Outcomes after laparoscopic adrenalectomy

Safety and surgical outcomes of robotic adrenalectomy from a 15-year experience at a single institution

Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.

Impact of frailty on complications and length of stay after minimally invasive adrenalectomy surgery

BACKGROUND

Adrenal disease requiring surgery incidence increases with age, and minimally invasive adrenalectomy procedures have improved the safety of adrenal surgery. This study evaluates the perioperative outcomes of elective adrenalectomies when performed in older patients and how frailty affects such outcomes.

METHODS

Patients undergoing elective minimally invasive adrenalectomy were identified using the American College of Surgeon's National Surgical Quality Improvement Program Participant Use Targeted File years 2005 to 2020. The surgical indication was categorized as a benign disease, an endocrine disorder, or a malignant disease. Frailty was defined using the 5-item modified frailty index. Multivariable regressions were used to model the relationship of age and frailty with surgical outcomes.

RESULTS

In 8,693 minimally invasive adrenalectomy patients, 5,281 (61%) were female, 5,026 (58%) were White, and 1,924 (22%) were aged 65 years or older. Surgical indications were benign disease 5,487 (63%), endocrinopathy 2,850 (33%), and malignancy 356 (4%). Patients aged <65 years (compared to those aged ≥65) were more likely to have a 5-item modified frailty index = 0 (26% vs 14%, respectively) and less likely to have a 5-item modified frailty index = ≥3 (2% vs 4%, respectively; P < .001).

OUTCOMES

30-day mortality 20 (0.2%), complications 459 (5%), return to operating room 73 (0.8%), and median length of stay 2 days. Thirty-day mortality was associated with a 5-item modified frailty index ≥3 (P = .009) and endocrine disease (P = .005) but not with age. Complications were associated with a 5-item modified frailty index ≥2 (≤P < .001) and malignant disease (P = .002), but not with age.

CONCLUSION

Minimally invasive adrenalectomy has low 30-day mortality and complication rates that increase with frailty and not age. Frailty is a better predictor than the age of most adverse outcomes after elective minimally invasive adrenalectomy.

Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures

BACKGROUND

Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA.

METHODS

Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression.

RESULTS

We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥  DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]).

CONCLUSIONS

LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality

BACKGROUND

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths.

METHODS

ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework.

RESULTS

A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery.

CONCLUSION

This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

High-Volume Center Experience with Laparoscopic Adrenalectomy over Two Decades

Background: Study aims to demonstrate single-institution two decades experience with lateral transperitoneal laparoscopic adrenalectomies. Methods: Retrospective study involved 991 operations grouped into 4 cohorts. Data was collected on the patients’ age, sex, side and size of the lesion, histopathological type, hormonal activity, conversion to open adrenalectomy, operating time, length of hospital stay, perioperative complications. Results: The operations were right-sided (n = 550), left-sided (n = 422), bilateral (n = 19). Mean tumor size was 41.9 mm. Histopathological examination revealed 442 adenomas, 191 nodular hyperplasias, 218 pheochromocytomas, 33 malignancies and 126 other lesions. 541 patients had hormonally active tumors. Mean operating time for unilateral laparoscopic adrenalectomy was 141 min. Mean length of hospital stay was 5.27 days. Intraoperative complications rate was 2.3%. Conversion rate was 1.5%. 54 of patients had 70 postoperative complications. Reoperation rate was 1%. Mortality rate was 0.1%. Statistically significant differences were found in all factors, apart from age, sex, side and size of the lesion, reoperations rate (p > 0.05). Conversions rate, complications rates, length of hospital stay were highest in the first group (p < 0.05). Operating time shortened in the first decade. Conclusions: Laparoscopic adrenalectomy is a safe procedure with negligible mortality. Conversions rate, perioperative complications rate, and length of hospital stay, significantly decreased over time.

A Descriptive Comparative Analysis of the Surgical Management of Adrenal Tumors: The Open, Robotic, and Laparoscopic Approaches

Background

Currently, adrenalectomies are trending toward minimally invasive approach including robotic and laparoscopic surgery. We aimed to describe the clinical presentation and outcomes associated with the 3 different surgical approaches in patients who underwent adrenalectomy for adrenal mass at a single tertiary center.

Methods

A retrospective descriptive observational study was conducted to include all patients who underwent surgical interventions for adrenal gland mass between 2004 and 2019. Patients were categorized into three groups according to the interventional approach (open, robotic vs. laparoscopic adrenalectomy) and data were analyzed and compared.

