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Walz MK. [Minimally invasive techniques in adrenal gland surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:850-855. [PMID: 35927340 DOI: 10.1007/s00104-022-01682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.
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Affiliation(s)
- Martin K Walz
- Klinik für Chirurgie und Zentrum Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Henricistraße 92, 45136, Essen, Deutschland.
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Walz MK, Metz KA, Theurer S, Myland C, Alesina PF, Schmid KW. Differentiating Benign from Malignant Adrenocortical Tumors by a Single Morphological Parameter-a Clinicopathological Study on 837 Adrenocortical Neoplasias. Indian J Surg Oncol 2020; 11:705-710. [PMID: 33281410 PMCID: PMC7714795 DOI: 10.1007/s13193-020-01205-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023] Open
Abstract
The morphological differentiation between benign and malignant adrenocortical tumors is an ongoing problem in diagnostic pathology. In recent decades the complex scoring systems have been widely used to calculate the probability of malignancy in adrenocortical tumors on the basis of a variety of histomorphological parameters. We herewith present a substantially simplified method to diagnose adrenocortical carcinoma by a single histomorphological parameter on a consecutive series of more than 800 adrenocortical tumors. Between January 2000 and May 2019, altogether 2305 adrenalectomies for of all types of diseases were removed, approximately 98% by minimally invasive approaches. After exclusion of pheochromocytomas, adrenal ganglioneuromas, adrenal metastases, Cushing’s disease related specimens, and Conn’s adenomas, the present series finally consisted of 837 adrenocortical tumors. All tumors were analyzed by experienced pathologists of a single institution using standard histopathological methods (Hematoxylin-Eosin and Ki67 stained sections). Clinical and histopathologic data were prospectively collected and retrospectively analyzed. Clinically, 385 patients had 420 functioning tumors (FT), and 417 had non-functioning adrenal tumors (NFT). The mean size of FT was 3.8 ± 1.4 cm (range 0.5–16 cm) and for NFT 4.5 ± 1.6 cm (range 1.5–18 cm). Histomorphologically, 32 adrenal tumors were classified as adrenocortical carcinoma (ACC; 3.8%). In all 32 cases (tumor size 9.1 ± 4.0 cm, range 3–18 cm), confluenting tumor necrosis could be demonstrated. The remaining 805 tumors (control group) completely lacked this highly reproducible single morphological feature. Ki67 levels above 10% were found in 31 of 32 ACCs and never in adrenocortical adenomas (ACA). With a mean follow-up of 8.2 years, 24 out of 32 patients primarily diagnosed as ACC developed distant metastases (75.0%), whereas all patients in the control group remained free of local or distant recurrence. We conclude that a single morphological parameter (confluenting tumor necrosis) is sufficient to predict a poor clinical course in adrenocortical tumors. The histomorphological diagnosis of this parameter is straightforward and highly reproducible.
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Affiliation(s)
- Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
| | - Klaus A Metz
- Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sarah Theurer
- Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Cathrin Myland
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
| | - Pier F Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
| | - Kurt W Schmid
- Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Seeliger B, Walz MK, Alesina PF, Agnus V, Pop R, Barberio M, Saadi A, Worreth M, Marescaux J, Diana M. Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model. Surg Endosc 2019; 34:1401-1411. [PMID: 31338664 DOI: 10.1007/s00464-019-06997-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/15/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. METHODS Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. RESULTS In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). CONCLUSIONS Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.
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Affiliation(s)
- Barbara Seeliger
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France. .,Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany. .,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.
| | - Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Pier F Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Interventional Radiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Alend Saadi
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Marc Worreth
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.,Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
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Alesina PF. Retroperitoneal adrenalectomy-learning curve, practical tips and tricks, what limits its wider uptake. Gland Surg 2019; 8:S36-S40. [PMID: 31404183 DOI: 10.21037/gs.2019.03.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The minimally invasive retroperitoneal approach to the adrenal surgery has been described in the early 90s following the first description of laparoscopic adrenalectomy. Although the advantages of the technique compared to laparoscopic surgery have been demonstrated in many studies, it remained for a long period confined to few centers. The operation has been standardized over the years into a safe and reproducible procedure that finally gained worldwide acceptance in the last 10 years. The present paper summarizes the surgical steps of the procedure focusing on the recent technical developments. Retroperitoneoscopic adrenalectomy should be part of the surgical armamentarium of any center dedicated to endocrine surgery.
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Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach. Surg Endosc 2018; 32:3732-3737. [PMID: 29855711 DOI: 10.1007/s00464-018-6262-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation. METHODS Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips. RESULTS Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86 min (range 40-135). There were no perioperative or postoperative complications. CONCLUSIONS Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.
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Ko J, Jeong J, Lee S, Son H, Kweon OK, Kim WH. Feasibility of single-port retroperitoneoscopic adrenalectomy in dogs. Vet Surg 2018; 47:O75-O83. [PMID: 29697143 PMCID: PMC6032942 DOI: 10.1111/vsu.12789] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 01/22/2018] [Accepted: 03/02/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the feasibility of single-port retroperitoneoscopic adrenalectomy (SPRA) in dogs. STUDY DESIGN A pilot experimental study. ANIMALS Eight healthy beagle dogs. METHODS SPRA was performed on the left and right sides (4 dogs each). Resection of the adrenal gland was performed through a SILS port using a retroperitoneal approach. Operative time was defined from skin incision to the completion of skin suture. Postoperative pain was evaluated by using 3 pain scores. Integrity of the adrenal gland capsule was evaluated by histologic assessment. RESULTS Mean time taken to complete the SPRA was 44.1 minutes (range, 37-51) and was significantly longer on the right side than on the left side (P < .05). There were no complications intraoperatively or during 14 days of postoperative monitoring. The adrenal gland capsule was found to be injured in 3 of the 8 dogs by histologic assessment. CONCLUSION This is the first report of SPRA in the veterinary literature. With this technique it is possible to perform adrenalectomy with some risk of capsule penetration and with excellent visibility. CLINICAL SIGNIFICANCE This study suggests that SPRA is feasible and can be used to resect small adrenal tumors with minimal complications.
