Factors influencing outcomes in laparoscopic adrenal surgery

Transabdominal and retroperitoneal adrenalectomy: comparative study

BACKGROUND

Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal adrenalectomies (LTA), while retroperitoneoscopic adrenalectomies (RPA) in the prone position have certain advantages for patients. The aim of this study was to compare the effectiveness and safety of the transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.

MATERIALS AND METHODS

Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age ranged from 19 to 79 years, with a mean age of 50.5 ± 10.2 years. The patient pool consisted of 315 women and 157 men. Tumor sizes ranged from 1 to 10 cm.

RESULTS

In a study of 316 patients undergoing LTA versus 156 with RPA, the TLA averaged 82.5 min (70-98), while the RPA took 56.4 min (46-62) (P < 0.001). Intraoperative blood loss was 110 cc for the LTA group and 80 cc for the RPA group (P < 0.05) Conversion rates stood at 2.5% for transabdominal and 4.5% for retroperitoneoscopic procedures (P = 0.254). At 24 h post-operation, pain scores were 3.6 and 1.6, respectively (P < 0.001). Time to resume solid oral intake was 15.2 h for TLA and 8 h for RPA, with hospital stays at 4.5 days and 3 days respectively (P < 0.001). Short-term complications occurred in 8.9% of transabdominal and 12.2% of retroperitoneoscopic patients (P = 0.257).

CONCLUSIONS

For small tumors, RPA offers advantages over the transabdominal method in surgery time, blood loss, post-op pain, and recovery. These benefits are enhanced for patients with prior abdominal surgeries. However, large tumors present challenges in the retroperitoneal approach due to limited space and anatomical orientation. If complications emerge, surgeons can seamlessly switch to the LTA.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis

PURPOSE

Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions.

METHODS

From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted.

RESULTS

After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000].

CONCLUSIONS

Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

Perioperative factors influencing the difficulty of retroperitoneal laparoscopic adrenalectomy: a single-center retrospective study

Purpose

Identifying patients in whom adrenalectomy may be more difficult can help with surgical decision-making. This study investigated the perioperative factors affecting the difficulty of retroperitoneal laparoscopic adrenalectomy (RLA).

Methods

Sixty-eight patients who underwent RLA at our hospital between December 1, 2020 and May 1, 2021 were included. The difficulty of RLA was assessed by operating time and intraoperative blood loss. We analyzed the relationship between surgical difficulty and patient sex, age, and body mass index, pathological type, tumor side, tumor size, distance from the lower pole of the adrenal tumor to the upper pole of the kidney (DAK), and distance from the lower pole of the adrenal tumor to the renal pedicle (DARP).

Results

Mean operating time was 105.38 ± 33.31 min and mean intraoperative blood loss was 32.28 ± 22.88 ml. Univariate linear regression analysis showed that age (P = 0.047), tumor size (P = 0.002), DAK (P = 0.002), and DARP (P < 0.001) were significantly correlated with a longer operating time. Univariate logistic regression analysis showed that DARP (P = 0.001), DAK (P = 0.001), tumor size (P = 0.002), and age (P = 0.033) were significantly correlated with a longer operating time. Multivariate logistic regression indicated that DARP (OR 5.341; 95% CI 1.704–16.739; P = 0.004), and tumor size (OR 4.433; 95% CI 1.434–13.709; P = 0.010) were independent predictors of operating time.

Conclusion

Age, tumor size, DAK, and DARP were predictors of the difficulty of RLA. Older age, lower DARP and DAK, and a larger tumor size were associated with a longer operating time. DARP and tumor size were independent predictors of surgical difficulty.

Is 6 cm Diameter an Upper Limit for Adrenal Tumors to Perform Laparoscopic Adrenalectomy?

