The influence of new technologies on laparoscopic adrenalectomy: our personal experience with 91 patients

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

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

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

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience

BACKGROUND

The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery. The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others.

METHODS

A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate.

RESULTS

There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn't significant statistical difference (p = 0.178).

CONCLUSIONS

Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient's satisfaction.

Laparoscopic Adrenalectomy for Large Adrenocortical Carcinoma

Background:

Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas. However, the oncological effectiveness of LA remains unclear. This review presents the current knowledge of the feasibility and oncological effectiveness of laparoscopic surgery for ACC, with an analysis of data for outcomes and other parameters.

Database:

A systematic review of the literature was performed by searching the PubMed and Medline databases for all relevant articles in English, published between January 1992 and August 2014 on LA for adrenocortical carcinoma.

Discussion:

The search resulted in retrieval of 29 studies, of which 10 addressed the outcome of LA versus open adrenalectomy (OA) and included 844 patients eligible for this review. Among these, 206 patients had undergone LA approaches, and 638 patients had undergone OA. Among the 10 studies that compared the outcomes obtained with LA and OA for ACC, 5 noted no statistically significant difference between the 2 groups in the oncological outcomes of recurrence and disease-free survival, whereas the remaining 5 reported inferior outcomes in the LA group. Using a paired t test for statistical analysis, except for tumor size, we found no significant difference in local recurrence, peritoneal carcinomatosis, positive resection margin, and time to recurrence between the LA and OA groups. The overall mean tumor size in patients undergoing LA and OA was 7.1 and 11.2 cm, respectively (P = .0003), and the mean overall recurrence was 61.5 and 57.9%, respectively. The outcome of LA is believed to depend to a large extent on the size and stage of the lesion (I and II being favorable) and the surgical expertise in the center where the patient undergoes the operation. However, the present review shows no difference in the outcome between the 2 approaches across all stages. A poor outcome is likely to result from inadequate surgery, irrespective of whether the approach is open or laparoscopic.

Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors

Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.

Randomized study comparing use of THUNDERBEAT technology vs standard electrosurgery during laparoscopic radical hysterectomy and pelvic lymphadenectomy for gynecologic cancer

STUDY OBJECTIVE

To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors.

DESIGN

Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy.

PATIENTS

Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B).

INTERVENTION

Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02).

CONCLUSION

TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer.

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.

Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach

BACKGROUND

Laparoscopic adrenalectomy (LA) is the standard treatment for benign adrenal lesions. The laparoscopic approach has also been increasingly accepted for adrenal metastases but remains controversial for adrenocortical carcinoma (ACC). In a retrospective cohort study we compared the outcome of LA versus open adrenalectomy (OA) in the treatment of stage I and II ACC.

METHODS

This was a double cohort study comparing the outcome of patients with stage I/II ACC and a tumor size <10 cm submitted to LA or OA at Lille University Hospital referral center from 1985 to 2011. Main outcomes analyzed were: postoperative morbidity, overall survival, and disease-free survival.

RESULTS

Among 111 consecutive patients operated on for ACC, 34 met the inclusion criteria. LA and OA were performed in 13 and 21 patients, respectively. Baseline patient characteristics (gender, age, tumor size, hormonal secretion) were similar between groups. There was no difference in postoperative morbidity, but patients in LA group were discharged earlier (p < 0.02). After a similar follow-up (66 ± 52 for LA and 51 ± 43 months for OA), Kaplan-Meier estimates of disease-specific survival and disease-free survival were identical in both groups (p = 0.65, p = 0.96, respectively).

CONCLUSIONS

LA was associated with a shorter length of stay and did not compromise the long-term oncological outcome of patients operated on for stage I/II ACC ≤ 10 cm ACC. Our results suggest that LA can be safely proposed to patients with potentially malignant adrenal lesions smaller than 10 cm and without evidence of extra-adrenal extension.

Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele?

OBJECTIVE

To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study.

PATIENTS

Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009.

FINDINGS

Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079).

SUMMARY

Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations.

Safety and efficacy of new integrated bipolar and ultrasonic scissors compared to conventional laparoscopic 5-mm sealing and cutting instruments

Background

Hemostasis is a central issue in laparoscopic surgery. Ultrasonic scissors and bipolar clamps are commonly used, with known advantages with each technique.

