0.55) or reoperation rate (5% vs. 1%; p = 0.11). There was no mortality.

Conclusions

No significant difference was found between the left and right laparoscopic adrenalectomy in terms of operating time, occurrence of serious intraoperative complications, conversion rate or postoperative outcome. Therefore, the opinion that the right-sided procedure is more difficult does not seem to be justified for laparoscopic adrenalectomy from the anterior approach.

Robotic assisted adrenalectomy: Is it ready for prime time?

Adrenal surgery is undergoing continuous evolution and minimally invasive surgery is increasingly being used for the surgical management of adrenal masses. With robotic-assisted surgery being a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma, the use of the robot has been expanded to include robotic-assisted adrenalectomy, offering an alternative minimally invasive platform for adrenal surgery. We performed a literature review on robotic-assisted adrenalectomy, reviewing the current surgical techniques and perioperative outcomes.

Risk factors for complications after adrenalectomy: results from a comprehensive national database

PURPOSE

Most knowledge regarding outcome after adrenal surgery stems from retrospective studies reported by highly specialized centres. The aim of this study was to report a national experience of adrenalectomy with particular attention to predictive factors for postoperative complications, conversion from endoscopic to open surgery and length of hospital stay.

METHODS

Adrenalectomies reported in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009-2014 were included. Risk factors for complications, conversion and hospital stay >3 days were assessed using univariable and multivariable logistic regression analysis.

RESULTS

There were 659 operations. Endoscopic adrenalectomy was performed in 513 (77.8%) operations and almost half of these were robotic assisted. The median length of hospital stay was 3 (range 1-30) days. There was no 30-day mortality. In 43 (6.6%) patients, at least one complication was registered. The only factor associated with complications in multivariable analysis was conversion to open surgery odds ratio (OR) 3.61 (95% confidence interval 1.07 to 12.12). The risk for conversion was associated with tumour size OR 1.03 (1.00 to 1.06) and with malignancy on histopathology OR 8.33 (2.12 to 32.07). Length of hospital stay increased in patients with operation of bilateral tumours OR 3.13, left-sided tumours OR 1.98, hyper secretion of catecholamines OR 2.32, conversion to open surgery OR 42.05 and open surgery OR 115.18.

CONCLUSIONS

The present study shows that endoscopic surgery is widely used. Complications were associated with conversion and the risk for conversion was associated with tumour size and malignant tumour. Hospital stay was short.

Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy: a shift to a new golden standard?

Purpose

There has been an increased utilization of the posterior retroperitoneal approach (PRA) for adrenalectomy alongside the “classic” laparoscopic transabdominal technique (LTA). The aim of this study was to compare both procedures based on outcome variables at various ranges of tumor size.

Methods

A retrospective analysis was performed on 204 laparoscopic transabdominal (UMC Groningen) and 57 retroperitoneal (UMC Utrecht) adrenalectomies between 1998 and 2013. We applied a univariate and multivariate regression analysis. Mann-Whitney and chi-squared tests were used to compare outcome variables between both approaches.

Results

Both mean operation time and median blood loss were significantly lower in the PRA group with 102.1 (SD 33.5) vs. 173.3 (SD 59.1) minutes (p < 0.001) and 0 (0–200) vs. 50 (0–1000) milliliters (p < 0.001), respectively. The shorter operation time in PRA was independent of tumor size. Complication rates were higher in the LTA (19.1%) compared to PRA (8.8%). There was no significant difference in recovery time between both approaches.

Conclusions

Application of the PRA decreases operation time, blood loss, and complication rates compared to LTA. This might encourage institutions that use the LTA to start using PRA in patients with adrenal tumors, independent of tumor size.

Adrenal masses: A urological perspective

Adrenal masses have become increasingly common due to widespread use of sectional imaging. Urologists are commonly faced with management decisions in patients with adrenal masses. Systemic review of available literature related to surgical adrenal disease was performed to summarise the most pertinent information related to adrenal masses, diagnostic evaluation and surgical treatment. Detailed hormonal evaluation of adrenal disease was not included, being part of endocrinological rather than urological practice. Adrenal masses exhibit a wide spectrum of presentation and pathology, and treatment requires different surgical techniques. Full understanding of the pathology and management of such masses should be completely familiar to practicing urologists.

Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery

Background

Laparoscopic adrenalectomy is an effective method for benign adrenal tumor removal. In the literature, both lateral transperitoneal (TLA) and posterior retroperitoneoscopic (RPA) approaches are described. Since 2007, the number of patients increased significantly in our center. Therefore, RPA was introduced in 2011 because of its potential advantages in operating and recovery times. The learning curve of RPA is now evaluated.

