Bilateral laparoscopic adrenalectomy for Cushing's disease

Comparison of synchronous bilateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy: results of a multicenter study

BACKGROUND

Different techniques for laparoscopic adrenalectomy have been proposed with the lateral transperitoneal approach and posterior retroperitoneal approach being the two more frequently minimally invasive surgeries in most of the clinics. There are no sufficient studies in which the results of lateral transperitoneal and posterior retroperitoneal approaches in synchronous bilateral laparoscopic adrenalectomy have been compared. In the current study, we aimed to report our multicenter results of the lateral transperitoneal and posterior retroperitoneal synchronous bilateral laparoscopic adrenalectomy experience in patients who had different bilateral adrenal pathologies and to compare the outcomes of these two different operative procedures.

METHODS

Between 2012 and 2018, a total of 52 patients with a mean age of 43.5 years underwent simultaneous bilateral laparoscopic adrenalectomy at 6 different centers. Twenty-seven and 25 patients underwent bilateral lateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy, respectively. Patients' age, gender, body max index, operative indications, mass size, operation time, blood loss, length of hospitalization, intraoperative and postoperative complications and pathology reports were analyzed.

RESULTS

Synchronous bilateral transperitoneal group was younger than synchronous posterior retroperitoneal group (37 years vs. 50.4 years.) (p: 0.001). Posterior retroperitoneal group had significantly decreased operating time and less blood loss than transperitoneal group. No significant difference was found with regard to postoperative hospital stay, perioperative and postoperative complications between two groups. Majority of the histopathological results were adrenal hyperplasia associated with Cushing's disease (61.5%). Less frequent pathological results were adrenal adenoma and pheochromocytoma (15.4% and 13.5%, respectively). During the follow-up period, no recurrence or disease-related mortality was observed in the patients.

CONCLUSION

Our results shows that shorter operative time and less bleeding can be achieved with posterior retroperitoneal approach in synchronous bilateral laparoscopic adrenalectomy. In our series, intraoperative and postoperative complication rates were similar between both surgical approaches.

The Treatment of Cushing's Disease

Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.

Laparoscopic bilateral transperitoneal adrenalectomy for Cushing syndrome: surgical challenges and lessons learnt

PURPOSE

Laparoscopic adrenalectomy is well established for treatment of adrenal lesions. However, bilateral adrenalectomy for Cushing syndrome is a challenging and time-consuming operation. We report our experience of laparoscopic bilateral adrenalectomy for this disease in 19 patients.

MATERIALS AND METHODS

From September 2009 to August 2012, we have operated 19 patients with Cushing syndrome and performed bilateral laparoscopic adrenalectomy using the transperitoneal approach; synchronous in 15 patients and staged in 4 patients. In 15 patients, the surgery was carried out sequentially on both the sides in lateral position with intraoperative change in position. Complete adrenalectomy including periadrenal fat was carried out on both the sides.

RESULTS

Nineteen patients were referred from Department of Endocrinology for bilateral adrenalectomy for adrenocorticotropin hormone (ACTH)-dependent and ACTH-independent Cushing syndrome. The indications for surgery were Cushing disease in 15 patients, occult/ectopic source of ACTH in 2 patients, and primary adrenal hyperplasia in 2 patients. Fifteen patients underwent bilateral adrenalectomy during the same operation. Four patients underwent staged procedures. All procedures were completed laparoscopically with no conversions. The mean operating time for simultaneous bilateral adrenalectomy was 210 minutes (range, 150 to 240 min). This included the repositioning and reprepping time. There were no major intraoperative complications. The average blood loss was 100 mL (range, 50 to 200 mL). None of the patients required blood transfusions in the postoperative period. The postoperative complications included minor port-site infection in 2 patients. One severely debilitated patient died on the 14th postoperative day because of hospital-acquired pneumonia. The remaining 18 patients have done well in terms of impact on the disease.

CONCLUSIONS

Laparoscopic bilateral adrenalectomy for Cushing syndrome is feasible and safe. It confers all the advantages of minimally invasive approach such as less postoperative pain, shorter hospitalization, lesser wound complications, and faster recovery. The advantages of the laparoscopic approach have led to an earlier referral for bilateral adrenalectomy by endocrinologist in patients with failed pituitary surgery.

