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Sengun B, Iscan Y, Tataroglu Ozbulak GA, Kumbasar N, Egriboz E, Sormaz IC, Aksakal N, Deniz SM, Haklidir M, Tunca F, Giles Senyurek Y. Artificial Intelligence in Minimally Invasive Adrenalectomy: Using Deep Learning to Identify the Left Adrenal Vein. Surg Laparosc Endosc Percutan Tech 2023; 33:327-331. [PMID: 37311027 DOI: 10.1097/sle.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/18/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Minimally invasive adrenalectomy is the main surgical treatment option for the resection of adrenal masses. Recognition and ligation of adrenal veins are critical parts of adrenal surgery. The utilization of artificial intelligence and deep learning algorithms to identify anatomic structures during laparoscopic and robot-assisted surgery can be used to provide real-time guidance. METHODS In this experimental feasibility study, intraoperative videos of patients who underwent minimally invasive transabdominal left adrenalectomy procedures between 2011 and 2022 in a tertiary endocrine referral center were retrospectively analyzed and used to develop an artificial intelligence model. Semantic segmentation of the left adrenal vein with deep learning was performed. To train a model, 50 random images per patient were captured during the identification and dissection of the left adrenal vein. A randomly selected 70% of data was used to train models while 15% for testing and 15% for validation with 3 efficient stage-wise feature pyramid networks (ESFPNet). Dice similarity coefficient (DSC) and intersection over union scores were used to evaluate segmentation accuracy. RESULTS A total of 40 videos were analyzed. Annotation of the left adrenal vein was performed in 2000 images. The segmentation network training on 1400 images was used to identify the left adrenal vein in 300 test images. The mean DSC and sensitivity for the highest scoring efficient stage-wise feature pyramid network B-2 network were 0.77 (±0.16 SD) and 0.82 (±0.15 SD), respectively, while the maximum DSC was 0.93, suggesting a successful prediction of anatomy. CONCLUSIONS Deep learning algorithms can predict the left adrenal vein anatomy with high performance and can potentially be utilized to identify critical anatomy during adrenal surgery and provide real-time guidance in the near future.
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Affiliation(s)
- Berke Sengun
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yalin Iscan
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | | | | | - Ismail C Sormaz
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | | | - Fatih Tunca
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Yasemin Giles Senyurek
- Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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Laparoendoscopic single-site adrenalectomy versus multi-port laparoendoscopic adrenalectomy: A systemic review and meta-analysis. Ann Med Surg (Lond) 2021; 66:102388. [PMID: 34113440 PMCID: PMC8170104 DOI: 10.1016/j.amsu.2021.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/03/2021] [Accepted: 05/09/2021] [Indexed: 11/22/2022] Open
Abstract
Background To investigate the outcomes of laparoendoscopic single-site adrenalectomy (LESS-A) compared to multi-port laparoendoscopic adrenalectomy (m-LA). Methods Studies comparing LESS-A with m-LA were identified from PubMed, Embase, and Cochrane Library before June 2020. Post-operative pain, resumption outcomes, and perioperative outcomes were analyzed. We conducted meta-analyses using the Mantel-Haenszel method with random-effects model. Subset analyses were conducted according to peritoneal and retroperitoneal approaches. A small study effect was illustrated using funnel plots and Egger's test. Results One randomized controlled trial (RCT) and nineteen retrospective cohort studies involving 1554 patients were included for analyzed. Pooled analysis showed that LESS-A had significantly lower postoperative pain scores (MD −0.77, 95%CI −1.45 to −0.10) and less pain medication used (RR 0.74, 95%CI 0.60 to 0.91) compared to m-LA. Besides, LESS-A had significantly shorter hospital stays (MD −0.75, 95%CI −1.18 to −0.33), shorter duration of oral intake resumption (MD −0.33, 95%CI −0.60 to −0.06), and better cosmetic satisfaction (SMD 1.15, 95%CI 0.21 to −2.09). As for perioperative outcomes, LESS-A led to significant longer operative time (MD 13.43, 95%CI 4.08 to 22.77). No significant differences were observed in terms of the remaining perioperative outcomes. Conclusions LESS-A is associated with less post-operative pain and quicker recovery duration. However, the longer operative time of LESS-A compared with m-LA is a drawback. Multi-port laparoscopic adrenalectomy (m-LA) is widely used for treatment of benign adrenal tumor. Laparoscopic single-site adrenalectomy (LESS-A) had significant less post-operative pain and less pain medication consumption comparing with m-LA. LESS-A had better resumption outcomes, including shorter hospital stay and quicker post-operative oral intake. LESS-A offer better cosmetic satisfaction. Longer operative time is a drawback of LESS-A.