Methods

All data of patients undergoing laparoscopic adrenalectomy from 2007 until 2014 were prospectively collected. Patients were eligible for RPA with a tumor <7 cm, with BMI < 35 kg/m², and with low suspicion of malignancy. The learning curve of RPA was measured by operating time. Furthermore, blood loss, preoperative complications and hospital stay were analyzed. Descriptive statistics were performed using SPSS 20.0.

Results

In the study period, 290 patients underwent surgery, of whom 113 underwent RPA. After starting with RPA, operating times decreased significantly (median 100 min in the first 20 patients to 60 min after 40 patients, p < 0.05). There was a significant difference in operating times (median 108 vs. 62 min, p < 0.05) and hospital stay (median 4 vs. 3 days, p < 0.05) in unilateral surgery in favor of RPA, compared to TLA. Also in bilateral surgery, operating times were significantly shorter (median 236 vs. 117 min, p < 0.05). In both groups, few major complications occurred.

Conclusion

After the introduction of RPA, a short learning curve was seen for a single surgeon with extensive experience in laparoscopic adrenal surgery. Compared to TLA, RPA has significant advantages in operating times and hospital stay. Therefore, RPA may be the preferred approach for patients with BMI < 35 kg/m² and small benign adrenal tumors (<7 cm).

Laparoscopic transperitoneal adrenalectomy in morbidly obese patients is not associated with worse short-term outcomes

OBJECTIVES

To evaluate the impact of obesity and morbid obesity on short-term outcomes after laparoscopic adrenalectomy.

METHODS

The study included 520 consecutive patients undergoing laparoscopic adrenalectomy for adrenal tumor. The entire study group was divided depending on the body mass index: group 1 (normal weight), <25 kg/m² ; group 2 (overweight), 25-30 kg/m² ; and group 3 (obese) 30-40 kg/m² . Additionally, group 4 (morbidly obese) was distinguished. Study end-points were: operative time, intraoperative blood loss, total length of hospital stay, morbidity rate and 30-day readmission rate.

RESULTS

The mean operative times were 88.8, 94.7, 93.5, and 99.9 min in groups 1, 2, 3 and 4, respectively (P = 0.1444). Complications were comparable between groups (12.8% vs 8.8% vs 8.2% vs 11.5%, P = 0.5295). The mean intraoperative blood loss was 66.8 versus 78.3 versus 60.7 versus 92.4, P = 0.1399. There were no differences in conversion rate between groups.

CONCLUSIONS

Obesity has no influence on short-term outcomes of laparoscopic transperitoneal adrenalectomy. This procedure is feasible regardless of the body mass index. Therefore, it can be offered to all patient groups including those morbidly obese individuals in whose case preoperative weight loss seems unnecessary.

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan

OBJECTIVE

To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan.

METHODS

Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates.

RESULTS

Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series.

CONCLUSIONS

Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma

Perioperative hemodynamic instability still remains the biggest surgical and anesthetic challenge in surgery for pheochromocytoma. The aim of this review was to discuss pre-, intra- and postoperative factors that may impact on hemodynamic condition of a patient. It describes patients' preparation with appropriate medication, principles of surgical technique as well as risk factors for development of hemodynamic instability in postoperative period. Currently the gold standard in the treatment of pheochromocytoma is preoperative use of alpha-blockers and laparoscopic surgery. This approach allowed improving outcomes by lowering both mortality and morbidity.

Inferior Vena Cava Syndrome Caused by Port Site Hemorrhage as a Complication of Laparoscopic Adrenalectomy

Inferior vena cava (IVC) syndrome results from obstruction of the IVC. Occlusion of the IVC caused by external pressure is a well-recognized complication of malignancy; meanwhile, benign causes of IVC obstruction are not frequently encountered without deep vein thrombosis. There have been a few reports of benign external compression of the IVC. We here show a rare and unique case of benign IVC syndrome in a 47-year-old woman, which was caused by hemorrhage as a complication of laparoscopic adrenalectomy on postoperative day 1. She had undergone laparoscopic adrenalectomy, performed successfully for primary aldosteronism, but she lost consciousness for about 10 seconds on postoperative day 1. After emergency medical care, her sinus rhythm and stable hemodynamic status were restored. At that time, computed tomography showed retroperitoneal hematoma caused by port site bleeding with the IVC compressed excessively, and we considered that drastic IVC syndrome may have occurred. Hemostatics and complete rest improved her general condition gradually, and she left the hospital on postoperative day 20. Laparoscopic adrenalectomy is technically feasible and has several advantages over open adrenalectomy, such as less intraoperative blood loss and a shorter hospital stay. However, surgeons must be careful of potential critical complications.