Background: We aimed to compare the results of patients who underwent laparoscopic adrenalectomy (LA) for masses ≥6 cm versus <6 cm in diameter in our tertiary referral university hospital. Materials and Methods: Three hundred thirty consecutive patients were divided into two groups according to tumor size (≥6 and <6 cm in diameter). Demographic variables, body mass index (BMI), lesion localization (right/left), tumor diameter, pathological diagnosis and surgical outcomes, including operation time, estimated blood loss (EBL), conversion to open surgery, complications, and length of hospital stay were compared between groups. Results: Between February 2008 and March 2020, 53 patients (29 male-24 female) with ≥6 cm (L group) adrenal tumor and 277 patients (105 male-172 female) with <6 cm tumor (S group) underwent transperitoneal LA. One hundred sixty-eight (50.9%) tumors localized on the left side. In L group mean tumor size in female and male patients was 87.5 ± 40.8 mm (range 50-225 mm) and 67.3 ± 18.4 mm (range 10-100 mm), respectively (P < .05). Age, American Society of Anesthesiology scores, BMI, and mean operation time were similar between groups (P > .05). Postoperative complications were more often in L group (P = .005). EBL in group L and group S was 86 ± 70.4 mL (range 10-500 mL) and 55 ± 44.2 mL (range 10-300 mL), respectively (P = .003). Length of hospital stay in group L and group S was 3.7 ± 3.5 days (range 1-26) and 3 ± 1.6 days (range 1-9), respectively (P = .086). Significant variables in multivariate analysis, including gender (male), EBL, and postoperative complication rate, were entered into multivariate regression analysis, which presented that EBL and postoperative complication rates were independent significants for the L group. Conclusion: Six centimeters should not be considered as an upper limit of transperitoneal lateral LA and may be safely performed in centers with experience. Further studies are needed to confirm our data.

Lateral retroperitoneoscopic adrenalectomy: advantages and drawbacks

Lateral retroperitoneoscopic adrenalectomy (LRA) is performed mostly by urologists. It is gaining popularity among general surgeons because of the direct access to the adrenal gland. However, the management of large tumors remains controversial. We report our experience and discuss the advantages and the drawbacks of this approach. Between December 2011 and April 2015, 89 consecutive patients underwent LRA for adrenal tumors. Conversion to open surgery, operative time, blood loss, hospital stay, intra-operative complications, early and late postoperative complications, and mortality were analyzed. The entire group was divided into patients with large tumors (> 5 cm) and patients with small tumors (≤ 5 cm), which were further compared. The conversion rate was 1.1%. The mean operative time was 107.4 ± 27.95 min, the mean blood loss 33.15 ± 25.45 ml. The mean hospital stay was 4.7 ± 2.05 days. Most of the complications were minor. There was zero mortality. Concerning the size of the tumor, we found statistically significant difference in operative time (p = 0.001), hospital stay (p = 0.020), incidence of early postoperative complications (p = 0.049), and conversion rate to open surgery (p = 0.037). LRA is a feasible, effective and safe procedure that offers additional advantages over the standard transabdominal approach because of its direct access to the adrenal gland. However, malignancy, large tumor size, bilateral pathology, and concomitant intra-abdominal pathology may represent a potential setback for this approach.

Comparing the efficacy and safety of laparoscopic and robotic adrenalectomy: a meta-analysis and trial sequential analysis

PURPOSE

A systematic literature review and a meta-analysis were designed and conducted, in order to provide an up-to-date comparison of the robotic (RA) and laparoscopic (LA) adrenalectomy in terms of perioperative efficacy and safety.

METHODS

The present meta-analysis was completed in accordance with the guidelines provided by the PRISMA study group and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened. For the reduction of type I errors, a trial sequential analysis (TSA) was performed.

RESULTS

Overall, 21 studies and 2997 patients were included in this study. RA was associated with a significantly lower open conversion rate (OR: 1.79; 95%CI: 1.10, 2.92) and length of hospitalization (LOS WMD: 0.52; 95%CI: 0.2, 0.84). Marginal results regarding blood loss were recorded (WMD: 2.02; 95%CI: 0.0, 4.03). TSA could not validate the superiority of RA in open conversion rate and blood loss. LA and RA were similar in terms of operative duration (P = 0.18) and positive margin (P = 0.81), complications (P = 0.94) and mortality rate (P = 0.45).

CONCLUSIONS

Even though RA and LA were equivalent regarding perioperative safety, RA was associated with a favorable LOS.