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Surgical Indications and Techniques for Adrenalectomy. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:8-22. [PMID: 32377128 PMCID: PMC7192258 DOI: 10.14744/semb.2019.05578] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 01/26/2023]
Abstract
Indications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancy and functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secreting adrenal tumors in which adrenalectomy is indicated are as follows: Cushing’s syndrome, arises from hypersecretion of glucocorticoids produced in fasciculata adrenal cortex, Conn’s syndrome, arises from an hypersecretion of aldosterone produced by glomerulosa adrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing’s disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layer of the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication for adrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the gold standard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits of the surgeon are also important, along with the patient’s characteristics. The most common type of surgery performed in the world is laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy can be performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted, which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopic adrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomy can be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multiple adrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%). The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy or suspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchi or modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as a block. The open retroperitoneal approach can be applied posteriorly or laterally.
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Laparoscopic Approach to the Adrenal Masses: Single-Center Experience of Five Years. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:52-57. [PMID: 32377134 PMCID: PMC7192254 DOI: 10.14744/semb.2019.40225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/30/2019] [Indexed: 12/27/2022]
Abstract
Objectives: Currently, laparoscopic adrenalectomy is the gold standard technique for suitable patients with adrenal masses. In this study, we aimed to assess the postoperative results of patients who underwent laparoscopic adrenalectomy. Methods: Between January 2014 and October 2019, 76 cases were operated and retrospectively evaluated. Laparoscopic transabdominal adrenalectomy was applied to the patients. Demographic profiles, preoperative indications, intraoperative and postoperative complications, mortality and length of hospital stay were evaluated. Results: Seventy-six patients (30 male, 46 female) with a mean age of 47.2±11.7 (range 22-71) years underwent laparoscopic adrenalectomy. Thirty-nine of the patients had right; 33 of the patients had left adrenal masses. Three patients had bilateral adrenal cortical hyperplasia. One patient was operated for paraganglioma. Conversion to open adrenalectomy was observed in four patients (5.26%). Nine patients (11.8%) experienced intraoperative and postoperative complications. Intraoperative and postoperative complications were bleeding from spleen (2 cases) and upper pole of kidney (1 case), renal artery injury (1 case), bleeding from liver parenchyma (2 cases), ischemia of spleen and pancreas (1 case), small intestinal injury (1 case) and incisional hernia (1 case). The complication rate is acceptable and comparable with other studies in the literature. Conclusion: Laparoscopic adrenalectomy can be safely applied in suitable patients with acceptable complications and low conversion rates.
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Kato Y, Kato R, Takayama M, Ikarashi D, Onoda M, Matsuura T, Kanehira M, Takata R, Baba S, Kimura T, Otsuka K, Sugimura J, Omori S, Sasaki A, Obara W. Single-stage laparoscopic surgery for bilateral organ tumors using a transumbilical approach with a zigzag incision: a report of two cases. BMC Urol 2018; 18:28. [PMID: 29716558 PMCID: PMC5930829 DOI: 10.1186/s12894-018-0343-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 04/18/2018] [Indexed: 12/02/2022] Open
Abstract
Background Reduced port laparoscopic surgery (RPLS) is comparable to conventional multiport laparoscopic surgery and has the potential to provide improved cosmesis and decreased pain; as such, it satisfies a growing demand for less invasive surgical procedures. Moreover, a zigzag incision of the umbilicus results in a less visible scar in plastic surgery. Here we report a series of two cases with bilateral organ tumors treated by single-stage RPLS using a combination of a transumbilical approach and a zigzag incision. Case presentation Case 1: A 63-year-old man was diagnosed with right renal cell carcinoma (RCC) (clear cell carcinoma, pT1a, venous invasion (−)) and a splenic tumor (cavernous hemangioma). Case 2: An 84-year-old woman was diagnosed with concurrent left RCC (clear cell carcinoma, pT1b, 65 × 65 mm, venous invasion (+)) and ascending colon cancer (adenocarcinoma pT3 with no nodal involvement (0/48)). The perioperative course was uneventful in both cases. However, an additional incision was required in Case 2 for specimen excision. Therefore, the scars were more obvious in Case 2 than in Case 1. Conclusions Although more cases are required to evaluate the superiority of this technique, this novel procedure could be considered for patients with bilateral lesions.