Results

A total of 124 patients underwent adrenalectomies (61.3% robotic, 22.6% open, and 16.1% laparoscopic approach). Incidentally discovered adrenal mass was reported in 67% of patients, and hypertension was the most prevalent comorbidity (53%). The tendency for malignancy increased with increasing tumor size while the functioning tumors were more in the smaller tumor size. Larger tumors were more common in younger patients. The robotic approach showed shorter surgical intensive care and hospital length of stay. Patients in the open adrenalectomy group frequently presented with abdominal pain (p = 0.001), had more nonfunctional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), and were frequently operated on the right side (p = 0.03). There was no post-operative mortality; however, during follow-up, 8 patients died (3 open, 3 laparoscopic and, 2 robotic approach). The median follow-up was 746 days (range 7–5,840).

Conclusions

The study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach for patients with benign functioning adrenal tumors of a diameter &lt;6 cm. However, the choice of a surgical approach varies according to the adrenal mass presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of the robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, cost, and quality of life.

The ADRENAL score: A comprehensive scoring system for standardized evaluation of adrenal tumor

OBJECTIVES

To propose an original and standardized scoring system to quantify the functional and anatomical characteristics of adrenal tumor.

MATERIALS AND METHODS

Four groups of consecutive adrenalectomies (n = 458) with heterogeneity in tumor characteristics and surgical approaches, including 212 laparoscopic cases (Group 1) and 105 robotic cases (Group 2) from The First Affiliated Hospital of Nanchang University, 28 robotic cases from Temple University Hospital (Group 3) and 113 laparoscopic cases from The First Affiliated Hospital of Guangxi Medical University (Group 4). All patients were followed up for 4.5 to 5.5 years. Six parameters including functional status or suspicion of malignancy, tumor size, relationship to adjacent organs, intratumoral enhancement on CT, nearness of the tumor to major vessels and body mass index were assessed and scored on a 0, 1 and 2 points scale. Correlation between the sum of the 6 scores and tumor laterality (ADRENAL score) verse operative time (OT), estimated blood loss (EBL), perioperative complications, transfusion, conversion and length of hospital stay was analyzed.

RESULTS

ADRENAL score was a strong predictor of both OT and EBL in all four groups (p < 0.05 for all tests). In Group 2 and 4, higher ADRENAL score seemed to correlate with longer hospital stay. No statistically significant correlation between ADRENAL score and complication, transfusion or conversion was noted yet.

CONCLUSIONS

ADRENAL score appears to be a valid predictor of surgical outcomes. It may provide a common reference for adrenal surgery training program, preoperative risk assessment and stratified comparative analysis of adrenal surgeries via different techniques and approaches.

Stereotactic body radiation therapy for adrenal gland metastases: outcome and predictive factors from a multicenter analysis

Adrenal metastases occur in 15-35% of oncological patients. Surgery is the first treatment option. Stereotactic body radiotherapy (SBRT) has been largely explored in oligometastatic patients unfit for surgery, representing an effective and non-invasive local treatment. The results of a multi-institutional experience of SBRT on adrenal metastases in the oligorecurrent or oligoprogressive setting are herein reported. We collected data of adrenal gland metastases treated with SBRT in three Italian centers from 2010 to 2020. End-points of the present study were: Overall survival (OS), Local control of treated metastases (LC), Progression free survival (PFS), and toxicity. 149 adrenal gland metastases were treated with SBRT in 142 patients. The most common primary tumor was lung cancer (58.4%), followed by kidney cancer (9.4%). Median lesion's volume was 28.5 cm³ (2.5-323.4). The median SBRT dose was 40 Gy (10-60). Median follow-up was 14.4 months. One- and two-year OS were 72.3% and 53.5%. At univariate analysis performance status correlated with survival (HR 1.57, p = 0.006). One- and two-year LC were 85.4% and 79.2%, with lung primary tumor (HR 0.33, p = 0.021) and BED10 (HR 0.97, p = 0.036) significant independent factors. One- and two-year PFS were 37.7% and 24.8%. Median time to polymetastatic disease was 11.3 months. Grade 1 and 2 toxicity occurred in 21 (14.7%) and 3 (2.1%) patients. The results from this large multi-center study confirm the efficacy and safety of SBRT in the management of adrenal gland metastases, as a valid alternative to other more invasive local approaches.

Minimally invasive adrenalectomy for large pheochromocytoma: not recommendable yet? Results from a single institution case series

BACKGROUND

Minimally invasive adrenalectomy represents the treatment of choice of pheochromocytoma (PCC). For large or invasive PCCs, an open approach is currently recommended, in order to ensure complete tumor resection, prevent tumor rupture, avoid local recurrence, and limit perioperative hemodynamic instability. The aim of this study is to analyze perioperative outcomes of laparoscopic adrenalectomies (LAs) for large adrenal PCCs.