Methods

The prototype of new surgical scissors, delivering ultrasonically generated frictional heat energy and bipolar heat energy simultaneously (THUNDERBEAT^® [TB]), was compared to ultrasonic scissors (Harmonic ACE^® [HA]) and an advanced bipolar device (LigaSure^® [LS]) using a pig model. As safety parameters, temperature profiles after single activation and after a defined cut were determined. As efficacy parameters, seal failures and the maximum burst pressure (BP) were measured after in vivo sealing of vessels of various types and diameters (categories 2–4 and 5–7 mm). Moreover, the vertical width of the tissue seal was measured on serial histological slices of selected arteries. The cutting speed was measured during division of isolated arteries and during dissection of a defined length of compound tissue (10 cm of mesentery). Burst-pressure measurement and histological analysis were performed by investigators blinded to the used sealing device.

Results

Using the TB, the burst pressure in larger arteries was significantly higher (734 ± 64 mmHg) than that of the HA (453 ± 50 mmHg). No differences in the rate of seal failures were observed. The cutting speed of the TB was significantly higher than that of all other devices. Safety evaluation revealed temperatures below 100 °C in the bipolar device. The maximum temperature of the HA and the TB was significantly higher. No relevant differences were observed between the HA and the TB.

Conclusions

The ultrasonic and bipolar technique of the TB has the potential to surpass the dissection speed of ultrasonic devices with the sealing efficacy of bipolar clamps. However, heat production that is comparable to conventional ultrasonic scissors should be minded for clinical use.

A multi-center study on the surgical management of metastatic disease to adrenal glands

BACKGROUND

In the management of adrenal lesions in oncological patients, many issues are still controversial: morphological signs of suspected malignancy, accuracy of imaging examinations, use of fine needle aspiration (FNA), and the role of laparoscopy. The present study attempts to address these questions through the evaluation of the management of adrenal metastases (AM) in a wide cohort of patients included in the Italian Register of Endoscopic Adrenal Surgery.

METHODS

In January 2009, all patients recorded on the Register were evaluated, on the basis of CT scan, MRI, and FNA. The diagnostic, surgical, and follow-up data of 95 patients with pre-operative AM diagnosis have been reviewed. On the basis of the fulfilled criteria three patterns were identified: "diagnostic", "suspect," and "non-diagnostic."

RESULTS

CT scan sensitivity was 41.5%/77.9% and specificity was 54.5%/90.9% for "diagnostic"/"diagnostic" + "suspect" examinations, respectively. MRI sensitivity was 15.7%/78.9% and specificity was non-determinate/83.3% for "diagnostic"/"diagnostic" + "suspect" exams, respectively. Sensitivity of FNA was 33.3%. About surgery, conversions rate was 16.6%; no mortality or re-operations were reported; complications rate was 10.7%; and no relation was noted between tumor size and surgical outcome. Mean survival was 32 months; 5-year survival was 23%, independent of AM size; survival for lung AM was similar to that of breast and kidney AM.

CONCLUSIONS

Laparoscopy for AM, in expert hand, seems to be a feasible and oncologically safe approach. Due to the unsatisfactory diagnostic accuracy for AM, every oncological patient with suspect adrenal lesions should be encouraged to undergo this surgical procedure.

Incidental and metastatic adrenal masses

In the last decades discoveries of adrenal masses incidentally during the course of diagnostic procedures for unrelated disorders (incidentalomas) have become progressively more frequent. The clinician in this position must answer two main questions: Is the mass benign or malignant?, and To what extent is the adrenal secretion altered? To come to a clinical decision, several diagnostic tools need to be engaged, starting with an accurate and correct radiological evaluation and a hormonal assessment of the adrenal function. When necessary, other diagnostic procedures such as functional imaging and fine-needle biopsy (FNB) can be considered in selected cases. Surgical removal is recommended for clinically relevant hypersecretory masses, as well as for masses suspected to be malignant. Most frequently, adrenal incidentalomas (AIs) are represented by benign cortical adenomas, a subset of which causes a mild hypercortisolism, known as subclinical Cushing's syndrome (SCS). The criteria to define this syndrome, as well as its treatment, are still debated and controversial. AIs that are not surgically removed should be re-examined in time to exclude a supervening increase in size or function. Follow-up criteria have not been established. Laparoscopic surgery is the recommended procedure to remove benign masses. The surgical procedure for adrenal malignancies is still debated.

