Technical difficulties of transumbilical laparoendoscopic single-site adrenalectomy: comparison with conventional laparoscopic adrenalectomy

Laparoendoscopic single-site adrenalectomy versus multi-port laparoendoscopic adrenalectomy: A systemic review and meta-analysis

Background

To investigate the outcomes of laparoendoscopic single-site adrenalectomy (LESS-A) compared to multi-port laparoendoscopic adrenalectomy (m-LA).

Methods

Studies comparing LESS-A with m-LA were identified from PubMed, Embase, and Cochrane Library before June 2020. Post-operative pain, resumption outcomes, and perioperative outcomes were analyzed. We conducted meta-analyses using the Mantel-Haenszel method with random-effects model. Subset analyses were conducted according to peritoneal and retroperitoneal approaches. A small study effect was illustrated using funnel plots and Egger's test.

Results

One randomized controlled trial (RCT) and nineteen retrospective cohort studies involving 1554 patients were included for analyzed. Pooled analysis showed that LESS-A had significantly lower postoperative pain scores (MD −0.77, 95%CI −1.45 to −0.10) and less pain medication used (RR 0.74, 95%CI 0.60 to 0.91) compared to m-LA. Besides, LESS-A had significantly shorter hospital stays (MD −0.75, 95%CI −1.18 to −0.33), shorter duration of oral intake resumption (MD −0.33, 95%CI −0.60 to −0.06), and better cosmetic satisfaction (SMD 1.15, 95%CI 0.21 to −2.09). As for perioperative outcomes, LESS-A led to significant longer operative time (MD 13.43, 95%CI 4.08 to 22.77). No significant differences were observed in terms of the remaining perioperative outcomes.

Conclusions

LESS-A is associated with less post-operative pain and quicker recovery duration. However, the longer operative time of LESS-A compared with m-LA is a drawback.

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Multi-port laparoscopic adrenalectomy (m-LA) is widely used for treatment of benign adrenal tumor.

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Laparoscopic single-site adrenalectomy (LESS-A) had significant less post-operative pain and less pain medication consumption comparing with m-LA.

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LESS-A had better resumption outcomes, including shorter hospital stay and quicker post-operative oral intake.

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LESS-A offer better cosmetic satisfaction.

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Longer operative time is a drawback of LESS-A.

Optimal instrument length for transumbilical laparoendoscopic single site (U-LESS) surgery

The aim of our study was to recommend a novel method for measuring the distance from the umbilicus to intra-abdominal organs, as well as recommend an instrument length that would accommodate transumbilical laparoendoscopic single-site (U-LESS) surgeries to these areas. From CT scans of 50 men and 50 women, we calculated the distance from the umbilicus to 11 intra-abdominal points of interest using two triangles oriented perpendicular to each other. Using known lengths of the triangles, we used the Pythagorean theorem to calculate distances with and without insufflation. Distances were measured from the umbilicus to the xyphoid process, superior most aspect of the spleen, neck of the gallbladder, bifurcation of the descending aorta, adrenal glands, superior pole(s) of the kidneys, inferior most aspect of the inguinal canal, suprapubic margin, and the apex of the prostate (or female bladder neck). We found that an instrument working length of 43 cm would be sufficient to facilitate U-LESS surgery for all of our patients to each of the measured points of interest. The technique described in this paper serves as a useful method by which to measure the distance from the umbilicus to any intra-abdominal point of interest. These measurements would allow surgeons to correctly select instruments with adequate length when planning to perform U-LESS surgery.