Laparoscopic transabdominal lateral adrenalectomy

Laparoscopic adrenalectomy is a mainstay of operative options for adrenal tumors and allows surgeons to perform adrenalectomies with less morbidity, less post-operative pain, and shorter hospital stays. The literature has demonstrated its efficacy to be equal to open adrenalectomy in most cases. With regard to malignant primary and metastatic lesions, controversy still remains, however, consideration of a laparoscopic approach for smaller, well circumscribed and non-invasive lesions is reasonable. During any laparoscopic resection, when there is doubt about the ability to safely remove the lesion with an intact capsule, conversion to an open approach should be considered. The primary goal of a safe and complete oncologic resection cannot be compromised. For most benign lesions, laparoscopic approaches are safe and feasible and conversion to an open approach is necessary only for lesions where size limits the ability of a minimally invasive resection.

[Perioperative analgesia in urology and potential influence of anesthesia on oncologic outcomes of surgery]

INTRODUCTION

The objective of the current article was to present a review concerning current concepts of perioperative analgesia in urology and to assess the potential influence of anesthesia on oncologic outcomes after surgery.

PATIENTS AND METHODS

Data on general anesthesia and perioperative analgesia were explored on Medline using the following MeSH terms: anesthesia; analgesia; pain urology; cancer; morphine; nefopam; tramadol; ketamine; local anesthetics; non-steroid anti-inflammatory treatments; surgery; cancer. Publications were considered on the following criteria: methodology, relevance and date of publication.

RESULTS

The concepts of acute and chronic pain after surgery are discussed, as well as prevention and treatment. Types of available pharmacological substances are listed and the possible routes of administration for these products. The concept of multimodal analgesia and preemptive analgesia are exposed and their role for the prevention of perioperative pain. Recent studies suggest a relationship between the modes of anesthesia and analgesia in cancer surgery, and recurrence of the disease after surgery.

CONCLUSION

Current concepts of perioperative analgesia offer new perspectives to urologists in the management of pain. Current scientific literature advocates regional anesthesia, the fight against pain and stress, and decreased use of opioids. In addition, the use of a multimodal analgesia seems to be an option for an optimal oncologic management of urologic tumours.

Management of Cushing disease

Cushing disease is caused by a corticotroph tumor of the pituitary gland. Patients with Cushing disease are usually treated with transsphenoidal surgery, as this approach leads to remission in 70-90% of cases and is associated with low morbidity when performed by experienced pituitary gland surgeons. Nonetheless, among patients in postoperative remission, the risk of recurrence of Cushing disease could reach 20-25% at 10 years after surgery. Patients with persistent or recurrent Cushing disease might, therefore, benefit from a second pituitary operation (which leads to remission in 50-70% of cases), radiation therapy to the pituitary gland or bilateral adrenalectomy. Remission after radiation therapy occurs in ∼85% of patients with Cushing disease after a considerable latency period. Interim medical therapy is generally advisable after patients receive radiation therapy because of the long latency period. Bilateral adrenalectomy might be considered in patients who do not improve following transsphenoidal surgery, particularly patients who are very ill and require rapid control of hypercortisolism, or those wishing to avoid the risk of hypopituitarism associated with radiation therapy. Adrenalectomized patients require lifelong adrenal hormone replacement and are at risk of Nelson syndrome. The development of medical therapies with improved efficacy might influence the management of this challenging condition.

Laparoscopic bilateral adrenalectomy: results for 30 consecutive cases

BACKGROUND

Most patients requiring bilateral adrenalectomy have adrenocorticotropin hormone (ACTH)-dependent Cushing's syndrome. Some of these patients are severely debilitated from the chronic effects of cortisol overproduction. This study aimed to analyze the indications, safety, efficacy, and outcomes for laparoscopic bilateral adrenalectomy from the authors' experience.

METHODS

A retrospective review was conducted at a university tertiary referral center. Between March 1996 and August 2006, 30 consecutive patients underwent simultaneous laparoscopic bilateral adrenalectomy. The patient records were analyzed to obtain patient demographics, disease etiology, surgical approach, operating room information, postoperative complications (30 days), hospital length of stay (LOS), and follow-up information.