Laparoscopic adrenalectomy: Single centre experience

BACKGROUND

Laparoscopic adrenalectomy is an attractive alternative to the traditional open approach in the surgical excision of an adrenal gland. It has replaced open adrenalectomy in our institution and we review our experience to date.

METHODS

All cases of laparoscopic adrenalectomies in our hospital over eight years (from 2001 to May 2009) were retrospectively reviewed. Patient demographics, diagnosis, length of hospital stay, histology and all operative and post-operative details were evaluated.

RESULTS

Fifty-five laparoscopic adrenalectomies (LA) were performed on 51 patients over eight years. The mean age was 48 years (Range 16-86 years) with the male: female ratio 1:2. Twenty-three cases had a right adrenalectomy, 24 had a left adrenalectomy and the remaining four patients had bilateral adrenalectomies. 91% were successfully completed laparoscopically with five converted to an open approach. Adenomas (functional and non functional) were the leading indication for LA, followed by phaeochromocytomas. Other indications for LA included Cushing's disease, adrenal malignancies and rarer pathologies. There was one mortality from necrotising pancreatitis following a left adrenalectomy for severe Cushing's disease, with subsequent death 10 days later.

CONCLUSION

Laparoscopic adrenalectomy is effective for the treatment of adrenal tumours, fulfilling the criteria for the ideal minimally invasive procedure. It has replaced the traditional open approach in our centre and is a safe and effective alternative. However, in the case of severe Cushing's disease, laparoscopic adrenalectomy has the potential for significant adverse outcomes and mortality.

Energy-based hemostatic devices in laparoscopic adrenalectomy

PURPOSE

In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy.

METHODS

Forty-six patients, aged 54.6 +/- 46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27 +/- 4.8 kg/m(2). Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age.

RESULTS

Mean operating time was 126.5 +/- 52 min, blood losses were 101 +/- 169 mm, conversion rate was 6.5%, morbidity was 26%, and hospitalization was 5.3 +/- 2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p = 0.007) and had more complications (p = 0.016) than those undergone operation on the right side.

CONCLUSIONS

Obesity (BMI > 30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon's preference.

Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

The use of the harmonic scalpel in thyroidectomy: 'beyond the learning curve'

INTRODUCTION

Safe and effective haemostasis in surgery is clearly essential, and in the neck where risks of airway compromise are also present any new technology that purports to offer advantages must be rigorously evaluated. We describe our experience with the use of the Harmonic Scalpel [Ethicon UK] in thyroidectomy.

PATIENTS AND METHODS

A retrospective clinical review of 183 patients undergoing hemi or total thyroidectomies from 12 months prior to using the harmonic scalpel (2003; n = 77) and 12 months 'beyond the learning curve' (2006; n = 106).

RESULTS

The results demonstrate that, once past the learning curve, the use of the harmonic scalpel during thyroidectomy significantly reduces operative time and postoperative hypocalcaemia, and is as safe as conventional surgery with regard to voice change and bleeding.

CONCLUSIONS

The harmonic scalpel is as safe as conventional methods of haemostasis and operations using this technique are quicker once the need to have repetitive 'clip, cut and tie' routines is avoided.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy has become an accepted method for removing benign lesions of the adrenal gland. There are few contraindications to the laparoscopic approach, and the transperitoneal and retroperitoneal techniques yield excellent results. Virtually all benign lesions and select malignant lesions can be removed laparoscopically. Laparoscopic adrenalectomy has been shown to be a safe and effective approach to many forms of adrenal pathologic conditions. It should be considered the standard of care in the management of benign lesions of the adrenal gland that require surgical removal.

Factors influencing the rising rates of adrenal surgery: analysis of a 25-year experience

BACKGROUND

Adrenal surgery has been radically changed by laparoscopy and it is reasonable to wonder whether the increase in the number of adrenalectomies is entirely justified. There is still debate on the transperitoneal versus the retroperitoneal approach, the advantages and drawbacks of which are discussed here.