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Affiliation(s)
- Jonghyeok Ko
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Junemoe Jeong
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | | | - Hyunglak Son
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Oh-Kyeong Kweon
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Wan Hee Kim
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
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Walz MK, Iova LD, Deimel J, Neumann HPH, Bausch B, Zschiedrich S, Groeben H, Alesina PF. Minimally Invasive Surgery (MIS) in Children and Adolescents with Pheochromocytomas and Retroperitoneal Paragangliomas: Experiences in 42 Patients. World J Surg 2018; 42:1024-1030. [DOI: 10.1007/s00268-018-4488-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Comparative outcomes of lateral transperitoneal adrenalectomy versus posterior retroperitoneoscopic adrenalectomy in consecutive patients: A single surgeon's experience. Asian J Surg 2017; 39:74-80. [PMID: 26117204 DOI: 10.1016/j.asjsur.2015.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 03/30/2015] [Accepted: 04/15/2015] [Indexed: 11/21/2022] Open
Abstract
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.
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Sho S, Yeh MW, Li N, Livhits MJ. Single-incision retroperitoneoscopic adrenalectomy: a North American experience. Surg Endosc 2016; 31:3014-3019. [DOI: 10.1007/s00464-016-5325-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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Abstract
The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.
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Affiliation(s)
- Barbra S Miller
- University of Michigan Health System, 1500 East Medical Center Drive, 2920F Taubman Center, Ann Arbor, MI 48109-5331, USA
| | - Gerard M Doherty
- Department of Surgery, Boston University, 75 East Newton Street, Boston, MA 02118, USA
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Qadan M, Curet MJ, Wren SM. The evolving application of single-port robotic surgery in general surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:26-33. [DOI: 10.1002/jhbp.37] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Motaz Qadan
- Department of Surgery; Stanford University Medical Center; Palo Alto CA USA
| | | | - Sherry M. Wren
- Department of Surgery; Stanford University Medical Center; Palo Alto CA USA
- Department of Surgery; Veterans Affairs Palo Alto Health Care System; 3801 Miranda Avenue Palo Alto CA 94304 USA
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Uras C, Aytac E, Aydogan F. Videoendoscopic single-port axillary dissection. J Minim Access Surg 2013; 7:246-8. [PMID: 22022116 PMCID: PMC3193697 DOI: 10.4103/0972-9941.85650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Accepted: 03/23/2011] [Indexed: 11/18/2022] Open
Abstract
Videoendoscopy is newly used in breast and axillary surgery. Single-port surgery is one of the newest methods of minimally invasive surgery. This report describes the first case of videoendoscopic single-port axillary dissection. In histopathological evaluation, 24 lymph nodes were identified and one node was infiltrated by the cancer cells. Videoendoscopic single-port axillary dissection is a precise and improvable technique. Single-port videoendoscopic axillary dissection could be more feasible with individual tools that will be designed for minimally invasive breast surgery.
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Affiliation(s)
- Cihan Uras
- Department of Surgery, Division of Breast Diseases, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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Park JH, Kim SY, Lee CR, Park S, Jeong JS, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS. Robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access: technical feasibility and preliminary results. Ann Surg Oncol 2013; 20:2741-5. [PMID: 23494081 DOI: 10.1245/s10434-013-2891-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy (PRA) has several benefits compared with transperitoneal adrenalectomy in that it is safe and has a short learning curve. In addition, it provides direct short access to the target organ, prevents irritation to the intraperitoneal space, and does not require retraction of adjacent organs.1 (-) 3 We have performed several cases of robot-assisted PRA using single-port access for small adrenal tumors. This multimedia article introduces the detailed methods and preliminary results of this procedure. METHODS Five patients underwent single-port robot-assisted PRA between March 2010 and June 2011 at our institution. During the procedure, patients were placed in a prone jackknife position with their hip joints bent at a right angle (Fig. 1). A 3 cm transverse skin incision was made just below the lowest tip of the 12th rib (Fig. 2), and the Glove port (Nelis, Kyung-gi, Korea) was placed through the skin incision while maintaining pneumoretroperitoneum (Fig. 3). CO2 was then insufflated to a pressure of 18 mm Hg to create an adequate working space. A 10 mm robotic camera with a 30-degree up view was placed at the center of the incision through the most cephalic portion of the Glove port. A Maryland dissector or Prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA) was placed on the medial side of the incision, and Harmonic curved shears (Intuitive Surgical) were placed on the lateral side of the incision (Fig. 4). Using the Maryland dissector and the harmonic curved shears, the Gerota fascia is opened, perinephric fat is dissected, and the kidney upper pole is mobilized to expose the adrenal gland (Fig. 5). Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction (Fig. 6). After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is ligated with a 5 mm hemolock clip (Fig. 7). Patient clinicopathologic data were analyzed retrospectively. RESULTS The mean patient age was 56.6 ± 8.7 (range, 47-69) years. Right and left side approaches were used in two and three patients, respectively. All cases were adrenal cortical adenoma. The mean tumor size was 1.48 ± 0.28 (range, 1.0-1.7) cm. The mean surgery duration (skin to skin) was 159.4 ± 57.6 (range, 103-245) minutes, and the mean estimated blood loss was 46.0 ± 56.8 (range, 5-120) ml. The average time to oral intake and postoperative hospital stay were 0.65 ± 0.11 (range, 0.54-0.79) days and 4.0 ± 2.23 (range, 3-8) days, respectively. There were no conversions to open surgery or postoperative compli- cations. DISCUSSION Some trials of minimally invasive single-access surgery of the adrenal gland have recently been performed.4 (,) 5 However, these new techniques have several limitations as a result of restrictions on instrumentation movement because of the small access ports used and relatively low-quality images produced. The recent introduction of the da Vinci S surgical robot system (Intuitive Surgical) to endoscopic surgery has improved instrumental dexterity and provided the surgeon with an ergonomically designed operating system. This system is also potentially safer and more meticulous in performing operations than endoscopic procedures as a result of a 3-D, magnified, stable operative view.6 (,) 7 The advantages of the da Vinci S surgical robot system and the numerous benefits of the posterior retroperitoneal approach motivated us to utilize single-port robot-assisted PRA. The primary selection criteria were small tumor size and a minimal amount of periadrenal fatty tissue because robot-assisted PRA using single-port access provides a small operative space, which causes manipulation problems when tumors are large. To ensure the safe application of these new techniques, we recommend that novice surgeons begin using single-port robot-assisted PRA for smaller tumors < 2 cm in patients with a body mass index of < 30 kg/m(2), gradually extending the size and body mass index as they accumulate experience. Although robot-assisted PRA using single-port access could not be compared with the other robotic adrenalectomy techniques in this study, the potential advantages of this approach compared to conventional robot-assisted transperitoneal adrenalectomy include a reduction in postoperative ileus, bacterial contamination, and intestinal complications because the peritoneal cavity is not opened, in addition to a reduction in postoperative pain because of its minimally invasive nature. CONCLUSIONS Our initial experiences with robot-assisted PRA using single-port access assured us of its safety and feasibility for the resection of small adrenal tumors. Although single-port robot-assisted PRA appears to be safe and feasible, further experience and research is required to optimize patient selection criteria and verify its advantages over the traditional three-incision PRA technique.