RESULTS

The 30 participants (22 women and 8 men) had a mean age of 44 years. The indications for bilateral adrenalectomy were refractory Cushing's disease (n = 16), occult ectopic ACTH syndrome (n = 9), and bilateral pheochromocytoma (n = 5). A mean of 53 months elapsed between onset of symptoms and adrenalectomy. Laparoscopic bilateral adrenalectomy was completed for all the patients with no intraoperative complications. Four patients (13%) experienced six complications. The mean postoperative LOS was 3.5 days (range, 1-12 days). Seven patients required a preoperative LOS, for a mean of 7.1 days (range, 1-20 days), and a postoperative LOS, for a mean of 5 days (range, 2-12 days). The 23 patients who did not require preoperative hospitalization had a mean postoperative LOS of 3 days (range, 1-7 days). All the patients received postoperative steroid replacement and appropriate follow-up assessment with an endocrinologist. At this writing, the patients with Cushing's syndrome available for follow-up evaluation continue to receive steroid replacement, and all the pheochromocytoma patients have experienced a documented postoperative biochemical cure.

CONCLUSIONS

Laparoscopic bilateral adrenalectomy is safe and effective for this high-risk patient population. Although patients should be monitored closely in the postoperative period, most are discharged with glucocorticoid and mineralocorticoid replacement in a short time without complications.

Role for laparoscopic adrenalectomy in patients with Cushing's syndrome

Laparoscopic adrenalectomy is one of the most clinically important advances in the past 2 decades for the treatment of adrenal disorders. When compared to open adrenalectomy, laparoscopic adrenalectomy is equally safe, effective, and curative; it is more successful in shortening hospitalization and convalescence and has less long-term morbidity. The laparoscopic approach to the adrenal is the procedure of choice for the surgical management of cortisol-producing adenomas and for patients with corticotropin (ACTH) dependent Cushing's syndrome for whom surgery failed to remove the source of ACTH. The keys to successful laparoscopic adrenalectomy are appropriate patient selection, knowledge of anatomy, delicate tissue handling, meticulous hemostasis, and experience with the technique of laparoscopic adrenalectomy.

The current status of laparoscopic adrenalectomy

In this article the authors have attempted to summarize and evaluate the current literature regarding the feasibility and indications of the laparoscopic approach to the resection of adrenal lesions. The overall results suggest that laparoscopic adrenalectomy is safe, effective, and has major advantages for patients in terms of decreased pain, hospital stay, and short- and long-term morbidity. For large and malignant lesions, good judgment and careful consideration must be given to the entire clinical picture so that the laparoscopic approach is used for patients who will derive benefits from the minimally invasive approach without compromising an oncologically sound resection or safety of operation. Additional studies will help clarify these remaining controversies further. The laparoscopic approach for adrenalectomy has demonstrated that significant and beneficial advances in surgery are improving the care offered patients.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Simultaneous Bilateral Laparoscopic Adrenalectomy for Adrenocorticotropic Hormone-Independent Macronodular Adrenal Hyerplasia: Report of a Case

Cushing's syndrome caused by adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH) is an extremely rare disease, which shows bilateral macronodular adrenal hypertrophy and autonomous cortisol production. We herein report a case of AIMAH treated successfully by minimally invasive simultaneous bilateral laparoscopic adrenalectomy. A 73-year-old woman with hypertension, diabetes mellitus, and osteoporosis was referred to our hospital because of an incidentally found huge bilateral adrenal mass. An abdominal computed tomography scan showed large bilateral adrenal glands with multiple nodules. A diagnosis of AIMAH was made and a simultaneous bilateral laparoscopic adrenalectomy was thus performed. The total operation time was 310 min and blood loss was 70 g. Both glands were hypertrophic (right 5 x 3 cm, 48.5 g and left 4 x 2 cm, 39.2 g) and consisted of multiple golden yellow macronodules. The postoperative course was uneventful. A simultaneous bilateral adrenalectomy for AIMAH performed by an experienced surgical team is therefore considered to be a safe and minimally invasive procedure.