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Affiliation(s)
- Yoichiro Kato
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan.
| | - Renpei Kato
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Misato Takayama
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Daiki Ikarashi
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Mitsutaka Onoda
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Tomohiko Matsuura
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Mitsugu Kanehira
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Ryo Takata
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Jun Sugimura
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - So Omori
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
| | - Wataru Obara
- Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan
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Current surgical technique and outcomes of laparoendoscopic single-site adrenalectomy. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ball MW, Hemal AK, Allaf ME. International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy. BJU Int 2016; 119:13-21. [PMID: 27431446 DOI: 10.1111/bju.13592] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The aim of this study was to provide an evidence-based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single-site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence-based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first-line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the 'gold standard'. Large adrenal tumours without preoperative or intra-operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.
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Affiliation(s)
- Mark W Ball
- James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mohamad E Allaf
- James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Fukumoto K, Miyajima A, Hattori S, Matsumoto K, Abe T, Kurihara I, Jinzaki M, Kikuchi E, Oya M. The learning curve of laparoendoscopic single-site adrenalectomy: an analysis of over 100 cases. Surg Endosc 2016; 31:170-177. [PMID: 27194254 DOI: 10.1007/s00464-016-4950-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/18/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recently, laparoendoscopic single-site adrenalectomy (LESS-A) has been developed as an alternative treatment for adrenal tumors. Although LESS-A is more technically complex than conventional laparoscopic adrenalectomy, its learning curve and the factors associated with poor surgical outcomes are poorly understood. We analyzed the learning curve of LESS-A and attempted to identify risk factors associated with worse surgical outcomes. METHODS We identified 103 patients who underwent LESS-A [performed by the same surgeon (A.M.)] from 2009 to 2015. The learning curve was analyzed using the moving average method (the 10-case moving average), and we assessed potential risk factors for a prolonged pneumoperitoneum time. RESULTS The learning curve stabilized at 30 cases. The cases were divided into two groups, the learning stage (LS) (cases 1-29) and master stage (MS) (cases 30-103) groups. The percentage of females and the frequency of previous abdominal surgery were higher in the LS group (p = 0.022 and 0.001, respectively). In the LS group, the mean pneumoperitoneum time was 92 ± 35 min, which was significantly longer than the equivalent value for the MS group (55 ± 18 min, p < 0.001). In the LS group, univariate analysis revealed that tumor size (≥50 mm) and the visceral fat area (VFA)/total fat area (TFA) ratio (≥0.49) were significantly associated with a prolonged pneumoperitoneum time (p = 0.046 and 0.046, respectively). In the multivariate analysis, tumor size and the VFA/TFA ratio were confirmed to be associated with a prolonged pneumoperitoneum time (p = 0.029 and 0.029, odds ratio 20.83 and 20.83, respectively). On the other hand, none of the examined factors were found to be associated with a prolonged pneumoperitoneum time in the MS group. CONCLUSIONS LESS-A was performed safely in most cases. However, surgeons who are learning the LESS-A procedure need to pay attention to tumor size and visceral obesity.
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Affiliation(s)
- Keishiro Fukumoto
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan
| | - Akira Miyajima
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan.