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Affiliation(s)
- Jae Hyun Park
- Department of Surgery, Yonsei University Wonju College of Medicine, Seoul, South Korea
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Genetic and clinical features of multiple endocrine neoplasia types 1 and 2. JOURNAL OF ONCOLOGY 2012; 2012:705036. [PMID: 23209466 PMCID: PMC3503399 DOI: 10.1155/2012/705036] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/16/2012] [Indexed: 12/12/2022]
Abstract
Multiple endocrine neoplasia (MEN) are clinical inherited syndromes affecting different endocrine glands. Three different patterns of MEN syndromes can occur (MEN 1, MEN 2A, and MEN 2B). MEN syndromes are very rare, affect all ages and both sexes are equally affected. MEN 1 is characterized by the neoplastic transformation of the parathyroid glands, pancreatic islets, anterior pituitary, and gastrointestinal tract. Heterozygous MEN 1 germline mutations have been detected in about 70–80% of patients with MEN 1. The mutations are scattered throughout the entire genomic sequence of the gene. MEN 1 patients are characterized by variable clinical features, thus suggesting the lack of a genotype-phenotype correlation. Therapeutical approaches are different according to the different endocrinopathies. The prognosis is generally good if adequate treatment is provided. In MEN 2 syndromes, the medullary thyroid cancer (MTC) is almost invariably present and can be associated with pheochromocytoma (PHEO) and/or multiple adenomatosis of parathyroid glands with hyperparathyroidism (PHPT). The different combination of the endocrine neoplasia gives origin to 3 syndromes: MEN 2A, MEN 2B, and FMTC. The clinical course of MTC varies considerably in the three syndromes. It is very aggressive in MEN 2B, almost indolent in the majority of patients with FMTC and with variable degrees of aggressiveness in patients with MEN 2A. Activating germline point mutations of the RET protooncogene are present in 98% of MEN 2 families. A strong genotype-phenotype correlation has been observed and a specific RET mutation may be responsible for a more or less aggressive clinical course. The treatment of choice for primary MTC is total thyroidectomy with central neck lymph nodes dissection. Nevertheless, 30% of MTC patients, especially in MEN 2B and 2A, are not cured by surgery. Recently, developed molecular therapeutics that target the RET pathway have shown very promising activity in clinical trials of patients with advanced MTC. MEN 2 prognosis is strictly dependent on the MTC aggressiveness and thus on the success of the initial treatment.
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Miller JA, Kwon DS, Dkeidek A, Yew M, Hisham Abdullah A, Walz MK, Perrier ND. Safe introduction of a new surgical technique: remote telementoring for posterior retroperitoneoscopic adrenalectomy. ANZ J Surg 2012; 82:813-6. [PMID: 23013552 DOI: 10.1111/j.1445-2197.2012.06188.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy (PRA) is a safe and effective approach to adrenalectomy, offering less pain and faster recovery than open or laparoscopic surgery. Although the popularity of PRA is increasing, few surgical centres have extensive experience with the procedure. The ideal approach to achieve proficiency with any new technique involves on-site observation of an experienced surgeon-mentor, followed by mentored hands-on experience of the surgeon-learner. However, it is not always feasible for a surgeon-mentor to offer on-site supervision to the surgeon-learner in his or her home institution. Advances in Internet applications have made remote telementoring a viable alternative to on-site mentoring in selected situations. METHODS We describe our experience in safely introducing PRA to Melbourne, Australia, where no highly experienced surgeon-mentors were available. A surgeon with experience of 12 PRA procedures attended from interstate, along with live telementoring via Skype video link by an overseas surgeon who had performed more than 200 PRA procedures, to mentor the surgeon-learner performing her first three cases. RESULTS The operating surgeon's first three PRA procedures proceeded uneventfully, with no complications, relatively short operative times and one-night hospital stays for all three patients. Twenty-two more have been performed since, without complications. CONCLUSION Remote telementoring is a safe and feasible way to assist surgeons in safely introducing new techniques. This strategy is particularly applicable in centres where no surgeon-mentor is locally available. It is important that the surgeon-learner has the skills and experience to complete the procedure using alternative techniques in the case of complications or technical failure.
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Affiliation(s)
- Julie A Miller
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.
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Vidal Ó, Astudillo E, Valentini M, Ginestà C, García-Valdecasas JC, Fernandez-Cruz L. Single-incision transperitoneal laparoscopic left adrenalectomy. World J Surg 2012; 36:1395-9. [PMID: 22392358 DOI: 10.1007/s00268-012-1555-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period. RESULTS There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay. CONCLUSION SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.
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Affiliation(s)
- Óscar Vidal
- General and Endocrine Surgery Unit, Department of General and Digestive Surgery, Digestive Diseases and Metabolism Institute, Hospital Clínic i Provincial, Universitat de Barcelona, CIRBERHED, IDIBAPS, Villarroel 170, 08036 Barcelona, Spain.