Comparison of Technical Details and Short-term Outcomes of Single-incision Versus Multiport Laparoscopic Adrenalectomy

To date, the single-incision laparoscopic surgery (SILS) technique has been applied to a wide range of general surgical procedures; however, there are still scant data and debates on adrenal procedures. The aim of this study was to compare surgical outcomes of single-incision versus laparoscopic multiport adrenalectomy. The patients were divided into 2 study groups on the basis of the surgical approach: SILS (group 1) and multiport laparoscopic surgery (group 2). Patient demographics and their perioperative and postoperative results were evaluated retrospectively from the medical records. A total of 80 patients were included in the study. There were 44 patients in group 1 and 36 patients in group 2. The average operative time, estimated blood loss, and tumor size were similar between the study groups. There were no mortalities in both groups and the mean duration of hospital stay was 3 days for both groups. Without using any single-incision access trocars and articulated instrumentation, we achieved the same surgical outcomes in our SILS adrenalectomy series compared with conventional multiport laparoscopy series in terms of postoperative short-term outcomes and cost-effectivity.

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.

Patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical laparoendoscopic single-site adrenalectomy

INTRODUCTION

Laparoendoscopic single-site surgery is a recently innovated urologic surgical procedure. Transumbilical laparoendoscopic single-site adrenalectomy (LESS-A) is technically safe and feasible in patients with benign adrenal tumors. To improve patient counseling and informed consent, we evaluated patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical LESS-A.

METHODS

We reviewed 24 patients who underwent transumbilical LESS-A and assessed their operative and esthetic outcomes and incisional pain. Incisional pain was evaluated using a 10-point visual analog scale, and the body image and cosmetic satisfaction were measured using a questionnaire that included a body image scale (range, 5-20 points) and a cosmetic scale (range, 3-24 points).

RESULTS

Pure LESS-A was performed on 10 patients using a multichannel port; an additional 5-mm trocar was used in two obese patients. Supplementary to the single-incision approach, one or two 3-mm ports were used in 12 patients. The mean operative time was 203 min; the mean blood loss was 41 mL. The mean pain visual analog scale scores on postoperative days 1, 3, and 7 were 3.5, 2.2 (P = 0.012), and 1.5 points (P = 0.018), respectively. The mean body image scale and cosmetic scale scores indicating wound satisfaction 1 month after the surgery were 20 and 22 points, respectively. Although one patient had liver injury during surgery, the postoperative course during the 3-month follow-up was uneventful.

CONCLUSION

Transumbilical LESS-A confers less postoperative pain and better cosmetic satisfaction than conventional laparoscopic adrenalectomy. Therefore, this procedure could potentially become a standard treatment option for benign adrenal tumors.

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.

Comparison of Modified Retroperitoneal Adrenalectomy With the Gold Standard for Benign Adrenal Tumors

OBJECTIVES

To compare our modified retroperitoneoscopic adrenalectomy with the standard procedure.

METHODS

A total of 68 patients underwent modified retroperitoneoscopic adrenalectomy. Simultaneously, another 23 patients were treated using the standard procedure. The demographic data and perioperative outcomes of the patients were obtained for statistical analysis.

RESULTS

No significant differences in age, evaluated blood loss, oral intake, and hospital stay were observed. The mean operation time in the modified group was shorter than that in the standard group (58.3±16.4 vs. 79.5±23.6 min, P<0.05). The median total length of incision was shorter in the modified group than in the standard group (4.5±0.8 vs. 6.4±1.1 cm, P<0.05). The modified group also showed significantly better pain control (3 vs. 6 diclofenac sodium use, P<0.05) and cosmetic outcome (score, 9.1±1.8 vs. 8.2±2.1, P<0.05) than the standard group.

CONCLUSIONS

Our modified retroperitoneoscopic adrenalectomy is a safe and alternative procedure for adrenal tumors. This procedure offers superior cosmetic outcome, better pain control, and shorter operation time compared with the standard retroperitoneal adrenalectomy.

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the 'gold standard'. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.

The learning curve of laparoendoscopic single-site adrenalectomy: an analysis of over 100 cases

BACKGROUND

Recently, laparoendoscopic single-site adrenalectomy (LESS-A) has been developed as an alternative treatment for adrenal tumors. Although LESS-A is more technically complex than conventional laparoscopic adrenalectomy, its learning curve and the factors associated with poor surgical outcomes are poorly understood. We analyzed the learning curve of LESS-A and attempted to identify risk factors associated with worse surgical outcomes.