Transperitoneal laparoscopic surgery in large adrenal masses

INTRODUCTION

The laparoscopic adrenalectomy (LA) has become the gold standard since the transperitoneal laparoscopic approach was first reported.

AIM

To evaluate the applicability, safety and short-term results of laparoscopic surgery in adrenal masses over 6 cm.

MATERIAL AND METHODS

Demographic data, hormonal activities, imaging modalities, operative findings, operation time, conversion rates, complications, duration of hospital stay and histopathologic results of 128 patients who underwent laparoscopic adrenalectomy were evaluated retrospectively. Patients included in the learning curve (n = 23), robotic surgery cases (n = 15) and patients with suspected metastasis (n = 4) were excluded from the study. Six cm mass size was taken as a reference and two groups were formed (group 1: < 6 cm, group 2: ≥ 6 cm). The results of the two groups were compared.

RESULTS

There were 64 cases in group 1 and 22 cases in group 2. Functional mass ratio and mass sides were similar between the groups (p = 0.30 and p = 0.17, respectively). The mean mass size in group 1 was 36.4 ±11.2 mm and in group 2 82.4 ±15.5 mm. The conversion rate was similar between the two groups (p = 0.18). The duration of surgery was 135.5 ±8.29 min in group 1, 177.0 ±14.9 min in group 2 (p = 0.014). Morbidity and lengths of hospital stay were similar (p = 0.76, p = 0.34 respectively). Adrenocortical carcinoma was detected in three cases in group 1, which were completed laparoscopically, and in two cases in group 2, which were converted to open surgery (p = 0.46).

CONCLUSIONS

Although open surgery is still recommended in the guidelines, studies are now being carried out to ensure that laparoscopy can be safely performed on masses over 6 cm. There was no difference between short-term follow-up and histopathologic results in our study.

Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy]

BACKGROUND

The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate.

METHODS

Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed.

RESULTS

We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively.

CONCLUSION

A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.

Feasibility and safety profile of posterior retroperitoneoscopic adrenalectomy in high-risk patients - A retrospective analysis

OBJECTIVES

Posterior retroperitoneoscopic adrenalectomy (PRA) is used for removal of benign adrenal lesions. Though literature shows low complication rate in this procedure, there is no consensus about safety profile of PRA in high-risk patients. This study aimed to determine the feasibility and safety profile of PRA in high-risk patients.

METHODS

This retrospective study recruited all patients who underwent PRA for benign adrenal lesions in the study center. Patients with an American Society of Anesthesiologists (ASA) score of ≥3, on anticoagulant therapy or a body mass index (BMI) over 30 were classified as high-risk patients. We analyzed patients' demographics, comorbidities, perioperative mean arterial pressure and operative time, postoperative complications and tumor characteristics. Mortality and morbidity rates and length of hospital stay of the high-risk and low-risk groups were compared. The chi-square and t tests were used to determine relationships between categorical variables between groups.

RESULTS

Forty two PRA procedures were done on 21 men and 21 women; mean age of 50 years in low and 62 years in high risk groups. Twenty six (61.9%) patients had high-risk profile. We recorded 4 (9.5%) intra- and postoperative complications, while one (2.3%) PRA was converted to open due to intra-operative hemorrhage. Mean operative time of 86.45 and 108.19 min (p = 0.204), and postop hospital stay of 4.44 and 6.65 (p = 0.25) days were recorded for low and high risk groups, respectively. Intraoperative arterial pressure of ≥170 mmHg was noted for 6 low and 11 high risk patients (p = 885).

CONCLUSION

Our results indicate that PRA for benign adrenal lesions is safe and feasible in patients with a high-risk profile without a risk of increased peri- and postoperative complications.

SURGICAL MANAGEMENT OF THE ADRENAL GLAND TUMORS - SINGLE CENTER EXPERIENCE

Context

Incidentally discovered solid adrenal tumors must be evaluated from two points of view: the risk of malignancy and the secretory feature.

Objective

Our aim was to evaluate the surgical technique option in relation with clinical and histopathologic features.

Design

We performed a retrospective study that included patients with adrenal gland tumors.