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Surgical treatment options for aldosteronomas. Wideochir Inne Tech Maloinwazyjne 2012; 7:260-7. [PMID: 23362425 PMCID: PMC3557732 DOI: 10.5114/wiitm.2011.29898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 05/03/2012] [Accepted: 05/29/2012] [Indexed: 11/17/2022] Open
Abstract
Introduction Single access retroperitoneoscopic adrenalectomy (SARA) is the most feasible approach for removing aldosteronomas. Aim To analyse the advantages and disadvantages of surgical approaches to treating small adrenal tumours. Material and methods In the period 2002-2011, 31 patients were operated on at Vilnius University Hospital Santariskiu Clinics for aldosteronomas. Adrenalectomies were performed in the lateral laparoscopic (group A, n = 6), the endoscopic retroperitoneal (group B, n = 20), and the single incision laparoscopic surgery (SILS) and SARA (group C, n = 5) approaches. Seventy five percent of patients were operated on by the same surgeon. The duration of adrenalectomies, and intraoperative and postoperative complications were compared. The possibility of minimally invasive adrenalectomies was evaluated. Results According to the patients’ age, body mass index and tumour size, the groups were equal. The average duration of surgery in group A was shorter than in groups B and C (91 ±23 min vs. 118 ±57 min vs. 144 ±88 min). Right laparoscopic adrenalectomy was longer than the left (105 ±26 min vs. 77 ±6 min), whereas right endoscopic retroperitoneal adrenalectomy was shorter than the left (109 ±50 min vs. 126 ±57 min). The best cosmetic view was in group C. The SARA method was converted into the endoscopic retroperitoneal approach and then into the laparoscopic for one patient. There were no intraoperative or postoperative complications. Conclusions Evaluating the minimal invasion of the method, its abilities and simplicity of conversion into another type of endoscopic surgical way, the SARA approach should be the first option for removing aldosteronomas.
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19
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Luo Y, Chen X, Chen Z, He Y, Li N, Lai C, Xie C. Retroperitoneal Laparoendoscopic Single-Site Adrenalectomy: Our Initial Technical Experience. J Laparoendosc Adv Surg Tech A 2012; 22:584-6. [PMID: 22691159 DOI: 10.1089/lap.2011.0468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yancheng Luo
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Xiang Chen
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Zhi Chen
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Yao He
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Nannan Li
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Cheng Lai
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
| | - Chaoqun Xie
- Department of Urology, Xiangya Hospital, Central South University, Hunan, China
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Beiša V, Kildušis E, Strupas K. Single access retroperitoneoscopic adrenalectomy: initial experience. Wideochir Inne Tech Maloinwazyjne 2012; 7:45-9. [PMID: 23256000 PMCID: PMC3516963 DOI: 10.5114/wiitm.2011.25640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 07/23/2011] [Accepted: 09/13/2011] [Indexed: 11/17/2022] Open
Abstract
Today, endoscopic adrenalectomy has become a gold standard in endocrine surgery. To minimize the morbidity and improve cosmesis, single access retroperitoneoscopic adrenalectomy (SARA) has been developed as an alternative to traditional multiport laparoscopy and single port access (SPA) surgery, potentially exploiting even more the already proven benefits of minimally invasive surgery. We applied the SARA technique to adrenalectomy using the posterior retroperitoneal approach. The aim is to highlight the current situation regarding the feasibility and safety of single access retroperitoneoscopic adrenalectomy and to present our initial experience. Between October 2010 and February 2011, a 74-year-old woman (body mass index (BMI) - 31 kg/m(2)) with pheochromocytoma (1.2 cm in size) and 3 women, aged 45, 46 and 66 years (BMI - 27, 32, 33 kg/m(2)), respectively, and all diagnosed with Conn's adenoma (from 1.2 cm to 2.0 cm in size), underwent single access retroperitoneoscopic adrenalectomies. Operations were performed using conventional laparoscopic (STORZ) equipment. No conversions to the open or conventional retroperitoneal approach were necessary. There were no perioperative or postoperative complications. Operating time ranged from 60 min to 80 min. All patients left the hospital 2 days after surgery. The single access retroperitoneoscopic technique has been successfully applied to adrenalectomy as an available alternative to multiport laparoendoscopic adrenalectomy and single port access surgery. Exposure, visualization and dissection are the same as in retroperitoneal endoscopic adrenalectomy. The SARA surgery offers patient benefits such as faster convalescence, decreased postoperative scarring, better cosmetic effect and financial benefit.
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Affiliation(s)
- Virgilijus Beiša
- Vilnius University Hospital Santariskiu Clinics, Center of Abdominal Surgery, Lithuania
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Choi SH, Hwang HK, Kang CM, Lee WJ. Transumbilical single port laparoscopic adrenalectomy: a technical report on right and left adrenalectomy using the glove port. Yonsei Med J 2012; 53:442-5. [PMID: 22318837 PMCID: PMC3282955 DOI: 10.3349/ymj.2012.53.2.442] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recently, single port laparoscopic surgery has been the focus of attention due to the advanced laparoscopic skills accumulated from experience and developments in laparoscopic instruments. Herein, we present two cases of initial single port laparoscopic adrenalectomies. Case 1 was a 38-year-old female patient diagnosed with primary hyperaldosteronism because of a the right adrenal 2.5-cm sized adenoma, and case 2 was a 31-year-old female patient diagnosed with primary adrenal Cushing's syndrome because of a left adrenal 2.9-cm sized adenoma. Both patients successfully underwent single port laparoscopic adrenalectomies via a transumbilical transperitoneal approach. There was no estimated blood loss and the total operating times were 60 and 70 minutes, respectively. Both patients recovered uneventfully. We believe that this technique presented could provide potential benefits (lesser wound pain, better cosmetic satisfaction, and shorter convalescence) if the indications are carefully selected.
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Affiliation(s)
- Sung Hoon Choi
- Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Clinic of Pancreatic and Biliary Cancer, Institute of Gastroenterology, Yonsei University Health System, Seoul, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Clinic of Pancreatic and Biliary Cancer, Institute of Gastroenterology, Yonsei University Health System, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Clinic of Pancreatic and Biliary Cancer, Institute of Gastroenterology, Yonsei University Health System, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, Clinic of Pancreatic and Biliary Cancer, Institute of Gastroenterology, Yonsei University Health System, Seoul, Korea
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22
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Abstract
Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.