METHODS

Between 1983 and 2007, we performed 279 adrenalectomies in 264 consecutive patients, divided into two groups: before and after the advent of laparoscopic adrenalectomy (LA). We analyzed the factors that increased the number of adrenalectomies in recent years. The LAs were further divided into three consecutive periods and the morbidity and conversion rates, and mean operating times were compared.

RESULTS

More procedures were performed after the advent of LA, i.e., 55 (19.7%) beforehand versus 224 (80.3%) afterwards, irrespective of the type of disease, for instance: incidentaloma, 17.6% versus 82.4% (p \ 0.0001); pheochromocytoma, 20.7% versus 79.3% (p\0.0001); Conn's disease, 19.8% versus 80.2% (p \ 0.0001); Cushing's disease, 17.2% versus 82.8% (p\0.0001); cortical carcinoma, 30% versus 70% (p\0.001). Analyzing the three LA periods, operating times were the only statistically significant variable (p\0.0001).

CONCLUSIONS

The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach (trans- or retroperitoneal) should depend on the surgeon's experience.

Previously unreported high-grade complications of adrenalectomy

BACKGROUND

Serious complications of adrenalectomy are rare but the incidence may be underestimated if they occur outside major referral centers. We report five cases of high-grade complications after adrenalectomy that have not been previously described.

METHODS

The records of five cases of adrenalectomy performed at outside hospitals were reviewed. Four cases were referred for management of complications and one for medical-legal review. The nature of the adrenal lesion, operative approach, complication(s), and subsequent clinical course and complication management were assessed. Both open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) cases were included.

RESULTS

Operative indications were pheochromocytoma (N = 3), aldosteronoma (N = 1), and a nonfunctioning 6-cm hypervascular mass (N = 1). Complications of adrenalectomy included: case 1--complete transection of the porta hepatitis during right LA resulting in hepatic failure requiring emergent liver transplantation; case 2--ligation of the hepatic artery during right OA resulting in recurrent cholangitis and bile duct sclerosis requiring liver transplantation; case 3--ligation of the left ureter during LA resulting in postoperative hydronephrosis and loss of renal function; case 4--loss of left kidney function after OA, likely secondary to renal artery ligation ultimately requiring laparoscopic nephrectomy; case 5--LA of a normal adrenal gland for a 6-cm hypervascular mass thought to be arising from the adrenal gland. Three-month postoperative imaging demonstrated a persistent mass and the patient underwent hand-assisted laparoscopic nephrectomy for a left upper pole renal cell carcinoma that was missed at the time of LA.

CONCLUSION

Despite the generally low morbidity of adrenalectomy, serious and potentially life-threatening complications can occur. Surgeon inexperience may be a factor in the occurrence of some of these complications which have not been previously described.

Comparison of the use of electrothermal bipolar vessel sealer with harmonic scalpel in total laparoscopic hysterectomy

AIM

The aim of the present study was to compare the use of electrothermal bipolar vessel sealer (EBVS) with harmonic scalpel (HS) during total laparoscopic hysterectomy with respect to operation time, estimated blood loss and related complications.

METHODS

A retrospective study was conducted in the university hospital. Forty patients who underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy were enrolled. Nineteen hysterectomies were performed with HS and in 21 patients the same surgeons used EBVS. Data about the characteristics of the patients, operation time, estimated blood loss, uterine weights, related complications and length of hospital stay were registered and compared.

RESULTS

Mean procedure time and estimated blood loss were significantly less in the EBVS arm (59.57 +/- 3.71 vs 90.95 +/- 5.73 min, P < 0.001; 87.76 +/- 25.48 vs 152.63 +/- 60.90 mL; P < 0.001, respectively). The change in hemoglobin and hematocrit values was found to be more significant in the HS group.

CONCLUSION

EBVS was found to be less time-consuming and caused less bleeding when compared with HS.

Laparoscopic adrenalectomy - a review of initial 24 consecutive patients

AIM

To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department.

METHODS

Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25-68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The clinical and intraoperative characteristics, complications and outcomes of all patients were analyzed.