METHODS

All consecutive LAs for PCC performed at a single institution between 1998 and 2020 were included. Two groups were defined: lesions larger (group 1) and smaller (group 2) than 5 cm. Short-term outcomes were compared in order to find any significant difference between the two groups.

OUTCOMES

One hundred fourteen patients underwent LA during the study period: 46 for lesions larger and 68 for lesions smaller than 5 cm. No significant differences were found in patients' characteristics, median operative time, conversion rate, intraoperative hemodynamic and metabolic parameters, postoperative intensive care unit (ICU) admission rate, complications rate, and length of hospital stay. Long-term oncologic outcomes were similar, with a recurrence rate of 5.1% in group 1 vs 3.6% in group 2 (p = 1).

CONCLUSION

Minimally invasive adrenalectomy seems to be safe and effective even in large PCC. The recommendation to prefer an open approach for large PCCs should probably be reconsidered.

Comparison of Posterior Retroperitoneoscopic Adrenalectomy Versus Lateral Transperitoneal Laparoscopic Adrenalectomy for Adrenal Tumors: A Systematic Review and Meta-Analysis

Objective

To discuss the differences in the effectiveness and security for adrenal tumors by posterior retroperitoneoscopic adrenalectomy (PRA) and lateral transperitoneal laparoscopic adrenalectomy (LTA).

Methods

We systematically searched PubMed, Embase, Scopus database and Cochrane Library, and the date was from above database establishment to November 2020. Stata 16 was used for calculation and statistical analyses.

Results

Nine studies involving eight hundred patients were included. The following differences were observed in favor of PRA vs LTA: less operative time (MD: -22.5; 95% CI -32.57 to -12.45; P=0.000), Fewer estimated blood loss (MD: -15.17; 95% CI -26.63 to -3.72; P=0.009), lower intensity of postoperative pain (MD: -0.56; 95% CI, -1.05 to -0.07; P=0.026), shorter length of hospital stay (MD: -1.15; 95% CI -1.94 to -0.36; P=0.04). No differences were shown in conversion rate (OR 2.07; 95%CI 0.71 to 6.03; P=0.181) and complications (OR 0.85;95% CI 0.46 to 1.56; P=0.597).

Conclusions

Posterior retroperitoneoscopic adrenalectomy was clinically superior to lateral transperitoneal laparoscopic adrenalectomy for adrenal tumors in operative time, estimated blood loss, length of hospital stay, and postoperative pain. Only in term of conversion rate and complications, both were similar.

Approach to the Patient with Subclinical Cushing's Syndrome

A growing number of patients with adrenal incidentalomas and subclinical Cushing's syndrome (SCS) led to an increasing number of different guidelines, and diagnostic and treatment recommendations. Excess cortisol secretion in patients with SCS is associated with several comorbidities, such as hypertension, dyslipidemia, type 2 diabetes mellitus, and obesity, which in the long-term increase mortality of these patients. Subtle cortisol secretion affects bone health, quality of life and causes depression, but due to the unapparent clinical features, patients with SCS are often at risk between over and under treatment. This narrative review aimed to summarize the latest recommendations on the approach to the patient with subclinical Cushing's syndrome.

Laparoscopic Versus Open Adrenalectomy: a Retrospective Comparative Study

BACKGROUND

Laparoscopic Adrenalectomy (LA) has rapidly become the gold standard in management of adrenal tumors as it has been found to be associated with better cosmoses, shorter hospital stay and rapid convalescence.

OBJECTIVE

The aim of this study was to compare laparoscopic and open approach to adrenal glands in terms of operative time, hospital stay, indications and blood loss at a tertiary medical center in Jordan.

METHODS

A retrospective comparative study which included all patients who underwent adrenalectomy (open or laparoscopic) from 2005 to 2015 at King Hussein Medical Center (KHMC). Patients' demographics ,outcomes and essential study variables were extracted from patients' files. Data analysis was performed using SPSS17 and Stata 10.

RESULTS

One hundred and three patients (mean age 44.9 years) were included, 90.2% of them underwent laparoscopic adrenalectomy. The size of the tumors ranged from 2 to 17 cm (mean 6.6 cm).The operative time, blood loss and hospital stay were significantly less in the laparoscopic group (P value <0.001). Patients in Open group had a significantly higher risk of incomplete excision of the tumors (P value=0.020).

CONCLUSION

Laparoscopic adrenalectomy is associated with decreased operative time, blood loss and hospital stay compared to open approach. Tumor size and its malignant potential should be no more regarded as an absolute contraindication to laparoscopic adrenal surgery.