METHODS

We identified 103 patients who underwent LESS-A [performed by the same surgeon (A.M.)] from 2009 to 2015. The learning curve was analyzed using the moving average method (the 10-case moving average), and we assessed potential risk factors for a prolonged pneumoperitoneum time.

RESULTS

The learning curve stabilized at 30 cases. The cases were divided into two groups, the learning stage (LS) (cases 1-29) and master stage (MS) (cases 30-103) groups. The percentage of females and the frequency of previous abdominal surgery were higher in the LS group (p = 0.022 and 0.001, respectively). In the LS group, the mean pneumoperitoneum time was 92 ± 35 min, which was significantly longer than the equivalent value for the MS group (55 ± 18 min, p < 0.001). In the LS group, univariate analysis revealed that tumor size (≥50 mm) and the visceral fat area (VFA)/total fat area (TFA) ratio (≥0.49) were significantly associated with a prolonged pneumoperitoneum time (p = 0.046 and 0.046, respectively). In the multivariate analysis, tumor size and the VFA/TFA ratio were confirmed to be associated with a prolonged pneumoperitoneum time (p = 0.029 and 0.029, odds ratio 20.83 and 20.83, respectively). On the other hand, none of the examined factors were found to be associated with a prolonged pneumoperitoneum time in the MS group.

CONCLUSIONS

LESS-A was performed safely in most cases. However, surgeons who are learning the LESS-A procedure need to pay attention to tumor size and visceral obesity.

Outcomes of laparoscopic adrenalectomy Conventional technique versus laparo-endoscopic single-site surgery

OBJECTIVE

Perform a comparative analysis of the outcomes of conventional laparoscopic adrenalectomy (LC) and the newly introduced laparo-endoscopic single-site surgery (LESS) over ten years.

MATERIAL AND METHOD

We retrospectively reviewed the experience of a single surgeon from our medical centre with laparoscopic adrenalectomy, either through LC or LESS, with 75 patients between August 2005 and June 2015. Here we describe: age, sex, size, lateralization, preoperative diagnosis, total operating time, intraoperative bleeding, conversion to open surgery, mean hospital stay, intra- and postoperative complications and histopathology report. We used Fischer's and the Chi-squared tests to compare categorical data and Student's T-test for a comparison of the means with a normal distribution. Statistical significance was determined when p<0.05.

RESULTS

LC was performed in 51 patients, and LESS in 24 patients. No statistical significance was found for total operating time (LC: 103.9±13.21min vs. LESS: 101.46±13.65min; p=0.07), estimated bleeding (LC: 258.82±136.92cc vs. LESS: 131,25±36,74cc; p=0.46), intraoperative complications (5 cases in LC, none in LESS; p=0.47), nor for postoperative complications (two in LC vs. one in LESS; p=0.69), as catalogued according to the modified Clavien classification system. We detected a statistical significance difference in the comparisons of the mean hospital stay, which was reduced in LESS (LC: 3.55±0.69 days vs. LESS: 2.21±0.31 days; p=0.01).

CONCLUSIONS

Adrenalectomy with LC is the approach of choice for surgical treatment of adrenal pathologies. The LESS technique is safe, improves the cosmetic results, and does not increase mortality if performed by experienced teams.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology

OBJECTIVE

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.

METHODS

A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.

RESULTS

Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.

CONCLUSIONS

Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Transumbilical laparoendoscopic single-site surgery versus conventional laparoscopy for the resection of retroperitoneal paragangliomas

OBJECTIVES

To compare transumbilical laparoendoscopic single-site surgery with conventional laparoscopy for the resection of retroperitoneal paragangliomas.