Subjects and methods

All patients were operated between 2012 and 2019 by the same surgical team in a single center.

Results

The batch included 102 patients with adrenal tumors operated through open surgery (OS, n=41) and laparoscopic surgery (LS, n=61). Tumor localization was especially on the right adrenal gland (n=52, 50.98%). Primary origin of the adrenal gland tumors was in 82 cases (80.39%) and a metastatic origin in 16 cases. Average dimension for surgical resected tumors was 4.02 cm (0.9-12 cm) for the LS group as compared to 7.22 cm (1.3-19 cm) for OS group with a predominant type of surgery represented by adrenalectomy and a conversion rate of 2.94%. The hospital stay was 7.22 days (5-12 days) in the LS group versus 12.72 days (6-57 days) in OS group with significant differences (p<0.01). Also, the postoperative recovery was significantly different (6.5 days versus 2.62 days, p<0.01).

Conclusion

Laparoscopic approach represents the gold standard in adrenal gland tumors less than five centimeters in size. Adrenalectomy is mostly performed by LS and adenoma is the most frequent histopathologic type, while pheochromocytoma is operated through OS. LS has a significantly reduced hospitalization and postoperative stay compared to OS.

Prolonged operative duration is associated with complications: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types.

METHODS

An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria.

RESULTS

Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time.

CONCLUSIONS

Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous microwave ablation of adrenal tumours under ultrasound guidance in 33 patients with 35 tumours: A single-centre experience

PURPOSE

The aim of this study was to investigate the efficacy and safety of percutaneous microwave ablation (MWA) of adrenal tumours under ultrasound (US) guidance.

MATERIALS AND METHODS

A total of 33 consecutive patients with 35 tumours were enrolled. The term 'technical success' is used to indicate whether the tumour was treated according to protocol and was covered completely by the ablation zone. Technical success, local tumour progression (LTP) and complications were recorded. For seven patients with eight biochemically active tumours, biochemical markers were recorded prior to and after the ablation procedure.

RESULTS

In this study, technical success was achieved in all cases. Follow-up imaging was performed on 31 patients with 33 tumours (excluding two patients who were lost to follow-up). LTP occurred for five tumours (15.2%) at a mean of 24 months of follow-up (range 3-82 months). In the subgroup analysis of tumour size and LTP, a significant difference was noted between tumours with a diameter ≤5 cm compared with those >5 cm (p < 0.01). For seven cases of metabolically active adrenal tumours, technical success was confirmed in all patients, and LTP occurred in one case of recurrent pheochromocytoma. All patients demonstrated the normalisation of abnormal biochemical markers after ablation. No major complications were observed.

CONCLUSION

Percutaneous MWA under US guidance is effective in terms of good local control of adrenal tumours with a diameter of less than or equal to 5 cm and is capable of treating biochemically active tumours harbouring clinical syndromes.

Trends in splenectomy: where does laparoscopy stand?

Background and Objectives:

Laparoscopic splenectomy (LS) has been shown to offer superior outcomes when compared to open splenectomy (OS). Despite the potential advantages associated with the minimally invasive technique, laparoscopy appears to be underused. We sought to evaluate the nationwide trends in LS.

Methods:

The Nationwide Inpatient Sample (NIS) database was queried for both OS and LS procedures performed from 2005 through 2010. Partial splenectomies and those performed for traumatic injury, vascular anomaly, or as part of a pancreatectomy were excluded. The included cases were examined for age of the patient and comorbid conditions. We then evaluated the postoperative complications, overall morbidity, mortality, and length of hospital stay.

Results:

A total of 37,006 splenectomies were identified. Of those, OS accounted for 30,108 (81.4%) cases, LS for 4,938 (13.3%), and conversion to open surgery (CS) for 1,960 (5.3%). The overall rate of morbidity was significantly less in the LS group than in the OS group (7.4% vs 10.4%; P < .0001). The LS group had less mortality (1.3% vs 2.5%, P < .05) and a shorter length of stay (5.6 ± 8 days vs 7.5 ± 9 days).