| | - Seiya Hattori
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan
| | - Kazuhiro Matsumoto
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan
| | - Takayuki Abe
- Center for Clinical Research, Keio University School of Medicine, Tokyo, Japan
- Biostatistics at Center for Clinical Research, Keio University School of Medicine, Tokyo, Japan
| | - Isao Kurihara
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-0016, Japan
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León-Medina P, Blanco-Díez A, Mejía-Chavarría D, Armas-Molina J, Molina-Cabrillana J, Artiles-Hernández J. Outcomes of laparoscopic adrenalectomy Conventional technique versus laparo-endoscopic single-site surgery. Actas Urol Esp 2016; 40:245-50. [PMID: 26811023 DOI: 10.1016/j.acuro.2015.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/28/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Perform a comparative analysis of the outcomes of conventional laparoscopic adrenalectomy (LC) and the newly introduced laparo-endoscopic single-site surgery (LESS) over ten years. MATERIAL AND METHOD We retrospectively reviewed the experience of a single surgeon from our medical centre with laparoscopic adrenalectomy, either through LC or LESS, with 75 patients between August 2005 and June 2015. Here we describe: age, sex, size, lateralization, preoperative diagnosis, total operating time, intraoperative bleeding, conversion to open surgery, mean hospital stay, intra- and postoperative complications and histopathology report. We used Fischer's and the Chi-squared tests to compare categorical data and Student's T-test for a comparison of the means with a normal distribution. Statistical significance was determined when p<0.05. RESULTS LC was performed in 51 patients, and LESS in 24 patients. No statistical significance was found for total operating time (LC: 103.9±13.21min vs. LESS: 101.46±13.65min; p=0.07), estimated bleeding (LC: 258.82±136.92cc vs. LESS: 131,25±36,74cc; p=0.46), intraoperative complications (5 cases in LC, none in LESS; p=0.47), nor for postoperative complications (two in LC vs. one in LESS; p=0.69), as catalogued according to the modified Clavien classification system. We detected a statistical significance difference in the comparisons of the mean hospital stay, which was reduced in LESS (LC: 3.55±0.69 days vs. LESS: 2.21±0.31 days; p=0.01). CONCLUSIONS Adrenalectomy with LC is the approach of choice for surgical treatment of adrenal pathologies. The LESS technique is safe, improves the cosmetic results, and does not increase mortality if performed by experienced teams.
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Han JH, Hong TH, You YK, Kim DG. Surgical results of reduced port laparoscopic adrenalectomy using a multichannel port in comparison with conventional laparoscopic adrenalectomy. Asian J Surg 2015; 40:6-11. [PMID: 25913731 DOI: 10.1016/j.asjsur.2015.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 02/24/2015] [Accepted: 03/02/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND We introduced a modified laparoscopic technique, dual-incision laparoscopic adrenalectomy (DILA), using a newly designed multichannel trocar, and we evaluated its perioperative outcomes and operative costs and compared them to those of conventional laparoscopic adrenalectomy (CLA). METHODS We retrospectively reviewed the medical records of 127 patients who underwent CLA with four trocars or DILA with two trocars at Seoul St. Mary's Hospital, Seoul, Korea between October 2007 and September 2014. We analyzed the patients' surgical outcomes and perioperative morbidities. RESULTS DILA was performed in 45 patients and CLA in 82 patients. There were no significant differences in operative time (DILA: 77.1 ± 28.4 minutes vs. CLA: 76.6 ± 28.0 minutes, p = 0.595) or estimated blood loss during surgery (DILA: 150.0 ± 85.5 mL vs. CLA: 175.5 ± 50.5 mL, p = 0.697). There were no differences in postoperative hospital stay, visual analog scale pain score, or postoperative complication rates between the two groups. However, the operative cost was significantly lower in the DILA group (DILA 813,603 ± 48,600 Korean won vs. CLA 968,368 ± 56,456 Korean won, p < 0.001). CONCLUSION This study demonstrated that DILA is a safe and feasible surgical approach for adrenal diseases. DILA may reduce the operative cost significantly compared with CLA.