METHODS

In the present case-control study, we compared 11 transumbilical laparoendoscopic single-site surgery procedures with 22 conventional laparoscopy procedures carried out to treat retroperitoneal paragangliomas between June 2004 and October 2013 at Peking Union Medical Hospital, Beijing, China. Operative time, estimated intraoperative blood loss, blood transfusions, intraoperative hypertension, intraoperative hypotension, highest intraoperative systolic blood pressure, lowest intraoperative systolic blood pressure, postoperative fatigue time, postoperative systematic inflammation reaction syndrome, 24-h postoperative visual analog scale scores, postoperative hospital stay duration, and postoperative complications were recorded and analyzed.

RESULTS

There were no significant differences in patient characteristics. All surgical procedures were successfully completed in both groups. Minor complications occurred in one case in the laparoendoscopic single-site surgery group and in two cases in the conventional laparoscopy group. In the laparoendoscopic single-site surgery group, the operative time was longer than that in the conventional laparoscopy group (P = 0.001). There were no significant differences in terms of intraoperative hypertension, intraoperative hypotension, highest intraoperative systolic blood pressure, lowest intraoperative systolic blood pressure, estimated blood loss, postoperative fatigue time, postoperative hospital stay or systematic inflammation reaction syndrome between the two groups. The 24-h postoperative visual analog scale score was lower in the laparoendoscopic single-site surgery group (P = 0.002). No recurrence or metastases were observed over the duration of the postoperative follow up.

CONCLUSIONS

In properly selected patients, transumbilical laparoendoscopic single-site surgery is a feasible, safe and effective procedure for the surgical treatment of retroperitoneal paragangliomas.

Surgical results of reduced port laparoscopic adrenalectomy using a multichannel port in comparison with conventional laparoscopic adrenalectomy

BACKGROUND

We introduced a modified laparoscopic technique, dual-incision laparoscopic adrenalectomy (DILA), using a newly designed multichannel trocar, and we evaluated its perioperative outcomes and operative costs and compared them to those of conventional laparoscopic adrenalectomy (CLA).

METHODS

We retrospectively reviewed the medical records of 127 patients who underwent CLA with four trocars or DILA with two trocars at Seoul St. Mary's Hospital, Seoul, Korea between October 2007 and September 2014. We analyzed the patients' surgical outcomes and perioperative morbidities.

RESULTS

DILA was performed in 45 patients and CLA in 82 patients. There were no significant differences in operative time (DILA: 77.1 ± 28.4 minutes vs. CLA: 76.6 ± 28.0 minutes, p = 0.595) or estimated blood loss during surgery (DILA: 150.0 ± 85.5 mL vs. CLA: 175.5 ± 50.5 mL, p = 0.697). There were no differences in postoperative hospital stay, visual analog scale pain score, or postoperative complication rates between the two groups. However, the operative cost was significantly lower in the DILA group (DILA 813,603 ± 48,600 Korean won vs. CLA 968,368 ± 56,456 Korean won, p < 0.001).

CONCLUSION

This study demonstrated that DILA is a safe and feasible surgical approach for adrenal diseases. DILA may reduce the operative cost significantly compared with CLA.

Laparoendoscopic single-site surgery adrenalectomy - own experience and matched case-control study with standard laparoscopic adrenalectomy

Introduction

At our institution, laparoendoscopic single-site surgery (LESS) has been established as a technique for laparoscopic nephrectomy since 2011, and since 2012 in selected cases for adrenalectomy (AE) as well.

Aim

To compare LESS AE with standard laparoscopic AE (SLAE).

Material and methods

Between 3/2012 and 7/2014, 35 adrenalectomies were performed. In 18 (51.4%), a LESS approach was chosen. Indications were strictly non-complicated cases (body mass index (BMI) < 34 kg/m², tumour ≤ 7 cm, non-malignant aetiology, no previous surgery). All LESS procedures were done by one surgeon. Standard equipment was a 10 mm rigid 0° camera, Triport+, one pre-bent grasper, and a sealing instrument. The approach was pararectal in all cases except one (transumbilical in a slim man). Three patients with LESS were excluded (2 partial AEs only, one adrenal cancer converted to SLAE and then to open surgery). These 15 LESS AE procedures were compared to 15 SLAEs with similar characteristics chosen among 54 SLAEs performed in the period 1/2008–2/2012.