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Affiliation(s)
- Marcelo Hisano
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Park JH, Walz MK, Kang SW, Jeong JJ, Nam KH, Chang HS, Chung WY, Park CS. Robot-assisted posterior retroperitoneoscopic adrenalectomy: single port access. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81 Suppl 1:S21-4. [PMID: 22319732 PMCID: PMC3267059 DOI: 10.4174/jkss.2011.81.suppl1.s21] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/26/2011] [Accepted: 05/04/2011] [Indexed: 01/24/2023]
Abstract
Laparoscopic adrenalectomy has become a gold standard in adrenal gland surgery. More recently, some minimally invasive trials have been conducted on single access surgery on the adrenal gland. In this study, we introduce our first experiences of robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access and the da Vinci system.
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Affiliation(s)
- Jae Hyun Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Alesina PF, Hinrichs J, Meier B, Schmid KW, Neumann HPH, Walz MK. Minimally invasive cortical-sparing surgery for bilateral pheochromocytomas. Langenbecks Arch Surg 2011; 397:233-8. [DOI: 10.1007/s00423-011-0851-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 09/08/2011] [Indexed: 11/28/2022]
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Abstract
Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).
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Affiliation(s)
- A Germain
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital d'adultes, CHU de Nancy-Brabois, université Henri-Poincaré-Nancy-1, 11, allée du Morvan, 54511 Vandœuvre-lès-Nancy, France
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Szucsik E, Hilder M, Lösch C, Walz MK, Wenger FA. [Additional personal contributions for minimally invasive surgery : How high is patient acceptance?]. Chirurg 2011; 82:1014-20. [PMID: 21800191 DOI: 10.1007/s00104-011-2089-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Increasing costs of the healthcare system might decrease the spectrum of insurance financed medical treatment in the future. Therefore we evaluated whether patients are prepared to pay partial costs of their own, especially for minimally invasive surgery. METHODICS: Between 1st July 2007 and 1st July 2008 patients were asked in a prospective trial preoperatively and postoperatively whether they would be prepared to pay an additional invoice of 200 EUR for a minimally invasive operation. Payment was reasoned by the hypothesis that insurance companies will reduce the DRG payment while costs are rising. RESULTS A total of 750 patients, men:women=279 (37.2%):471 (62.8%) undergoing elective minimally invasive operations were included in the trial. For the majority of patients (m=266:13; w=448:23) it was very important to be operated on in a center for minimally invasive surgery. Preoperatively and postoperatively the majority of patients voted for individual payment of 200 EUR to make minimally invasive surgery possible (84.4 versus 84.1%, respectively, p=0.79). Although 80.4% (411/511) of patients with national health insurance voted for payment, voting of patients with private insurance was significantly increased to 92.9% (222/239) (p<0.001). Voting for individual payment increased with a rising level of education (p=0.017), job position and income (p<0.001). Furthermore, it was significantly increased in married compared to single patients (86.5% versus 78.4%, respectively, p=0.038). CONCLUSION Before the operations 84.4% of patients voted for additional individual payment for minimally invasive operations but this was dependent on the socio-economic status.
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Affiliation(s)
- E Szucsik
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Universität Duisburg-Essen, Henricistr. 92, 45136, Essen, Deutschland.
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Barbaros U, Demirel T, Sumer A, Deveci U, Tukenmez M, Cansunar MI, Kalayci M, Dınccag A, Seven R, Mercan S. Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report. ISRN GASTROENTEROLOGY 2011; 2011:347487. [PMID: 21991503 PMCID: PMC3168390 DOI: 10.5402/2011/347487] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 03/22/2011] [Indexed: 12/17/2022]
Abstract
Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.
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Affiliation(s)
- Umut Barbaros
- Department of General Surgery, Istanbul Faculty of Medicine, University of Istanbul, Istanbul, Turkey
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Rane A, Cindolo L, Schips L, De Sio M, Autorino R. Laparoendoscopic single site (LESS) adrenalectomy: technique and outcomes. World J Urol 2011; 30:597-604. [PMID: 21519852 DOI: 10.1007/s00345-011-0678-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 04/08/2011] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Abhay Rane
- Department of Urology, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK.
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Karahasanoglu T, Hamzaoglu I, Baca B, Aytac E. Hybrid laparo-endoscopic single port transperitoneal right adrenalectomy. MINIM INVASIV THER 2011; 21:59-62. [PMID: 21395462 DOI: 10.3109/13645706.2010.543423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Laparoscopic surgery is a preferable technique for adrenalectomy. Laparo-endoscopic single port surgery (LESS) is one of the newest areas in minimally invasive surgery. The development of the technology has made many surgical procedures less invasive. In this paper, we report hybrid laparo-endoscopic single port transperitoneal right adrenalectomy for a non-functional adrenal mass.
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Affiliation(s)
- Tayfun Karahasanoglu
- Department of Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey.
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Our early experiences with single-incision laparoscopic surgery: the first 32 patients. Surg Laparosc Endosc Percutan Tech 2011; 20:306-11. [PMID: 20975500 DOI: 10.1097/sle.0b013e3181f20cf6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most of the laparoscopic surgeons have been attempting to reduce incisional morbidity and improve cosmetic outcomes by using fewer and smaller ports. Single-incision laparoscopic surgery (SILS) is a new laparoscopic procedure. Herein we would like to present our experiences. PATIENTS AND METHODS Between January 2009 and October 2009, data of the 32 patients who were operated through SILS are evaluated prospectively. There were 22 females and 10 males with a mean age of 45.1±14.8 years. Ten splenectomies for idiopathic thrombocytopenic purpura, 16 cholecystectomies for acute cholecystitis or asymptomatic gallstones, 3 appendectomies for acute appendicitis, one distal pancreatosplenectomy for Renal Cell Cancer metastases, 1 adrenalectomy for Conn Syndrome and 1 case of liver resection for hepatic adenoma were carried out. The most common splenectomy indication was idiopathic thrombocytopenic purpura, cholecystectomy indication was acute cholecystitis (n=8), and asymptomatic cholelithiasis (n=8), appendectomy indication was acute appendicitis, distal pancreatosplenectomy indication was renal cell cancer metastases, adrenalectomy indication was Conn syndrome and liver resection indication was left hepatic mass in between segments 1 and 2. SILS was carried out successfully in 31 patients. Only in 1 patient conversion was required owing to bleeding. RESULTS All procedures were carried out through a 2-cm umbilical incision. There was no mortality and morbidity recorded. CONCLUSIONS In experienced hands of minimally invasive surgeons, SILS incision laparoscopic surgery could be carried out successfully in a wide range of surgical operations. However, to be able to show the differences between Standard laparoscopic surgery and single SILS, prospective randomized comparative studies are required.