Laparoscopic adrenalectomy for patients who have Cushing's syndrome

Laparoscopic adrenalectomy is one of the most significant advances in the past 20 years for treating adrenal disorders. When compared with open adrenalectomy, laparoscopic adrenalectomy is equally safe, effective, and curative; it is more successful in shortening hospitalization and convalescence and has less long-term morbidity. The laparoscopic approach is the procedure of choice for the surgical management of cortisol-producing adenomas and for patients who have corticotropin (ACTH)-dependent Cushing's syndrome for whom surgery failed to remove the source of ACTH. The keys to successful laparoscopic adrenalectomy are appropriate patient selection, knowledge of anatomy, delicate tissue handling, meticulous hemostasis, and experience with the technique of laparoscopic adrenalectomy.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Adrenocorticotropin-independent macronodular adrenal hyperplasia treated by simultaneous bilateral laparoscopic adrenalectomy

A 61-year-old woman was admitted to our hospital with hypertension and diabetes mellitus, and was found to have Cushing's syndrome. Radiological and endocrinological findings suggested adrenocorticotropic hormone-independent macronodular adrenal hyperplasia. Simultaneous bilateral laparoscopic adrenalectomy was performed, minimizing the number of trocar sites and operation time. Success was attributed to the careful selection of trocar sites to permit safe dissection.

Laparoscopic adrenalectomy--indications and technique

Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.

Bilateral laparoscopic adrenalectomy: retroperitoneal and transperitoneal approaches

OBJECTIVES

To report our experience with bilateral laparoscopic adrenalectomy using either the retroperitoneal or the transperitoneal approach.

METHODS

Between June 1998 and October 2000, 6 consecutive patients with bilateral adrenal disease (Cushing syndrome in 4, pheochromocytoma in 1, and solitary adrenal metastases in 1) underwent bilateral laparoscopic adrenalectomy by way of the retroperitoneal or transperitoneal approach. Bilateral adrenalectomy was performed either synchronously (4 patients) or in a staged manner (2 patients).

RESULTS

All laparoscopic procedures were performed successfully. For the bilateral synchronous cases (n = 4) and metachronous cases (n = 4), the median surgical time was 278 and 195 minutes, blood loss was 175 and 125 mL, resumption of oral intake and ambulation required less than 1 day for both groups, and postoperative narcotic requirement comprised 14 and 10 mg morphine sulfate equivalent, respectively. For the synchronous and metachronous cases, the hospital stay was 1.5 and less than 1 day and convalescence was 3 and 2.5 weeks, respectively. An intraoperative surgical complication (adrenal vein bleeding) occurred in 1 case, but did not require open conversion. No postoperative complications or rehospitalization occurred. The retroperitoneal approach was used in 3 of the 4 bilateral synchronous and 3 of the 4 bilateral metachronous cases. In both synchronous and metachronous cases, the actual surgical time, blood loss, time to oral intake and ambulation, postoperative analgesia use, hospital stay, and convalescence of the transperitoneal approach were well within the range of those of the retroperitoneal approach.

CONCLUSIONS

Retroperitoneal and transperitoneal bilateral laparoscopic adrenalectomy is feasible, safe, and results in minimal postoperative morbidity.

Outcomes analysis in patients undergoing laparoscopic adrenalectomy for hormonally active adrenal tumors

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the preferred method of removal of most adrenal neoplasms, but few studies have evaluated the functional outcomes of this approach. The purpose of this study was to analyze our operative results and the clinical and biochemical responses to LA in patients with various hormonally active adrenal tumors.

METHODS

From 1993 through November 2000, 72 patients with functional adrenal tumors underwent attempted LA. Data were obtained retrospectively by review of medical records, during routine follow-up, and by patient questionnaire.

RESULTS

Indications for adrenalectomy were pheochromocytoma (n = 35), aldosteronoma (n = 29), cortisol-producing adenoma (n = 5), and adrenocorticotropic hormone-dependent Cushing's syndrome (n = 3). LA was completed in 70 of 72 patients, with 2 conversions (3%) to open adrenalectomy. Mean operative time for unilateral LA was 176 +/- 60 minutes, and postoperative length of hospital stay averaged 3.0 +/- 1.7 days. Complications, most of which were minor, occurred in 19% of patients; there were no serious complications or perioperative deaths. Two patients were unavailable for follow-up. At a mean follow-up interval of 37.6 months after LA (range, 2-90 months), resolution of clinical and biochemical signs of adrenal hyperfunction was accomplished in 34 of 34 patients with pheochromocytomas, 25 of 26 patients with aldosteronomas, 5 of 5 patients with cortisol-producing adenomas, and 3 of 3 patients with andrenocorticotropic hormone-dependent Cushing's syndrome. Two patients with multiple endocrine neoplasia (MEN) type 2 had contralateral pheochromocytomas removed 4 and 5 years after the initial surgery. Persistent hypertension necessitating medication was present in 72% of patients with aldosteronomas, although 92% of these patients had improved blood pressure control after LA. Recurrent hypokalemia developed in 1 patient (4%) with a cortical nodule in the contralateral adrenal. No local or distant tumor recurrences have occurred.