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Affiliation(s)
- Jae Hyun Han
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Young Kyoung You
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Goo Kim
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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Raakow J, Liesaus HG, Neuhaus P, Raakow R. Single-incision versus multiport laparoscopic appendectomy: a case-matched comparative analysis. Surg Endosc 2014; 29:1530-6. [PMID: 25294525 DOI: 10.1007/s00464-014-3837-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 08/15/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND The multiport technique is the gold standard for laparoscopic appendectomy, but the use of single-incision laparoscopy is on the increase. The aim of the present study was to compare case-matched cohorts of patients who had undergone single-incision laparoscopic appendectomy (SILA) with those who had undergone conventional multiport laparoscopic appendectomy (MLA). METHODS In a case-matched analysis, all single-incision laparoscopic appendectomies performed between July 2009 and December 2013 at one institution were reviewed and compared to multiport laparoscopic appendectomies performed during the same period. Patients who had undergone SILA were matched in terms of age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) scores with the same number of patients who had undergone MLA. Statistical evaluation included the description and comparison of demographic factors, details of surgery, and histological data. A univariate analysis was performed to assess potential risk factors for morbidity after SILA. RESULTS One hundred and fifty-six patients who had undergone SILA were reviewed, matched, and compared to the same number of patients who had undergone MLA. No significant difference was noted in mean operating times (50.83 vs. 50.61 min for SILA and MLA, respectively; p = 0.924) and the length of hospital stay (3.60 vs. 3.66 days; p = 0.704). No patient in either group required conversion to the open procedure while 6 (3.8 %) SILA patients were converted to multiport laparoscopy. SILA was not associated with significantly higher postoperative morbidity compared to MLA (9.6 % vs. 5.8 %; p = 0.288). Postoperative wound infection rates were higher after SILA (3.2 % vs. 0.6 %), but did not achieve statistical significance (p = 0.214). Statistical analysis revealed no risk factors for developing postoperative complications after the single-incision procedure. CONCLUSION SILA is a technically feasible and safe alternative to conventional MLA. The two procedures did not differ in terms of operating times, length of hospital stay, and postoperative outcomes.
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Affiliation(s)
- Jonas Raakow
- Department of General, Visceral and Transplantation Surgery, Universitätsmedizin Berlin, Charité Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany,
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Chen Y, Wu S, Kong J. Transumbilical single-incision laparoscopic combined cholecystectomy and appendectomy: a retrospective comparative study. J Laparoendosc Adv Surg Tech A 2014; 24:702-6. [PMID: 25244670 DOI: 10.1089/lap.2014.0182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Single-incision laparoscopic surgery (SILS) developed rapidly in recent years. This report describes our initial experience on SILS combined cholecystectomy and appendectomy (SILSC&A) with a unique method of umbilical reconstruction. In addition, a retrospective comparison with conventional combined laparoscopic cholecystectomy and appendectomy (LC&A) was analyzed. MATERIALS AND METHODS Between April 2009 and December 2013, 62 patients with benign gallbladder and appendix disease underwent laparoscopic combined cholecystectomy and appendectomy at our institution. Of these, 34 (54.8%) underwent SILSC&A (Group 1), and 28 (45.2%) underwent LC&A (Group 2). Demographic, intraoperative, and postoperative data were analyzed retrospectively and compared between the two groups. RESULTS No significant differences were identified in the preoperative patient characteristics between the two groups. SILSC&A was associated with a shorter operative time (62.2 ± 19.7 versus 77.5 ± 21.4 minutes, respectively; P = .005) and better cosmetic results (4.6 ± 0.7 versus 4.1 ± 0.6, respectively; P = .004). There were no significant differences between the two groups with respect to other postoperative variables. CONCLUSIONS The present study suggests that SILSC&A is as safe and efficacious as conventional LC&A in experienced hands. A uniform method of umbilical reconstruction is helpful in improving cosmesis and decreasing hernia rate. Long-term follow-up and further prospective randomized trials are anticipated.
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Affiliation(s)
- Yongsheng Chen
- Department of General Surgery, Shengjing Hospital of China Medical University , Shenyang, China
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Riedinger CB, Tobert CM, Lane BR. Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach. World J Clin Urol 2014; 3:54-65. [DOI: 10.5410/wjcu.v3.i2.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/07/2014] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.