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Uppal S, Frumovitz M, Escobar P, Ramirez PT. Laparoendoscopic single-site surgery in gynecology: review of literature and available technology. J Minim Invasive Gynecol 2011; 18:12-23. [PMID: 20965792 PMCID: PMC4361065 DOI: 10.1016/j.jmig.2010.07.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/20/2010] [Accepted: 07/22/2010] [Indexed: 01/22/2023]
Abstract
The objective of this article was to review the published literature on laparoendoscopic single-site surgery (LESS) in gynecology and to present current advances in instruments used in LESS surgery. Inasmuch as LESS surgery is relatively new, the current literature on use of this technique in gynecology is somewhat limited. Sixteen articles were available for the literature review: 10 case series, 2 comparative studies, 3 case reports, and 1 surgical technique demonstration. In recent years, however, improvements in traditional laparoscopic techniques and availability of more advanced instruments has made single-incision laparoscopy more feasible and safer for the patient. There is increasing interest in LESS surgery both as an alternative to traditional laparoscopy and as an adjunct to robotic surgery when performing complicated procedures through a single incision. Although LESS surgery provides another option in the arena of minimally invasive gynecologic surgery, the ultimate role of this approach remains to be determined.
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Affiliation(s)
- Shitanshu Uppal
- Department of Obstetrics and Gynecology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Michael Frumovitz
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Pedro Escobar
- Department of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Shi TP, Zhang X, Ma X, Li HZ, Zhu J, Wang BJ, Gao JP, Cai W, Dong J. Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard. Surg Endosc 2010; 25:2117-24. [PMID: 21170658 PMCID: PMC3116116 DOI: 10.1007/s00464-010-1506-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 11/15/2010] [Indexed: 12/22/2022]
Abstract
Background Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure. Methods Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence. Results The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03). Conclusions The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.
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Affiliation(s)
- Tao-ping Shi
- Department of Urology, Chinese People's Liberation Army General Hospital, Military Postgraduate Medical College, 28 Fuxing Road, Haidian District, 100853, Beijing, China
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33
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Kang SW, Chung WY. Robotic techniques for adrenal surgery. J Robot Surg 2010; 5:73-7. [DOI: 10.1007/s11701-010-0229-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 11/04/2010] [Indexed: 01/30/2023]
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Agha A, Hornung M, Iesalnieks I, Glockzin G, Schlitt HJ. Single-Incision Retroperitoneoscopic Adrenalectomy and Single-Incision Laparoscopic Adrenalectomy. J Endourol 2010; 24:1765-70. [DOI: 10.1089/end.2010.0238] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ayman Agha
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Hornung
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Igors Iesalnieks
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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35
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Teoh AYB, Chiu PWY, Wong TCL, Wong SKH, Lai PBS, Ng EKW. A case-controlled comparison of single-site access versus conventional three-port laparoscopic appendectomy. Surg Endosc 2010; 25:1415-9. [PMID: 20972583 DOI: 10.1007/s00464-010-1406-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 09/03/2010] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim of this study was to compare patients who underwent single-site access laparoscopic appendectomy (SSALA) to those who underwent conventional three-port laparoscopic appendectomy (TPLA) in a case-controlled manner. METHODS Consecutive patients who underwent SSALA for suspected acute appendicitis between April and September 2009 were retrospectively compared to those who underwent TPLA between January and December 2008 in a case-controlled manner. The patients were matched for age, gender, and pathological findings. The main outcome measurements included postoperative recovery, morbidities, and mortalities. RESULTS During the study period, a total of 30 patients underwent SSALA and these were matched with 60 TPLA patients. There were no significant differences in the mean operative time, hospital stay, and 30-day morbidity rate between the two groups. None of the patients required conversion. Two patients with significant contamination and abscess collection noted during SSALA required a relaparotomy for peritoneal lavage and adhesiolysis due to prolonged ileus. CONCLUSIONS SSALA is feasible and the perioperative outcome was comparable to that of TPLA. However, future prospective studies will need to evaluate whether SSALA can adequately tackle patients with significant peritoneal contamination.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
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Chung SD, Huang CY, Wang SM, Tai HC, Tsai YC, Chueh SC. Laparoendoscopic single-site (LESS) retroperitoneal adrenalectomy using a homemade single-access platform and standard laparoscopic instruments. Surg Endosc 2010; 25:1251-6. [PMID: 20848138 DOI: 10.1007/s00464-010-1352-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 08/17/2010] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study aimed to evaluate laparoendoscopic single-site (LESS) adrenalectomy via the retroperitoneal approach using the Alexis wound retractor with standard laparoscopic instrumentation. METHODS Since October 2009, seven LESS retroperitoneal adrenalectomies have been completed successfully with a homemade single port created using an Alexis wound retractor as an access platform through a 3-cm incision beneath the tip of the 12th rib. RESULTS All the LESS procedures for these seven patients with adrenal tumors (size, 1.3-6.0 cm; 4 right, 1 left) were completed successfully without traditional laparoscopic conversion or complication. The average operative time was 159 min, and the estimated blood loss was 100 ml. The average hospital stay was 2 days (range, 1-3 days). CONCLUSIONS The preliminary results show that LESS retroperitoneal adrenalectomy is a safe and feasible procedure for functional adrenal tumors using standard laparoscopic instruments.