RESULTS

The mean operative time for laparoscopic adrenalectomy was 136 minutes. Intraoperative hypertension occurred in 8 patients. Intraoperative hypotension occurred in 2 patients. One patient required conversion due to dense adhesions and hemorrhage. Postoperative complications were seen in six patients - immediate postoperative hypotension (2 patients), features of steroid withdrawal (2 patients) and postoperative pyrexia (2 patients). Five patients with pheochromocytoma required antihypertensive drugs in the postoperative period. There was no mortality in our series.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe operation that incorporates all the benefits of minimal access surgery and is associated with a satisfactory postoperative outcome. A careful preoperative preparation in functioning adrenal tumours aids in the faster recovery of these patients.

Adrenalectomy in Veterans Affairs and Selected University Medical Centers: Results of the Patient Safety in Surgery Study

BACKGROUND

Data from the Patient Safety in Surgery Study were used to compare preoperative risk factors, intraoperative variables, and surgical outcomes of adrenalectomy procedures performed in 81 Veterans Affairs (VA) hospitals with those performed in 14 private-sector (PS) hospitals.

STUDY DESIGN

This study is a retrospective review of prospectively collected data on all patients undergoing adrenalectomy in the VA and PS for fiscal years 2002 through 2004. Bivariate analysis compared VA and PS preoperative risk factors, intraoperative variables, and 30-day morbidity and mortality. Regression risk-adjustment analysis was used to compare 30-day postoperative morbidity in the VA and PS.

RESULTS

During the 3 years studied, 178 VA patients and 371 PS patients underwent adrenalectomy procedures with a median per site of 2 (range 1-9) and 21 (range 8-70) procedures per VA and PS hospital, respectively. The VA patients had considerably more comorbidities than PS patients. The unadjusted 30-day morbidity rate was significantly higher in VA (16.29%) than PS (6.74%) hospitals (p = 0.0003); after controlling for the higher rate of comorbidities, the adjusted odds ratio for morbidity in the VA versus the PS hospitals was no longer significant (odds ratio = 1.328; 95% CI, 0.488-3.613). Unadjusted mortality rate was VA 2.81%, PS 0.27%, p = 0.0074. The low event rate overall precluded risk adjustment for mortality.

CONCLUSIONS

The VA adrenalectomy population has more preoperative risk factors and substantially higher unadjusted 30-day postoperative morbidity and mortality rates than the PS population. After risk adjustment, there is no significant difference in morbidity between the VA and the PS. A larger study population is needed to compare risk-adjusted mortality between the VA and PS.

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

BACKGROUND

Since laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA.

METHODS

From January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology.

RESULTS

There was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40-90 mins) and 68.6 mins (range 50-130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55-100 mins) and 94 mins (range 65-140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant).

CONCLUSIONS

EBVS in LA may provide a significantly short operating time and blood loss.

Posterior Retroperitoneoscopic Adrenalectomy: A Comparison between the Initial Experience in the Invention Phase and Introductory Phase of the New Surgical Technique

BACKGROUND

Today, the posterior retroperitoneoscopic technique has become a standard procedure in adrenal surgery. The procedure allows direct access to the adrenal glands, but it seems to be difficult because of the uncommon anatomic view. This study compares the learning period of the new procedure of "posterior retroperitoneoscopic adrenalectomy" in the primary invention phase and the secondary introductory phase in a different hospital 10 years later.

MATERIALS AND METHODS

The analysis included 100 posterior retroperitoneoscopic adrenalectomies (PRA) and involved 50 procedures in each center. Group A consisted of 44 patients (14 males, 30 females; age: 48.7 +/- 14.5 years) undergoing surgery between 07/1994 and 8/1996 (24 right, 26 left; 8 Cushing adenomas, 14 Conn adenomas, 11 pheochromocytomas, 7 nonfunctioning adrenocortical adenomas, 10 ACTH-dependent adrenal hyperplasias). Group B consisted of 50 patients (12 males, 38 females; mean age 59.3 +/- 10.7 years) operated between 01/2004 and 01/2006 (28 right, 22 left tumors; 5 Cushing adenomas, 12 Conn adenomas, 4 pheochromocytomas, 29 nonfunctioning adrenocortical adenomas). All PRAs were performed with the patient in the prone position with 3-4 trocars placed caudally in the region of the 11th and 12th ribs. In group A, the surgical team developed the technique of PRA themselves. Before their first PRA, the surgical team of group B was introduced to the technique by the group A surgeons and afterwards were supervised continuously.