Results

In 8 cases (53.3%) of LESS AE, a 3 mm port was added to elevate the liver/spleen. Mean parameters of LESS AE vs. SLAE (Wilcoxon test): maximal tumour diameter 43.7 mm vs. 36.1 mm (p = 0.28), time of surgery 63.3 min vs. 55.3 min (p = 0.22), blood loss 38.0 ml vs. 38.0 ml (p = 0.38), BMI 26.9 kg/m² vs. 28.5 kg/m² (p = 0.13), discharge from hospital 5.4 days vs. 3.9 days (p = 0.038). There were no complications in either group.

Conclusions

The LESS AE is feasible in selected cases, especially small left-sided tumours in thin patients with no history of previous abdominal operations, but requires an additional port in half of the cases.

Preservation of the saphenous vein during laparoendoscopic single-site inguinal lymphadenectomy: comparison with the conventional laparoscopic technique

OBJECTIVE

To prospectively study the surgical strategies and clinical efficacy of laparoendoscopic single-site (LESS) inguinal lymphadenectomy compared with conventional endoscopic inguinal lymphadenectomy for the management of inguinal nodes.

PATIENTS AND METHODS

A total of 12 patients with squamous cell carcinoma of the penis who underwent penectomy between February and July 2013 were enrolled in the study. All 12 patients underwent bilateral inguinal lymphadenectomy (LESS inguinal lymphadenectomy in one limb and conventional endoscopic inguinal lymphadenectomy in the other) with preservation of the saphenous vein. All lymphatic tissue in the boundaries of the adductor longus muscle (medially), the sartorius muscle (laterally), 2 cm above the inguinal ligament (superiorly), the Scarpa fascia (superficially) and femoral vessels (deeply) was removed in both surgical techniques. All 24 procedures were performed by one experienced surgeon.

RESULTS

All 24 procedures (12 LESS and 12 conventional endoscopic inguinal lymphadenectomies) were completed successfully without conversion to open surgery. For LESS inguinal lymphadenectomy and conventional endoscopic inguinal lymphadenectomy groups, the mean ± sd operating time was 94.6 ± 14.8 min and 90.8 ± 10.6 min, respectively (P = 0.145). No significant differences in the incidence of postoperative complications (skin-related problems, hecatomb, lower extremity oedema, lymphatic complications and overall complications) were noted between the two groups (P > 0.05). No lower extremity oedema occurred in any limbs of the two groups. No significant differences were observed in either lymph node clearance rate or detection rate of histologically positive lymph nodes (P > 0.05). The patient satisfaction rate with scar appearance and cosmetic results was significantly better in the LESS inguinal lymphadenectomy group than in the conventional endoscopic inguinal lymphadenectomy group of (75 vs 25%; P = 0.039).

CONCLUSIONS

This preliminary study suggests that both LESS inguinal lymphadenectomy and conventional endoscopic inguinal lymphadenectomy are safe and feasible procedures for inguinal lymphadenectomy. Preservation of the saphenous vein during LESS inguinal lymphadenectomy/conventional endoscopic inguinal lymphadenectomy can effectively reduce the incidence of postoperative lower extremity oedema. LESS inguinal lymphadenectomy seems to provide better cosmetic results than conventional endoscopic inguinal lymphadenectomy.

Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Laparo-endoscopic single-site left adrenalectomy using conventional ports and instruments

Laparo-endoscopic single-site adrenalectomy (LESS-A) is commonly performed using specialized access devices and/or instruments. We report a LESS-A in a 47-year-old woman with a left aldosteranoma via a subcostal approach utilizing conventional laparoscopic ports and instruments. The feasibility and cost-effectiveness of this approach are highlighted and the literature on the subject is reviewed.

Laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-access platform and standard laparoscopic instruments: technical considerations and surgical outcomes

BACKGROUND

We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments.

METHODS

Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2-3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments.

RESULTS

All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71-257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss; the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1-6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conn's syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels; all patients were free of potassium supplementation.

CONCLUSION

Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.

Perioperative outcomes and cosmesis analysis of patients undergoing laparoendoscopic single-site adrenalectomy: a comparison of transumbilical, transperitoneal subcostal, and retroperitoneal subcostal approaches

OBJECTIVE

To compare the perioperative outcomes and cosmetic results for transumbilical (TU), transperitoneal subcostal (TS), and retroperitoneal subcostal (RS) laparoendoscopic single-site surgery (LESS) adrenalectomy (AD).

MATERIALS AND METHODS

An observational study was conducted of patients who were had undergone LESS-AD using a TU (n = 9), TS (n = 17), or RS (n = 16) approach. The perioperative outcomes and comprehensive cosmetic results were analyzed statistically.

RESULTS

The RS-LESS-AD patients were more likely to have an indication for surgery of a right adrenal mass (TU-LESS-AD 11.1% and TS-LESS-AD 5.9% vs RS-LESS-AD 43.8%, P = .016) or partial AD (0% vs 9% vs 87.5%, P < .001). The TU-LESS-AD procedures had a longer median operative time but significantly lower postoperative pain. The median cosmesis rating for the TU-LESS-AD, TS-LESS-AD, and RS-LESS-AD scar photographs was 10, 8, and 9, respectively (P = .010). Only the cosmesis ratings after the photograph viewing were statistically significant across the surgical approaches (9.5 vs 8 vs 9, P = .048). Assuming equivalent surgical complication risks across the approaches, the preference for future TU-LESS-AD, TS-LESS-AD, RS-LESS-AD was 86%, 6%, and 8%, respectively. As the theoretical risk of TU-LESS-AD increased, the preference for TU-LESS-AD decreased and the preference for TS-LESS-AD and RS-LESS-AD increased.

CONCLUSION

LESS-AD is an effective procedure with a high level of cosmesis using a TU, TS, or RS approach. The surgeon's background, patient characteristics, and cosmetic perception must be carefully considered as a part of the entire clinical picture so that LESS-AD can be used for patients who will derive the most benefit.

Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies

PURPOSE

To assess the surgical efficacy and potential advantages of laparoendoscopic single-site adrenalectomy (LESS-AD) compared with conventional laparoscopic adrenalectomy (CL-AD) based on published literature.

METHODS

An online systematic search in electronic databasesM including Pubmed, Embase, and the Cochrane Library, as well as manual bibliography searches were performed. All studies that compared LESS-AD with CL-AD were included. The outcome measures were the patient demographics, tumor size, blood loss, operative time, time to resumption of oral intake, hospital stay, postoperative pain, cosmesis satisfaction score, rates of complication, conversion, and transfusion. A meta-analysis of the results was conducted.

RESULTS

A total of 443 patients were included: 171 patients in the LESS-AD group and 272 patients in the CL-AD group (nine studies). There was no significant difference between the two groups in any of the demographic parameters expect for lesion size (age: P=0.24; sex: P=0.35; body mass index: P=0.79; laterality: P=0.76; size: P=0.002). There was no significant difference in estimated blood loss, time to oral intake resumption, and length of stay between the two groups. The LESS-AD patients had a significantly lower postoperative visual analog pain score compared with the CL-AD group, but a longer operative time was noted. Both groups had a comparable cosmetic satisfaction score. The two groups had a comparable rate of complication, conversion, and transfusion.

CONCLUSIONS

In early experience, LESS-AD appears to be a safe and feasible alternative to its conventional laparoscopic counterpart with decreased postoperative pain noted, albeit with a longer operative time. As a promising and emerging minimally invasive technique, however, the current evidence has not verified other potential advantages (ie, cosmesis, recovery time, convalescence, port-related complications, etc.) of LESS-AD.