Factors associated with prolonged hospital stay after laparoscopic adrenalectomy

Laparoscopy is the standard technique for resecting adrenal tumors, but short-term outcomes such as length of stay (LOS) vary widely between centers. We aimed to identify factors associated with LOS after lateral transperitoneal laparoscopic adrenalectomy (LTLA). We analyzed consecutive patients undergoing unilateral LTLA between April 2003 and April 2020. Prolonged LOS was defined as a stay longer than the 75th percentile of the overall cohort. To identify potential factors associated with prolonged LOS, we compared collected data from patients with LOS ≤ 2 days versus LOS > 2 days and elaborated multivariate logistic regression models. We included 150 patients (73 men and 77 women, median age 54 years), with benign (n = 128) and malignant tumors (n = 22). The median LOS after LTLA was 2 days; 64 (42.7%) patients had prolonged hospitalization. Variables significantly associated with prolonged LOS in the univariate analysis included ASA III + IV (p = 0.016), pheochromocytoma (p < 0.001), learning curve (p = 0.032), surgery on Thursday or Friday (p < 0.001), 2D laparoscopy (p = 0.003), operative time (p < 0.001), estimated blood loss (p < 0.001), drainage (p < 0.001), specimen size (p = 0.011), conversions (p = 0.002), complications (p = 0.019), and hospital stay (p < 0.001). After adjustment for patient, surgical, and tumor characteristics, risk factors associated with prolonged LOS in the multivariate analysis were specimen size > 9 cm (OR:13.03, p = 0.005), surgery on Thursday or Friday (OR:6.92, p = 0.001), estimated blood loss ≥ 60 ml (OR:6.22, p = 0.021), and drainage (OR:5.29, p = 0.005). Prolonged length of stay after LTLA was associated with specimen size > 9 cm, operating on Thursday or Friday, estimated blood loss ≥ 60 mL, and drainage.

Not all laparoscopic adrenalectomies are equal: analysis of postoperative outcomes based on tumor functionality

BACKGROUND

Laparoscopic adrenalectomy is known to have a low complication rate; however, the influence of functional tumor subtype on postoperative outcomes is not well defined.

METHODS

Patients undergoing laparoscopic adrenalectomy for benign adrenal tumors between 2009 and 2017 were selected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patient demographics, postoperative outcomes, and length of stay were compared between tumor subtypes.

RESULTS

A total of 3946 patients underwent a laparoscopic adrenalectomy during the study period; 3214 (81.5%) were performed for non-functional adenomas, and 732 (18.6%) for functional tumors-467 (64%) aldosteronomas, 184 (25%) cortisol-producing adenomas, and 81 (11%) pheochromocytomas. The risk of any complication was highest for patients with Cushing's (6.5%) and lowest with Conn's syndrome (1.1%) compared to other lesions (3.7% pheochromocytoma, 5.3% adenoma, p < 0.001). Among the patients with functional tumors, those with cortisol-producing adenomas had the highest rates of both deep surgical site infection (1.6%, p = 0.026) and urinary tract infection (2.2%, p = 0.029), whereas myocardial infarction was most prevalent in patients with pheochromocytoma (2.5%, p = 0.012). When adjusted for demographic differences, BMI, and comorbidity scores, no tumor type was associated with increased complication rate; instead aldosteronoma (vs. benign adenoma) was independently predictive of fewer adverse events [0.3 (95% CI 0.1-0.7), p = 0.004] and a shorter length of hospital stay [0.6 (95% CI 0.4-0.8), p = 0.001]. The overall mortality rate was low at 0.4%, although significantly higher in Cushing's patients (2.2%, p = 0.015).

CONCLUSIONS

Laparoscopic adrenalectomy is a safe operation with low mortality and complication rates. However, postoperative risks differ between tumor subtype, so patients should be counseled accordingly.

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.

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.

A Close Encounter - Left Pneumonia and Pancreatic Tail Fistula after Laparoscopic Left Adrenalectomy

Laparoscopic adrenalectomy is currently considered the gold standard for adrenal tumors up to 6 cm, and although with far less morbidity than the open alternative, when it comes to its complications we should not look away. The case concerns a 51-year old obese male that underwent left laparoscopic adrenalectomy for incidentaloma and developed pancreatic tail fistula. Without an evident pancreatic lesion during surgery and an uneventful early postoperative course the patient was discharged only to return 4 days later with respiratory symptoms and mild abdominal discomfort in the left upper quadrant. The CT scan diagnosed a left subphrenic fluid collection and left basal pneumonia, thus the patient underwent laparoscopic reintervention for drainage of the pancreatic fluid collection and received conventional antibiotherapy for pneumonia. The patient was discharged in good condition with the drainage tube in situ. The drainage tube was extracted 14 days later.