CONCLUSIONS

LA results in an excellent clinical outcome in patients with various functional endocrine tumors. LA is associated with few major complications, and clinical and biochemical cure rates are comparable with those of open adrenalectomy during long-term follow-up.

Simultaneous bilateral laparoscopic adrenalectomy in ACTH-independent macronodular adrenal hyperplasia

Laparoscopic surgery for urological conditions has now become popular worldwide. The case is reported of a 56-year-old woman who underwent simultaneous bilateral laparoscopic adrenalectomy for adrenocorticotropic hormone-independent macronodular adrenocortical hyperplasia (AIMAH), followed by autotransplantation of resected adrenal gland fragments. Simultaneous laparoscopic adrenalectomies seem feasible for a patient with AIMAH because of its minimally invasive nature. However, autotransplantation of adrenal fragments failed in this patient with AIMAH.

[Experiences with adrenalectomy in 1997. Apropos of 247 cases. A multicenter prospective study of the French-speaking Association of Endocrine Surgery]

STUDY AIM

The aim of this prospective study conducted by the AFCE was to analyze the indications, approach and results of all adrenalectomies performed during the year 1997 in 17 centers, active or specialized in endocrine surgery.

PATIENTS AND METHODS

During 1997, adrenalectomy was performed in 247 patients, 149 men and 98 women (mean age: 51 years). The lesion was located in the right side in 166 patients, in the left side in 99, in both sides in 28 patients and ectopic in four patients. Pheochromocytomas (n = 61), Conn adenomas (n = 50) and Cushing syndrome lesions (n = 48) were the most frequent in this series. Laparoscopic adrenalectomy was performed in 172 patients (70%) through a transperitoneal approach in all cases except one, and by 'open' surgery in 75 patients (30%).

RESULTS

In patients operated on by the laparoscopic approach, the mean duration of surgery was 132 min, and there were peroperative complications in 15 patients (8.7%), mainly hemorrhages. Conversion rate into laparotomy was 7%. In the postoperative course, there were three reoperations and two deaths, an early one in a patient reoperated for bleeding and a very late one in relation with necrotising acute pancreatitis. Mean duration of hospitalization was 5.8 d. Mean tumoral size was 49 mm. In patients operated on by 'open' surgery, the mean duration of surgery was 148 min. There was a postoperative complication in eight patients (10.6%), mostly hemorrhages, and two intraoperative deaths in relation with uncontrollable bleeding. Mean duration of hospitalization was 11 d. Mean tumoral size was 72 mm.

CONCLUSION

Laparoscopic adrenalectomy is now indicated for the majority of adrenal tumors. Several complications observed in this series were related to the learning curve in several centers. Laparoscopic adrenalectomy is the 'gold standard' in uni- or bilateral benign tumors no larger than 6 or 7 cm. 'Open' surgery is indicated in malignant tumors, especially in adreno-cortical carcinomas, and in all large tumors.

Laparoscopic adrenalectomy in the elderly

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.

[Frequency, intensity, development and repercussions of postoperative pain as a function of the type of surgery]

Type of surgery is the most important factor conditioning intensity and duration of postoperative pain. Thoracic and spinal surgery are the most painful procedures. Abdominal, urologic and orthopedic surgery lead to severe postoperative pain. Duration of severe pain rarely exceeds 72 hours. Mobilization increases pain intensity after abdominal, thoracic and orthopaedic surgery. Pain could occur after daycase minor surgical procedures and is often underestimated. Postoperative complications related to pain are difficult to disclose because of the interposition of the direct effects of analgesic treatments. Respiratory and cardiovascular postoperative complications are unrelated to postoperative pain in healthy subjects. This could be different in high risk patients. The surgical procedure is the major determinant of metabolic and psychologic postoperative deterioration. Adequate pain relief allows postoperative rehabilitation and physiotherapy programmes after abdominal and orthopaedic surgery. This could be expected to reduce hospital stay and improve convalescence.