Laparoendoscopic single site adrenalectomy: initial results of cosmetic satisfaction and the potential for postoperative pain reduction

Background

Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.

Methods

Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.

Results

Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.

Conclusions

LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique.

A systematic review and meta-analysis of current evidence comparing laparoendoscopic single-site adrenalectomy and conventional laparoscopic adrenalectomy

PURPOSE

To assess the efficacy and safety of laparoendoscopic single-site adrenalectomy (LESS-A) and conventional laparoscopic adrenalectomy (LA) as a systematic review and meta-analysis of current evidence.

METHODS

We conducted a thorough search for comparative studies that compared LESS-A and conventional LA in the following databases: MEDLINE, EMBASE, and the Cochrane library. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. The operative time, estimated blood loss in operation, the time to resume oral intake after surgery, postoperative hospital stay, and the visual analog pain scale (VAPS) score were included for analysis to compare the efficacy, while the complications together with the analgesia use were included for analysis to compare the safety.

RESULTS

Nine studies with 171 LESS-A cases and 272 conventional LA cases were identified. Although operative time was longer in LESS-A (mean difference [MD] 15.46, 95% confidence interval [CI] 11.18 to 19.74), estimated blood loss (MD 4.72, 95% CI 12.08 to 21.52) and the time to resume oral intake (MD -0.04, 95% CI -0.19 to 0.11) were similar; LESS-A presented a shorter postoperative stay in hospital (MD -0.60, 95% CI -0.86 to -0.35) and lower VAPS score (MD -1.21, 95% CI -1.44 to -0.97). Besides, the risk of minor postoperative complications (risk ratio [RR] 1.74, 95% CI 0.78 to 3.87) was similar. The postoperative analgesia demand in total (RR 0.65, 95% CI 0.52 to 0.81) together with the analgesia usage lasting more than 24 hours after surgery (RR 0.35, 95% CI 0.21 to 0.58) were associated with lower risk in LESS-A, however.

CONCLUSIONS

Based on current evidence, the operative time seems to be longer in LESS-A; however, operative blood loss and complications are similar. In addition, LESS-A presents a shorter hospital stay after surgery and more acceptable perception of pain than conventional LA.

Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital

INTRODUCTION

Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy.

METHODS

Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port.

RESULTS

The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days).

CONCLUSION

Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.

Current concepts in the management of adrenal incidentalomas

Adrenal tumors are among the commonest incidental findings discovered. The increased incidence of diagnosing adrenal incidentalomas is due to the widespread availability and use of noninvasive imaging studies. Extensive research has been conducted to define a cost-effective diagnostic and therapeutic protocol to guide physicians in managing incidental adrenal lesions. However, there is little consensus on the optimal management strategy. Published literature to date, describes a wide spectrum of treatment options ranging from excision of all adrenal lesions regardless of the size and functional status to extensive hormonal and radiological evaluation to avoid surgery. In this review, we present a comprehensive overview of the presentation, evaluation and management of adrenal incidentalomas. Additionally, we propose a management algorithm to optimally manage these tumors.

A comparative study of multiport versus laparoendoscopic single-site adrenalectomy for benign adrenal tumors

BACKGROUND

The safety and feasibility of laparoendoscopic single-site (LESS) adrenalectomy for benign adrenal lesions was proved in early clinical series. However, the advantages of LESS over multiport laparoscopic adrenalectomy still are under investigation.

METHODS

Since October 2009, the authors have prospectively performed LESS retroperitoneal adrenalectomy for 21 consecutive patients with benign adrenal tumors (LESS group). Another 28 patients with benign adrenal tumors were prospectively collected between June 2006 and October 2009 and served as a multiport laparoscopic adrenalectomy group. The patients' demographic data, operating time, estimated blood loss, peri- and postoperative complications, and short-term outcome were collected for further analysis.