Conclusions:

Despite the benefits conferred by LS, it appears to be underused in the United States. There has been an improvement in the rate of splenectomies completed laparoscopically when compared to NIS data from the past (8.8% vs 13%; P < .05). The conversion rate is appreciably higher for LS than for other laparoscopic procedures, suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients

BACKGROUND

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy.

THE AIMS OF OUR STUDY WERE

(1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy.

METHODS

This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed.

RESULTS

The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94).

CONCLUSIONS

Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Adrenalectomy for metastasis: long-term results and predictors of survival

The purpose of this study was to analyze our experience with surgically treated isolated adrenal metastases in order to find those factors which can significantly affect survival. This method includes a retrospective single-center chart review. We evaluated how overall survival and disease-free survival (DFS) were influenced by demographic, tumor, and procedure-related variables. Thirty-seven adrenalectomies were performed in 34 patients. Procedures included 25 laparoscopic and 12 open adrenalectomies. Median follow-up was 49 months. Median overall survival was 63 months. Patients submitted to laparoscopic approach had a median survival of 57 months while it was 65 months for those who underwent open procedure (p = 0.67). DFS was 30 months, and these were 35 and 25 months after laparoscopic approach and open approach, respectively (p = 0.59). The concurrent resection of the adrenal metastasis with the primary tumor was the only factor influencing DFS (HR 6.8 95 % CI 1.2-37.3, p = 0.02). Patients with non-small cell lung cancer (n = 15) had a median survival of 63 months and DFS of 35 months. Our experience confirms that adrenalectomy, regardless of the surgical approach, can offer durable disease-free and overall survival outcomes for surgical candidates with isolated adrenal metastases.

Laparoscopic adrenalectomy for pheochromocytoma is more difficult compared to other adrenal tumors

Introduction

Laparoscopic adrenalectomy is the gold standard for the treatment of benign adrenal tumors. However, some authors raise the problem of differences in surgery for pheochromocytoma in comparison to other lesions.

Aim

To compare laparoscopic adrenalectomy for pheochromocytoma and for other tumors.

Material and methods

Four hundred and thirty-seven patients with adrenal tumors were included in the retrospective analysis. Patients were divided into two groups: 1 (124 patients treated for pheochromocytoma) and 2 (313 patients with other types of tumor). The two groups were compared with respect to mean operative time, intraoperative blood loss, conversion rate, complication rate and the relationship of tumor size with operative time.

Results

The mean operative time in group 1 was 91 min, and in group 2 it was 82 min (p = 0.016). In both groups 1 and 2, tumor size correlated with operative time (p < 0.0001 and p = 0.0003, respectively). The mean blood loss in groups 1 and 2 was 117 ml and 54 ml, respectively (p = 0.0011). The complication rate in groups 1 and 2 was 4% and 4.2%, respectively (p = 0.9542). In groups 1 and 2, conversion was necessary in 2 (1.6%) and 5 (1.6%) cases, respectively (p = 0.9925).

Conclusions

Longer operative time and higher blood loss after laparoscopic adrenalectomy for pheochromocytoma indicate its greater difficulty. However, despite these drawbacks, minimally invasive surgery still seems to be an effective and safe method.

Advanced sealing and dissecting devices in laparoscopic adrenal surgery

OBJECTIVES

This study sought to analyze the impact of advanced sealing/dissecting devices on operative and postoperative outcomes in laparoscopic adrenalectomy.

METHOD

Patients were divided into three groups according to the devices used during their procedures [electrothermal bipolar vessel system (EBVS), ultrasound shears (US), and monopolar electrocautery (ME)]. A comparison of the perioperative outcomes was performed.

RESULTS

Conversion rates and intraoperative and postoperative complication rates did not differ among the three groups. Major blood loss that required transfusion was registered in only two cases, all of which were performed with ME. Procedures with EBVS were shorter than those with US or ME. For left adrenalectomies only, operative times were similar for US and EBVS. The use of EBVS was found to be an independent predictor of decreased operative time.

CONCLUSION

The use of advanced sealing devices was associated with reduced operative time, with particular benefits in left adrenalectomy. EBVS and US may provide better hemostasis than ME.