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Affiliation(s)
- Shiu-Dong Chung
- Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan
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Posterior retroperitoneoscopic adrenalectomy for clinical and subclinical Cushing's syndrome. World J Surg 2010; 34:1391-7. [PMID: 20143066 DOI: 10.1007/s00268-010-0453-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Because of co-morbidity, adrenalectomy for adrenal Cushing's syndrome may be associated with an increased complication rate and long operating times. In the present study we report our experience with the posterior retroperitoneoscopic adrenalectomy in a large group of patients with clinical or subclinical Cushing's syndrome. PATIENTS AND METHODS Between July 1994 and June 2009, 170 patients (17 males, 153 females age 50 +/- 13 years; range: 12-78 years) affected by Cushing's syndrome underwent operation via posterior retroperitoneoscopic access. Patients were divided into two groups, those with manifest Cushing's syndrome (mCS) [99 patients: 6 male, 93 female; age 45 +/- 13 years] and those with subclinical Cushing's syndrome (sCS) [71 patients: 11 male, 60 female; age: 56 +/- 11 years]. The sCS classification was assumed in cases without typical clinical symptoms but with a pathological dexamethasone suppression test. Partial adrenalectomy was performed in 35 cases (24 in the mCS-group and 11 in the sCS-group). RESULTS Mortality was zero; major complications did not occur. The incidence of postoperative minor complications was 5.3%. Mean operating time was 58 +/- 36 min (range: 20-230 min) and did not differ between mCS and sCS patients (58 versus 59 min; p = ns). Postoperative oral steroids supplementation (POSS) was administered in 136 patients (99 mCS, 37 sCS). If POSS was started, mean duration of therapy was 12.3 months (mCS) and 10.3 months (sCS) [p = 0.08], respectively. After a mean follow-up of 70.9 +/- 46.5 months the cure rate was 99.4%. CONCLUSIONS The posterior retroperitoneoscopic approach is fast and safe even in patients with Cushing's syndrome. Partial adrenalectomy represents a new option in the treatment of cortisol-producing adenomas.
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Walz MK, Groeben H, Alesina PF. Single-access retroperitoneoscopic adrenalectomy (SARA) versus conventional retroperitoneoscopic adrenalectomy (CORA): a case-control study. World J Surg 2010; 34:1386-90. [PMID: 20213204 DOI: 10.1007/s00268-010-0494-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Stimulated by the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES), minimizing the access even further has become a new trend in minimally invasive surgery. We compare our recently described new method of endoscopic single-access adrenalectomy with the conventional retroperitoneoscopic approach in a matched-pairs study. METHODS Fifty single-access retroperitoneoscopic adrenalectomies (SARA) were performed in 47 selected patients suffering from Conn's adenomas (n = 20), pheochromocytomas (n = 15), Cushing's adenomas (n = 6), and other diseases (n = 6). For SARA, a single 2-cm skin incision beneath the 12th rib was used. Following creation of the retroperitoneal space with the rigid endoscope, dissection was carried out single-handed. Another 47 patients served as control group; they were treated by the traditional retroperitoneoscopic three-port approach (CORA). Patients were matched with respect to gender, body mass index, diagnoses, tumor size, and tumor site. RESULTS Mortality was zero and no major complications occurred in both groups. SARA was completed in 41 cases (86%). The overall complication rate was 8.5% in SARA and 6.4% in CORA. Operative time was longer for SARA (56 +/- 28 min) than for CORA (40 +/- 12 min) (P < 0.05). Postoperatively, pain medication was administered in 47% of SARA patients and in 75% of CORA patients (P = 0.01). Mean hospital stay was 2.4 +/- 0.7 days (SARA) and 3.1 +/- 1.2 days (CORA) (P < 0.01). CONCLUSIONS Because feasibility and safety of SARA could be demonstrated in a large group of selected patients, this surgical technique may represent a new milestone in minimally invasive endocrine surgery.
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Affiliation(s)
- Martin K Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, 45136, Essen, Germany.
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Teoh AYB, Wong JSW, Chiu PWY, Lai PBS, Ng EKW. Laparoendoscopic single-site surgery cholecystectomy using a novel retraction device. SURGICAL PRACTICE 2010. [DOI: 10.1111/j.1744-1633.2010.00500.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lamadé W, Hochberger J, Ulmer C, Matthes K, Thon KP. Triluminal hybrid NOS as a novel approach for colonic resection with colorectal anastomosis. Surg Innov 2010; 17:28-35. [PMID: 20181546 DOI: 10.1177/1553350609359920] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimal invasive surgery has led to a significant decrease in surgical trauma, pain, recovery time and improved cosmesis compared with open surgery. However, scar development and the risk of hot spots for infections and hernias are still present. Natural orifice surgery (NOS) promises to offer even further reduction in invasiveness and thus may lead to even faster recovery. The goal of this study was to establish a NOS colonic resection by using commercially available standard surgical instruments avoiding major abdominal incisions. METHODS AND RESULTS This article reports a new triluminal hybrid NOS approach for sigmoid and colonic resection (Tri-Port-NOS-SIG), established using rigid laparoscopic instruments through the umbilicus, the vagina, and the rectum, without any major abdominal incision. The specimen was retrieved through the anus avoiding dilatation of the vagina. In an early series of 5 patients the first patient was a 37-year-old woman with a 10-year history of recurrent diverticulitis. She recovered quickly and was discharged on postoperative day 2. She returned to sports activity on day 12 postoperatively and to her heavy-duty job on day 16. The following 4 patients also recovered well and were discharged on postoperative days 7 (2 patients), 8, and 11, respectively. One patient experienced a temporary, mild paresthesia of the left lower dorsal leg, most likely because of intraoperative positioning. No major complications occurred. CONCLUSION Tri-Port-NOS-SIG offers a feasible scarless approach for abdominal resections using commercially available surgical instruments in experienced hands.