Risk Factors Associated With Perioperative Complications and Prolonged Length of Stay After Laparoscopic Adrenalectomy

Importance

Laparoscopic adrenalectomy is the gold standard for most adrenal disorders and its frequency in the United States is increasing. While national and administrative databases can adjust for patient factors, comorbidities, and institutional variations, granular disease-specific data that may significantly influence the incidence of perioperative complications and length of stay (LOS) are lacking.

Objective

To investigate factors associated with perioperative complications and LOS after laparoscopic adrenalectomy.

Design, Setting, and Participants

This cohort study was carried out at a single academic medical center, with all patients who underwent laparoscopic adrenalectomy between 1993 and 2017 by the endocrine surgery department. Multivariable linear and logistic regression were used to obtain adjusted odds ratios (ORs).

Main Outcomes and Measures

The primary outcome was perioperative complications with a Dindo-Clavien grade of 2 or more. The secondary outcome was prolonged length of stay, defined as a stay longer than the 75th percentile of the overall cohort.

Results

We identified 640 patients who underwent 653 laparoscopic adrenalectomies, of whom 370 (56.7%) were female. The median age was 51 (range, 5-88) years. A total of 76 complications with a Dindo-Clavien grade of 2 or more occurred in 55 patients (8.4%), with postoperative mortality in 2 patients (0.3%). The median hospital length of stay was 1 day (range, 0-32 days). Factors independently associated with increased complications were American Society of Anesthesiologists class 3 or 4 (OR, 2.78 [95% CI, 1.39-5.55]; P < .01), diabetes (OR, 2.39 [95% CI, 1.14-5.01]; P = .02), conversion to hand-assisted or open surgery (OR, 5.32 [95% CI, 1.84-15.41]; P < .01), a diagnosis of pheochromocytoma (OR, 4.31 [95% CI, 1.43-13.05]; P = .01), and a tumor size of 6 cm or greater (OR, 2.47 [95% CI, 1.05-5.78]; P = .04). Prolonged length of stay was associated with age 65 years or older (OR, 2.44 [95% CI, 1.31-4.57]; P = .01), an American Society of Anesthesiologists class 3 or 4 (OR, 3.48 [95% CI, 1.88-6.41]; P < .01), any procedural conversion (OR, 63.28 [95% CI, 12.53-319.59]; P < .01), and a tumor size of 4 cm or larger (4-6 cm: OR, 2.38 [95% CI, 1.21-4.67]; P = .01; ≥6 cm: OR, 2.46 [95% CI, 1.12-5.40]; P = .03).

Conclusions and Relevance

Laparoscopic adrenalectomy remains safe for most adrenal disorders. Patient comorbidities, adrenal pathology, and tumor size are associated with the risk of complications and length of stay and should all be considered in selecting and preparing patients for surgery.

Risk factors for complications after adrenalectomy: results from a comprehensive national database

PURPOSE

Most knowledge regarding outcome after adrenal surgery stems from retrospective studies reported by highly specialized centres. The aim of this study was to report a national experience of adrenalectomy with particular attention to predictive factors for postoperative complications, conversion from endoscopic to open surgery and length of hospital stay.

METHODS

Adrenalectomies reported in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009-2014 were included. Risk factors for complications, conversion and hospital stay >3 days were assessed using univariable and multivariable logistic regression analysis.

RESULTS

There were 659 operations. Endoscopic adrenalectomy was performed in 513 (77.8%) operations and almost half of these were robotic assisted. The median length of hospital stay was 3 (range 1-30) days. There was no 30-day mortality. In 43 (6.6%) patients, at least one complication was registered. The only factor associated with complications in multivariable analysis was conversion to open surgery odds ratio (OR) 3.61 (95% confidence interval 1.07 to 12.12). The risk for conversion was associated with tumour size OR 1.03 (1.00 to 1.06) and with malignancy on histopathology OR 8.33 (2.12 to 32.07). Length of hospital stay increased in patients with operation of bilateral tumours OR 3.13, left-sided tumours OR 1.98, hyper secretion of catecholamines OR 2.32, conversion to open surgery OR 42.05 and open surgery OR 115.18.

CONCLUSIONS

The present study shows that endoscopic surgery is widely used. Complications were associated with conversion and the risk for conversion was associated with tumour size and malignant tumour. Hospital stay was short.

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.