RESULTS

No serious intraoperative or postoperative complication occurred in either group. Group A experienced 7 conversions to open surgery, whereas group B had one conversion and one early reoperation due to bleeding (P = 0.03; chi(2)-test). The mean operative time was 117 +/- 41 minutes versus 83 +/- 35 minutes (group A and B respectively; P < 0.001; t-test). Estimated blood loss was similar in the two groups (47.2 +/- 46.2 ml versus 54 +/- 16.3 ml, group A versus B, respectively; P = 0.36; t-test).

CONCLUSIONS

The study demonstrates the feasibility, safety, and reproducibility of the new surgical method of PRA both when it is employed in the early phase of invention, as well as when performed by surgeon-learners. After comprehensive training, the operative time and conversion rate are dramatically reduced, allowing for a short learning period.

Laparoscopic resection of adrenal cortical carcinoma: a cautionary note

BACKGROUND

While laparoscopic removal of small, benign, functioning adrenal tumors is accepted, laparoscopic resection of adrenal tumors that may be adrenal cortical carcinoma (ACC) remains controversial.

METHODS

The records of all patients with ACC evaluated at a single institution from 1991 through 2004 were reviewed retrospectively.

RESULTS

Among 170 patients with ACC, 153 patients underwent open anterior adrenalectomy, 6 underwent laparoscopic adrenalectomy, 1 was treated via an open flank approach, and 10 had no operation. At a median follow-up of 28 months, 115 (86%) of 133 patients who had undergone open anterior resection of primary ACC had had a recurrence. Local recurrence and peritoneal carcinomatosis were components of initial failure in 46 (35%) and 11 patients (8%), respectively. In contrast, all 6 patients who underwent laparoscopic resection of ACC had recurrences, and peritoneal carcinomatosis was a component of initial failure in 5 (83%) of them (open vs laparoscopic resection, Fisher exact test P = .0001).

CONCLUSIONS

Laparoscopic resection of ACC is associated with a high risk of peritoneal carcinomatosis. Open adrenalectomy remains the standard of care for patients presenting with an adrenal cortical tumor for which ACC is in the differential diagnosis.

Minimal access adrenal surgery

Laparoscopic adrenalectomy has become the preferred method for removal of most adrenal tumors. An important component in selecting patients for this operation is to understand the clinical presentation and diagnostic workup for the various functioning and nonfunctioning adrenal tumors. In this review, an overview of the key clinical and diagnostic aspects of the most common adrenal tumors is presented. The indications and contraindications for a laparoscopic approach are discussed and the technique for laparoscopic adrenalectomy is then presented with inclusion of video links to demonstrate the technique. A review of the results of laparoscopic adrenalectomy is then considered with regard to common outcome measures and complications. A current controversy in adrenal surgery is the role of laparoscopic adrenalectomy in the management of patients with large tumors and malignant or potentially malignant adrenal lesions and the literature on this topic is reviewed in detail. The article concludes with a discussion of the indications and technique for partial adrenalectomy.

Efficacy and safety of ultrasonically activated shears in thyroid surgery

BACKGROUND

The purpose of this prospective study is to evaluate the efficacy of ultrasonically activated shears (UAS) in hemostasis as well as its safety in regard to complications in thyroid surgery.

METHODS

Three hundred patients who had undergone surgery on the thyroid gland were divided into 2 groups of 150 patients each. Hemostasis as well as division of blood vessels and thyroid tissue were performed with the use of UAS in the first group and by conventional ligations in the second group.

RESULTS

The use of UAS resulted in as much as a 39.7% reduction in the operative time of the total thyroidectomy and a 30.8% reduction of the lobectomy (p < .001). However, there was no important difference in the postoperative blood loss in either the temporary hypoparathyroidism or the paresis of recurrent laryngeal nerves.

CONCLUSIONS

The use of UAS in thyroid surgery is a safe method for hemostasis, as well as for the division of blood vessels and thyroid tissue. It leads to the reduction of the total operative time without serious complications.

Laparoscopic adrenalectomy, an initial experience of fifteen cases

BACKGROUND

Laparoscopic adrenalectomy is an attractive alternative to open surgery, but making the transition can be difficult.

AIM

To evaluate the initial experience of a general surgical team at a single institution at making the transition.