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Cindolo L, Gidaro S, Neri F, Tamburro FR, Schips L. Assessing Feasibility and Safety of Laparoendoscopic Single-Site Surgery Adrenalectomy: Initial Experience. J Endourol 2010; 24:977-80. [DOI: 10.1089/end.2009.0535] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Luca Cindolo
- Urology Unit, S. Pio da Pietrelcina Hospital, Vasto (CH), Italy
| | - Stefano Gidaro
- Urology Unit, S. Pio da Pietrelcina Hospital, Vasto (CH), Italy
- Department of Surgical and Experimental Sciences, Chieti–Pescara University, Chieti, Italy
| | - Fabio Neri
- Urology Unit, S. Pio da Pietrelcina Hospital, Vasto (CH), Italy
| | | | - Luigi Schips
- Urology Unit, S. Pio da Pietrelcina Hospital, Vasto (CH), Italy
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Wohllk N, Schweizer H, Erlic Z, Schmid KW, Walz MK, Raue F, Neumann HPH. Multiple endocrine neoplasia type 2. Best Pract Res Clin Endocrinol Metab 2010; 24:371-87. [PMID: 20833330 DOI: 10.1016/j.beem.2010.02.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Multiple endocrine neoplasia type 2 (MEN 2) is an autosomal dominant cancer syndrome with major components of medullary thyroid carcinoma (MTC), pheochromocytoma and hyperparathyroidism. The disease is caused by germline mutations of the RET proto-oncogene. Subtypes of MEN 2 include MEN 2A, MEN 2B and familial MTC (FMTC) which differ in pattern of additional lesions or--in FMTC--lack of pheochromocytoma. In 2009, after extensive review of the literature, the guidelines of the American Thyroid Association made several recommendations regarding clinical and genetic diagnostic testing and treatment options. In this article, the recently published literature is reviewed and concerns regarding future perspectives are added. In particular, a critical handling of rare DNA variants and double mutations is necessary. Up to now, mutation-specific risk profiles and mutation-associated treatment recommendations are unavailable. We emphasise the need for approved centres for treatment of patients affected by MEN 2, not only adults but young children as well. As a high level of skill is required for endoscopic adrenal-sparing surgery, surgeons should declare their expertise before operating such patients. Registry-based follow-up should be mandatory including documentation of short- and long-term outcome in order to provide valid data for future counselling of patients with MEN 2.
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Affiliation(s)
- Nelson Wohllk
- Department of Endocrinology, Hospital del Salvador, Universidad de Chile, Chile, Rancagua 835, Providencia Santiago de Chile
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Moreno Sanz C, Noguera Aguilar JF, Herrero Bogajo ML, Morandeira Rivas A, García Llorente C, Tadeo Ruíz G, Cuadrado García A, Picazo Yeste JS. [Single incision laparoscopic surgery]. Cir Esp 2010; 88:12-7. [PMID: 20385378 DOI: 10.1016/j.ciresp.2010.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 01/08/2010] [Accepted: 02/13/2010] [Indexed: 02/08/2023]
Abstract
One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.
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Affiliation(s)
- Carlos Moreno Sanz
- Servicio de Cirugía, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España.
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Abstract
Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.
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Affiliation(s)
- Anthony Y Tsai
- General Surgery Residency, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive #203, Indianapolis, IN 46202, USA.
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Autorino R, Stein RJ, Kaouk JH. Re: Luca Cindolo, Stefano Gidaro, Fabiola R. Tamburro, Luigi Schips. Laparo-endoscopic single-site left transperitoneal adrenalectomy. Eur Urol 2010;57:911–4. Eur Urol 2009; 57:e47; author reply e48-9. [PMID: 19747762 DOI: 10.1016/j.eururo.2009.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 08/26/2009] [Indexed: 01/08/2023]
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Branco AW, Kondo W, Stunitz LC, Filho AJB, de George MA. Transumbilical laparoscopic urological surgery: are special devices strictly necessary? BJU Int 2009; 104:1136-42. [PMID: 19338528 DOI: 10.1111/j.1464-410x.2009.08536.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the safety and feasibility of transumbilical laparoscopic surgery using conventional laparoscopic instruments and ports. PATIENTS AND METHODS Since January 2008 we have been using laparoscopic transumbilical procedures. Patient selection was determined by any situation, pathological or not, for which laparoscopy was deemed appropriate as the standard of care in our practice. Exclusion criteria included patients who had undergone multiple abdominal procedures. The Veress needle was placed through the umbilicus, to allow insufflation with carbon dioxide. A 10-mm trocar was placed in the peri-umbilical site for the laparoscope, followed by placing two additional 5-mm peri-umbilical trocars. The entire procedure was done using conventional laparoscopic instruments. At the end of surgery the trocars were removed and all three peri-umbilical skin incisions were united for specimen retrieval. Patients undergoing surgery using this approach were evaluated prospectively and data were collected during and after surgery for analysis. RESULTS Six procedures were performed using this technique (three nephrectomies, one adrenalectomy, one ureterolithotomy and one retroperitoneal mass resection). The mean operative duration and blood loss were 70.5 min and 108.3 mL, respectively. There were no complications during surgery and no patients needed a blood transfusion. Analgesia comprised metamizole (1 g intravenous every 6 h) and ketoprofen (100 mg intravenous every 12 h). The time to first oral intake was 8 h and the mean hospital stay was 28 h. CONCLUSION Laparoscopic transumbilical surgery seems to be feasible and safe even using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic urological procedures.
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Affiliation(s)
- Anibal W Branco
- Department of Urology, Cruz Vermelha Hospital and Vita Batel Hospital, Curitiba, Parana, Brazil
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Abstract
Nowadays, minimally invasive operating techniques are an essential part of adrenal gland surgery. Meanwhile four different methods are being used: laparoscopically in the supine or lateral position or retroperitoneoscopically as a prone or lateral method. Ideal indications for endoscopic adrenalectomy are adrenal hyperplasias and benign, hormonally active adrenal gland tumors up to 5 cm in diameter. In comparison to the conventional operating procedures, the endoscopic methods have the advantage of less blood loss and minimized postoperative pain as well as shortening of hospital stay. Yet in contrast, the operating time of these procedures is prolonged. To date, it is not evident whether laparoscopy or retroperitoneoscopy should be preferred. Laparoscopy offers a familiar anatomical exposure but requires 5-6 trocars. For the retroperitoneoscopic methods only 3 trocars are needed, but orientation in the operating field is more difficult. All endoscopic procedures on the adrenal gland are technically difficult. They require a extended experience in minimally invasive surgery as well as special knowledge in endocrine surgery.
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Affiliation(s)
- M K Walz
- Abteilung für Allgemeine Chirurgie, Zentrums für Chirurgie, Universitätsklinikum Essen
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