The effect of surgical treatment of phaeochromocytoma on concomitant arterial hypertension and diabetes mellitus in a single-centre retrospective study

INTRODUCTION

Phaeochromocytoma is one of the numerous causes of secondary hypertension. Furthermore, phaeochromocytoma may first present with type 2 diabetes mellitus. The objective of our study was to evaluate the effects of adrenalectomy on patient recovery with regards to normotension and well-controlled glycaemia.

MATERIAL AND METHODS

The retrospective analysis involved 67 patients with phaeochromocytoma operated between 2006 and mid-2012. The pre-operative diagnoses were made in the departments of internal medicine and endocrinology. Based on laboratory tests and diagnostic imaging, we were able to confirm the diagnosis of phaeochromocytoma in 42 (62.7%) patients. We verified the influence of adrenalectomy on the level of patient recovery, with regards to normotension and glycaemic control: arterial pressure and fasting glycaemia levels were obtained on the day of hospital discharge, at follow-up 3 months post-operatively and 1 year after surgical intervention.

RESULTS

Of the 67 patients operated for phaeochromocytoma, 48 (71.6%) were treated laparoscopically, whereas 19 (28.4%) underwent open adrenalectomy. Arterial hypertension was recorded in 53 (79.1%) cases. Furthermore, among this group, diabetes mellitus coexisted in 21 (31.3%) cases. Postoperatively, 70% of cases of arterial hypertension and 90% of type 2 diabetes mellitus were cured. Additionally, a high rate of patients reported a quantitative reduced use of antihypertensive medicines.

CONCLUSIONS

In the majority of patients, surgical treatment of symptomatic phaeochromocytoma leads to a regression of arterial hypertension, or a reduction of the number or doses of medicines taken in one's treatment, and glucose-intolerance symptoms.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

OBJECTIVE

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series.

MATERIAL AND METHODS

322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications.

RESULTS

Twenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V).

CONCLUSIONS

Standardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Prognostic indices of perioperative outcome following transperitoneal laparoscopic adrenalectomy

OBJECTIVES

We sought to identify preoperative patient and tumor characteristics that may be useful prognostic indicators of postsurgical outcome in patients undergoing laparoscopic adrenalectomy (LA).

SUBJECTS AND METHODS

Data from 92 patients who underwent 93 transabdominal LA procedures between 2006-2012 were retrieved. Patients were stratified based on estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Interdependencies between surgical outcome and patient demographics, tumor characteristics, comorbidities, and Charlson Comorbidity Index (CCI) were statistically analyzed. The predictive capacity of each index was assessed using receiver operating characteristic curves.

RESULTS

Neither age, gender, tumor laterality, body mass index, American Society of Anesthesiologists (ASA) score, nor CCI predicted the occurrence of perioperative complications. EBL was significantly associated with increased age, tumor size, ASA score, and CCI, whereas prolonged LOS was associated with higher ASA score. Tumor size was related, although not significantly, to LOS and perioperative complications. Tumors ≥7.5 cm in diameter were significantly associated with worse perioperative outcomes.

CONCLUSIONS

LA for adrenal lesions demonstrated reasonable complication rates and perioperative outcomes. Tumor size, CCI, and ASA score are predictive of increased EBL and LOS.

Impact of adrenalectomy and dexamethasone treatment on testicular morphology and sperm parameters in rats: insights into the adrenal control of male reproduction

Here we investigated the hypothesis that normal levels of glucocorticoids, a class of adrenal steroid hormones, are required for normal testicular and epididymal functions. We examined the effects of the manipulation of glucocorticoid plasma levels by bilateral adrenalectomy (1, 2, 7 and 15 days) alone or in combination with daily treatment with the synthetic glucocorticoid dexamethasone (DEX; 5 μg/kg, i.p., 6 days) on the morphology of the testis and sperm parameters in rats. We showed that adrenalectomy led to a reduction in testicular sperm count and daily sperm production starting 2 days after surgery and a differential decrease in sperm count in the epididymis, according to the region and time post-adrenalectomy analysed. In parallel, testes from 7-day adrenalectomized (ADX) rats displayed a higher frequency of damaged seminiferous tubules and the presence of elongated spermatids retained in the basal epithelial compartment in stages IX-XVII, which is indicative of defective spermiation. The alkaline comet assay revealed a late effect of adrenalectomy on epididymal sperm DNA fragmentation, which was increased only 15 days after surgery. DEX treatment prevented the changes in testicular and epididymal sperm count observed in 7-day ADX rats, but failed to protect the testis from ADX-induced morphological abnormalities. Thus, our results indicated that glucocorticoids may be involved in events related to the maintenance of spermatogenesis and sperm maturation during adulthood. These findings provide new insights into the importance of adrenal steroids to male fertility.

Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database

BACKGROUND

There are numerous factors that may contribute to microvascular free flap failure. Although technical issues are dominant factors, patient and clinical characteristics are also contributory. The aim of this study was to investigate non-technical variables associated with microsurgical free flap failure using a multi-institutional dataset.

METHODS

Utilizing the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database, we identified all patients who underwent microvascular free tissue transfer from 2005 through 2009. Univariate analysis was performed to determine the association of flap failure with the following factors: age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes, smoking, alcohol, American Society of Anesthesiologists classification, year of operation, operative time, number of flaps, and type of reconstruction. Factors with a significance of P < 0.2 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors.

RESULTS

A total of 639 patients underwent microsurgical free flap reconstruction with 778 flaps over the 4-year study period; 139 patients had two free flaps during the same operation. The overall incidence of flap failure was 4.4% (34/778) (95% confidence interval [CI]: 3.0%, 6.2%). Operative time was identified as an independent risk factor for free flap failure. After adjusting for other factors, those whose operative time was equal to or greater than the 75th percentile (625.5 min) were twice as likely to experience flap failure (AOR 2.09; 95% CI: 1.01-4.31; P = 0.045). None of the other risk factors studied were significant contributors.

CONCLUSIONS

In this series, the overall flap loss rate of was 4.4%. Operative time was a significant independent risk factor for flap failure.

Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients

BACKGROUND

Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA.

METHODS

A retrospective cohort study of prospectively collected data was conducted. Patients (≥ 16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α < 0.05).

RESULTS

In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p < 0.01), and fewer functioning lesions (p < 0.01). OA patients more often required concurrent procedures (p < 0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p < 0.01), nonfunctioning lesion (p < 0.01), diagnosis of adrenocortical carcinoma (p < 0.01), and the need for concomitant procedures (p < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures (p < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity.

CONCLUSIONS

Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.

Laparoscopic versus open adrenalectomy: another look at outcome using the Clavien classification system

BACKGROUND

A laparoscopic approach to adrenalectomy has become the procedure of choice for most adrenal resections. We hypothesized that laparoscopic adrenalectomy is less likely to result in intensive care unit (ICU) level complications or death than open adrenalectomy, despite baseline comorbidity mix.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, all laparoscopic and open adrenalectomies were identified by current procedural terminology. Adverse outcomes tracked in NSQIP were mapped to Clavien level based on need for ICU care or death. Univariate and multivariate analysis were used to compare groups.

RESULTS

There were 1,980 laparoscopic and 592 open procedures. Clavien 4 and 5 complications occurred in 45 (7.6%) of open and 35 (1.8%) of laparoscopic operations. The univariate odds ratio showed a 4.6-fold greater likelihood that a patient would have an ICU level complication (P < .001), and 4.9 odds ratio of death (P < .001) if an open rather than laparoscopic operation was performed. Regression modeling showed persistence of the protective effect of laparoscopy after adjusting for comorbidities with a multivariate odds ratio of 3.3 (P < .001).

CONCLUSION

The laparoscopic approach to adrenalectomy has an independent protective effect on ICU level complications and mortality when compared with open procedures. This correlation persists after correcting for multiple comorbidities.

Laparoscopic adrenalectomy--assessing the learning curve

Laparoscopic adrenalectomy (LA) has become the "gold standard" for treatment of most of adrenal tumors in last few years. It has many benefits comparing to open surgery, but still is considered as complicated procedure requiring experienced surgical team.

THE AIM OF THE STUDY

was to assess the learning curve of laparoscopic adrenalectomy and the outcome of the first consecutive 154 LA.

MATERIAL AND METHODS

154 consecutive patients undergoing LA between 2007 and 2010 were reviewed. Collected data included: patients demographics, clinical and histological diagnosis, side and length of operation, conversions to open surgery, complications and hospitalization time. Learning curve was evaluated by dividing all patients into three groups (group I - first 50 patients, group II - second 50 patients and group III last 54 patients). Differences between the groups were analyzed.

RESULTS

There were 154 LAs performed. Indications for LA were hormonally inactive adrenal adenoma(n=57), Conn's syndrome (n=30), Cushing's syndrome (n=28), pheochromocytoma (n=27), adrenal cyst (n=8), and others (n=4). Mean tumor size was 45.28 mm. There were 79 left-sided and 75 right-sided procedures and the average time of hospitalization was 4.64 days. Mean operative time was statistically different between the groups (216.2 min. - 164.6 min. - 131.9 min.; p<0.01) as well as the number of conversions to open surgery (18% - 4% - 3.7%; p=0.013). There was not any significant difference in the number of complications between analyzed groups (2% - 2% -3.7%).