METHODS

The details of 15 patients undergoing laparoscopic adrenalectomy were prospectively recorded over a 21-month period.

RESULTS

Fifteen glands were removed from fifteen patients. Nine of these were left-sided. The mean gland size was 3.4 cm. Pathology included six non-functioning adenomas, four Conn's syndrome, two Cushing's syndrome and three phaeochromocytomas. Mean operating time was 74 minutes (range 31-172 minutes), with one conversion to open procedure. There were no morbidities and no mortality.

CONCLUSION

Our initial experience demonstrates this approach to be the ideal technique for removal of benign adrenal tumours with significant advantages for the patient.

Laparoscopic adrenalectomy in patients with large adrenal tumors

OBJECTIVES

The maximum size of adrenal tumors that should be removed by laparoscopic adrenalectomy is controversial. We conducted a retrospective comparison of the results of laparoscopic adrenalectomy between patients with adrenal tumors > or =6 cm ('large tumors') and patients with adrenal tumors <6 cm ('small tumors').

METHODS

The participants in the study were 16 patients with large tumors and 111 patients with small tumors. The patients comprised 59 men and 68 women (mean age, 49.0 years; age range, 23-79) with varying diagnoses. Of the 16 patients with large tumors, five had Cushing's syndrome, four had pheochromocytomas, six had a non-functional tumor and one had malignant lymphoma. Adrenal tumors were confirmed by hormonal assays, biochemical tests and computed tomography. Of the 16 large tumors, five tumors were on the right and 11 were on the left.

RESULTS

We found no significant differences in general demographic parameters between patients with large and small tumors. The mean duration of surgery was not significantly different between two groups. (large tumors, 210 min; small tumors,175 min). The mean volume of blood loss was 212 mL for large tumors and 30 mL for small tumors (P < 0.001, significant difference). There was no significant difference in time until walking, duration of hospitalization or number of using analgesics used. The time to first oral intake of group 1 (<6 cm) was significantly shorter than group 2 (> or =6 cm). Tumor size (> or =7.5 cm) was an independent predictor of a longer operation and greater blood loss in large tumors.

CONCLUSIONS

Laparoscopic adrenalectomy for large tumors was safe and minimally invasive.

Laparoscopic adrenalectomy for malignancy

The superiority of the minimally invasive approach to adrenal resections has been well documented for benign pathology. With technical advances and increased experience, surgeons have successfully performed laparoscopic adrenalectomies for metastatic and primary malignancies of the adrenal gland. The technique of laparoscopic adrenalectomy as it pertains to malignant lesions is presented. A review of the literature demonstrates the safety and efficacy of laparoscopic adrenalectomy for metastatic colorectal, lung, and renal tumors. For primary adrenal malignancies, radical resections can be effectively performed laparoscopically; however, continued long-term follow-up is needed to establish the minimally invasive technique as the preferred approach.

¿Qué ha cambiado en la adrenalectomía? De la cirugía abierta a la laparoscópica

INTRODUCTION

After the introduction of the laparoscopic approach in adrenal surgery, this technique has become the gold standard in surgical adrenal diseases. Nevertheless, comparative studies with open surgery are scarce and the impact of laparoscopic techniques on these diseases is unknown.

OBJECTIVE

To evaluate our experience of adrenal surgery over a 14-year period, before and after the introduction of laparoscopic adrenalectomy, and to analyze the influence of this technique on the surgical management of adrenal diseases.

PATIENTS AND METHOD

From January 1990 to June 2004, 78 patients underwent adrenalectomy. Between 1990 and 1998, open adrenalectomy was performed in 24 patients, while between 1999 and 2004, 54 patients underwent the laparoscopic approach and 1 underwent open surgery. Data for the open group were retrospectively reviewed while those for the laparoscopic group were prospectively registered in the advanced laparoscopic surgery database of Hospital Sant Pau (HSP).