RESULTS

The demographic data were comparable between the two groups in terms of the patient age, gender, body mass index (BMI), laterality, diagnosis, and resected specimen weight. No major complication or mortality occurred in either group. Neither group had any conversions. No differences were observed between the two groups in terms of intraoperative hemodynamic status or peri- or postoperative complications. The LESS patients had quicker resumption of oral intake (0.18 vs 1 day; p < 0.001), a shorter hospital stay (2 vs 4 days; p < 0.001), and a reduced analgesic requirement postoperatively (0 vs 0.84 mg/kg; p = 0.023) than the multiport laparoscopic patients.

CONCLUSIONS

The results demonstrate that LESS adrenalectomy is as safe and effective as conventional multiport laparoscopic adrenalectomy for benign adrenal tumors. In addition, LESS adrenalectomy provides short-term convalescence advantages over multiport laparoscopic adrenalectomy.

Transumbilical laparo-endoscopic single site surgery for adrenal cortical adenoma inducing primary aldosteronism: initial experience

BACKGROUND

We have started using laparo-endoscopic single-site surgery (LESS) in urologic surgery, although its use has not gained momentum due to its level of difficulty. We here report our initial experience with transumbilical LESS for adrenal cortical adenoma by using a single port with a multichannel cannula (SILS port) and bent laparoscopic instrumentation.

FINDINGS

A multichannel port (SILS port), bent laparoscopic instrument (Roticulator Endo Mini-Shears) and Opti4 laparoscopic electrodes were used in all cases. The intraperitoneal space was approached through the umbilicus. The SILS port was placed through a 2 cm incision at the inner edge of the umbilicus. A 5 mm flexible laparoscope was introduced to keep the laparoscope outside, and surgical specimens were extracted using an Endocatch bag. In addition, as a case control study, we compared perioperative data of LESS adrenalectomy (LESS-A) with that of conventional laparoscopic adrenalectomy (LA). We performed transumbilical LESS-A for adrenal cortical adenoma in 12 cases, beginning in December, 2009. All procedures were successfully completed, with only one incision through the umbilicus, and without conversion to a standard laparoscopic approach. Mean operative time for LESS-A was 121.2 ± 7.8 min, which was slightly longer than LA (110.2 ± 7.3 min). For right adrenal tumors, we used a miniport (2 mm port) in addition to a SILS port, and were able to successfully perform adrenalectomy "with no visible scaring". Tumor laterality and patient BMI did not affect surgical morbidity in these procedures. Moreover, there was no significant difference between LESS-A and LA in blood loss, analgesic requirement, hospital stay, and scar satisfaction.

CONCLUSIONS

The transumbilical approach in LESS for adrenalectomy is safe and feasible and also improves cosmetic outcome compared with standard laparoscopic procedures. Improvements in surgical devices may aid the further development of this approach.

Laparoendoscopic single site (LESS) adrenalectomy: technique and outcomes

PURPOSE

To describe the surgical technique, to analyze outcomes and to provide an overview of the current status of laparoendoscopic single site (LESS) adrenalectomy.

METHODS

A comprehensive PubMed search was performed for all relevant urological literature regarding LESS and adrenal surgery. In addition, experience gained at the authors' own institutions was considered. Clinical descriptive and comparative reports on LESS adrenal surgery procedures were analysed.

RESULTS

LESS adrenal surgery has been effectively performed for a number of indications. A wide variety of approaches (transperitoneal versus retroperitoneal, multichannel trocar versus multiple ports, trans- or extraumbilical) have been described. LESS adrenalectomy seems to be safe, taking more time than the standard laparoscopic counterpart but appears to offer the patient less postoperative discomfort. Technical difficulties of the procedure include the requirement of more time for adjustment of articulating instruments, longer 'one-handed' manipulation time, and a high peroperative tissue re-grasping rate.

CONCLUSIONS

The feasibility and safety of LESS adrenalectomy has been demonstrated. Only long-term follow-up outcomes will prove its benefits over conventional laparoscopy and define the role and the oncological safety of LESS adrenal surgery.