CONCLUSION

To improve the outcome of LA it is necessary to perform approximately 40 to 50 procedures.

Current status of robotic surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms "robotic surgery, telesurgery, and laparoscopy." A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

Adrenal incidentalomas

The term adrenal incidentaloma (AI) is usually defined as an adrenal mass unexpectedly detected through an imaging procedure performed for reasons a priori unrelated to adrenal dysfunction or suspected dysfunction. The preferred approach to their management in terms of diagnosis, follow-up, and treatment remain controversial despite a state-of-the-science conference sponsored by the U.S. National Institutes of Health. Although most experts' recommendations tend to be relatively minor variations of the conference's approach, dissenting voices have been heard. Despite their frequent appearance, the challenge remains to recognize and treat the small percentage of AI that do pose a significant risk, either because of their hormonal activity or because of their malignant histology, while leaving the rest alone. Although the differential diagnosis of an incidentally discovered mass is quite extensive, most AIs are non-secreting cortical adenomas. The noninvasive differentiation of benign and malignant lesions depends upon imaging characteristics, and sometimes radiologic diagnosis can be definitive, but often it is not, Among function lesions, autonomous cortisol production seems to be the most common and may be associated with increased cardiovascular risk and clinical features of the "metabolic syndrome." Follow-up of cases in which a specific diagnosis is not made initially involves assessment for growth and development of hormonal function, but even here, controversy about the extent of evaluation persists.

Is tumour size a contraindication to laparoscopic adrenalectomy? Case report

The authors present a case report of a patient with a large, hormonally silent tumour of the right adrenal gland. Due to the patient's numerous strains, the necessity of two gynaecological operations, and treatment of broken bones, adrenalectomy was contraindicated for 2 years. After that time, the size of the tumour reached 18 cm × 12 cm. The patient was selected for laparoscopic adrenalectomy, which was successful. The size of the tumour and performed abdominal surgery did not constitute substantial obstacles, and the less invasive procedure was additionally justified by computed tomography and magnetic resonance imaging results, which demonstrated a benign lesion.

Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery?

PURPOSE

Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy, such as limited degree of freedom, 2D vision, fulcrum, and pivoting effect. Robotic systems provide corresponding solutions as 3D view, intuitive motion and enable additional degrees of freedom. This review provides an overview of the history of medical robotics, experimental studies, clinical state-of-the-art and economic impact.

METHODS

The Medline database was searched for the terms "robot, telemanipulat, and laparoscop." A total of 2,573 references were found. All references were considered for information on robotic assistance in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work.

RESULTS

In experimental studies, current robotic systems showed superior handling and ergonomics compared to conventional laparoscopic techniques. In gynecology especially for hysterectomy and in urology especially for prostatectomy, two procedures formerly performed via an open approach, the robot enables a laparoscopic approach. This results in reduced need for pain medication, less blood loss, and shorter hospital stay. Within abdominal surgery, clinical studies were generally unable to prove a benefit of the robot. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

CONCLUSION

Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. The most promising procedures are those in which the robot enables a laparoscopic approach where open surgery is usually required.

Risk factors for conversion and complications after unilateral laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most benign adrenal tumours, with a reported overall complication rate around 10 per cent. The aim of this study was to determine predictive factors for postoperative complications and conversion to open surgery after unilateral LA.

METHODS

From 1994 to 2009, consecutive patients undergoing unilateral LA by the lateral transabdominal approach were analysed from a prospectively maintained database. A mass larger than 12 cm in diameter and suspected primary adrenal carcinoma were considered contraindications to LA. Predictive factors for postoperative complications and conversion to open surgery were analysed.

RESULTS

Some 462 patients were analysed. There were no postoperative deaths. Postoperative complications occurred in 53 patients (11·5 per cent), medical complications in 28, and surgical complications in 33 patients. Six patients underwent reoperation for complications. Multivariable logistic regression analysis showed that conversion to open surgery (odds ratio (OR) 6·20, 95 per cent confidence interval 2·08 to 18·53; P = 0·001) and left-sided tumour (OR 1·89, 1·02 to 3·52; P = 0·044) were independent predictive factors for overall complications. Conversion to open surgery was the only independent predictive factor for medical complications (OR 12·88, 4·21 to 39·41; P = 0·001), and left-sided LA was the only predictive factor for surgical complications (OR 2·22, 1·01 to 4·89; P = 0·047). No factor was predictive of conversion to open surgery.

CONCLUSION

In this single-institution study, conversion to open surgery and left-sided tumours were independent predictive factors for overall complications, but none of the variables analysed was predictive of conversion.