RESULTS

The mean age was 47 years (16-75) in the open group and was 49 years (17-77) (p = NS) in the laparoscopic group. Distribution by surgical indication was similar in both periods concerning primary hyperaldosteronism, hypercortisolism, and pheochromocytoma, with a significant increase in surgical cases indicated by malignancy (1 vs 4) or incidentaloma (2 vs 13) (p<.001). Operating time was reduced from 150 min (65-210) in the open group to 90 min (30-300) in the laparoscopic group (p<.01). Morbidity was also reduced (20% vs 6%, p<.01). The size of lesions resected by open or laparoscopic surgery (4 cm [0.4-16] vs 3.5 cm [1.2-14]) was similar. The mean length of hospital stay was reduced from 8 days (3-13) to 3 days (2-12) (p<.01). The number of adrenalectomies performed in HSP was 24 in the first period (1990-1997) vs 40 in the second (1998-2004). This represented an increase from 3/year to 6.6/year mainly due to the increase in the number of incidentalomas.

CONCLUSIONS

The laparoscopic approach has improved immediate surgical results (operating time, morbidity, and length of hospital stay). There was a clear increase in the number of adrenalectomies, and especially of incidentalomas, due to improved diagnostic techniques and the availability of a less aggressive approach.

Laparoscopic adrenalectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Simultaneous bilateral laparoscopic adrenalectomy: a surgical option for multiple endocrine neoplasia (MEN 2) patients with bilateral pheochromocytomas

Multiple endocrine neoplasia (MEN 2) is a rare disorder. Of this group, 42% develop a pheochromocytoma of which 60% will have bilateral involvement. Although the benefits of unilateral laparoscopic adrenalectomy have been well documented, fewer cases of simultaneous bilateral laparoscopic adrenalectomy have been reported. We present the cases of three patients with MEN 2 who underwent successful simultaneous bilateral laparoscopic adrenalectomy after their initial presentation with bilateral pheochromocytoma. Although the management of bilateral pheochromocytomas has traditionally been approached via open laparotomy or bilateral posterior incisions, the bilateral laparoscopic approach should be considered a viable alternative for patients requiring surgical intervention. Clinical outcomes and complications are similar to open laparotomy. Simultaneous bilateral laparoscopic adrenalectomy is a safe and effective procedure that results in a more rapid recovery and a shorter hospital stay for patients with bilateral pheochromocytomas originating from MEN 2.

Evaluation of endoscopic and traditional open approaches to pheochromocytoma

BACKGROUND

Laparoscopic adrenalectomy is an excellent alternative to open surgery, while there are doubts in regard to laparoscopic treatment of pheochromocytoma due to its unsteady intraoperative hemodynamics. The goal of the study was to define optimal surgical approach to pheochromocytoma.

METHODS

A total of 99 patients with pheochromocytoma were operated from 1990 to 2002. Nine, 28, 40, and 22 patients were operated respectively through laparoscopic (group 1), thoracophrenotomic (group 2), lumbotomic (group 3), and laparotomic (group 4) approaches. Intraoperative parameters including those related with hemodynamic stability were studied. Postoperative analgesic medication, complications, and hospital stay were registered.

RESULTS

Mean operative time was 132 +/- 49 min, 104 +/- 29 min, 81 +/- 30 min, and 129 +/- 40 min, respectively, in groups 1, 2, 3, and 4. Thoracophrenotomic approach had a minimal time from starting of adrenal dissection to central adrenal vein crossing on the right side and lumbotomic approach on the left side. Laparoscopy showed longest length of that period on both sides. However, we observed more stable intraoperative dynamics during laparoscopic adrenalectomy in comparison with any traditional open approaches on both sides. Mean blood loss was 178 +/- 112 ml, 410 +/- 255 ml, 314 +/- 163 ml, and 420 +/- 398 ml, respectively, in groups 1, 2, 3, and 4. Blood transfusions were required in 0%, 35.7%, 20%, and 13.6% of cases, respectively, in groups 1, 2, 3, and 4. Using laparoscopic approach resulted in significant decrease of prescription of opoids, postoperative hospital stay, and rate of postoperative complications. Among traditional approaches lumbotomy presented better postoperative results due to its less invasive nature.

CONCLUSION

Laparoscopy is a method of choice to pheochromocytoma in experienced hands. Open approaches are still feasible. Among traditional approaches lumbotomy should be preferred. Thoracophrenotomy can be justified only for major tumors on the right side. Laparotomy is indicated in selected cases of extraadrenal pheochromocytoma.

The clinically inapparent adrenal mass: update in diagnosis and management

Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.