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Hattori S, Miyajima A, Hirasawa Y, Kikuchi E, Kurihara I, Miyashita K, Shibata H, Nakagawa K, Oya M. Surgical Outcome of Laparoscopic Surgery, Including Laparoendoscopic Single-Site Surgery, for Retroperitoneal Paraganglioma Compared with Adrenal Pheochromocytoma. J Endourol 2014; 28:686-92. [DOI: 10.1089/end.2013.0706] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Seiya Hattori
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Akira Miyajima
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Yousuke Hirasawa
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Isao Kurihara
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazutoshi Miyashita
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology and Metabolism, Oita University, Oita, Japan
| | - Ken Nakagawa
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
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Hirasawa Y, Miyajima A, Hattori S, Miyashita K, Kurihara I, Shibata H, Kikuchi E, Nakagawa K, Oya M. Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic adrenalectomy: a comparison of surgical outcomes and an analysis of a single surgeon’s learning curve. Surg Endosc 2014; 28:2911-9. [DOI: 10.1007/s00464-014-3553-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/12/2014] [Indexed: 10/25/2022]
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Bhandarkar DS, Mittal GK, Katara AN, Behera RR. Laparo-endoscopic single-site left adrenalectomy using conventional ports and instruments. Urol Ann 2014; 6:169-72. [PMID: 24833835 PMCID: PMC4021663 DOI: 10.4103/0974-7796.130660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 07/28/2012] [Indexed: 12/29/2022] Open
Abstract
Laparo-endoscopic single-site adrenalectomy (LESS-A) is commonly performed using specialized access devices and/or instruments. We report a LESS-A in a 47-year-old woman with a left aldosteranoma via a subcostal approach utilizing conventional laparoscopic ports and instruments. The feasibility and cost-effectiveness of this approach are highlighted and the literature on the subject is reviewed.
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Affiliation(s)
| | - Gaurav K Mittal
- Department of Surgery, Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, India
| | - Avinash N Katara
- Department of Minimal Access Surgery, Hinduja Hospital, Mahim, Mumbai, India
| | - Ramya R Behera
- Department of Minimal Access Surgery, Hinduja Hospital, Mahim, Mumbai, India
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Wang L, Wu Z, Li M, Cai C, Liu B, Yang Q, Sun Y. Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies. J Endourol 2013; 27:743-50. [PMID: 23611672 DOI: 10.1089/end.2012.0599] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To assess the surgical efficacy and potential advantages of laparoendoscopic single-site adrenalectomy (LESS-AD) compared with conventional laparoscopic adrenalectomy (CL-AD) based on published literature. METHODS An online systematic search in electronic databasesM including Pubmed, Embase, and the Cochrane Library, as well as manual bibliography searches were performed. All studies that compared LESS-AD with CL-AD were included. The outcome measures were the patient demographics, tumor size, blood loss, operative time, time to resumption of oral intake, hospital stay, postoperative pain, cosmesis satisfaction score, rates of complication, conversion, and transfusion. A meta-analysis of the results was conducted. RESULTS A total of 443 patients were included: 171 patients in the LESS-AD group and 272 patients in the CL-AD group (nine studies). There was no significant difference between the two groups in any of the demographic parameters expect for lesion size (age: P=0.24; sex: P=0.35; body mass index: P=0.79; laterality: P=0.76; size: P=0.002). There was no significant difference in estimated blood loss, time to oral intake resumption, and length of stay between the two groups. The LESS-AD patients had a significantly lower postoperative visual analog pain score compared with the CL-AD group, but a longer operative time was noted. Both groups had a comparable cosmetic satisfaction score. The two groups had a comparable rate of complication, conversion, and transfusion. CONCLUSIONS In early experience, LESS-AD appears to be a safe and feasible alternative to its conventional laparoscopic counterpart with decreased postoperative pain noted, albeit with a longer operative time. As a promising and emerging minimally invasive technique, however, the current evidence has not verified other potential advantages (ie, cosmesis, recovery time, convalescence, port-related complications, etc.) of LESS-AD.
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Affiliation(s)
- Linhui Wang
- Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, PR China
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Hu Q, Gou Y, Sun C, Xu K, Xia G, Ding Q. A systematic review and meta-analysis of current evidence comparing laparoendoscopic single-site adrenalectomy and conventional laparoscopic adrenalectomy. J Endourol 2013; 27:676-83. [PMID: 23391020 DOI: 10.1089/end.2012.0687] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess the efficacy and safety of laparoendoscopic single-site adrenalectomy (LESS-A) and conventional laparoscopic adrenalectomy (LA) as a systematic review and meta-analysis of current evidence. METHODS We conducted a thorough search for comparative studies that compared LESS-A and conventional LA in the following databases: MEDLINE, EMBASE, and the Cochrane library. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. The operative time, estimated blood loss in operation, the time to resume oral intake after surgery, postoperative hospital stay, and the visual analog pain scale (VAPS) score were included for analysis to compare the efficacy, while the complications together with the analgesia use were included for analysis to compare the safety. RESULTS Nine studies with 171 LESS-A cases and 272 conventional LA cases were identified. Although operative time was longer in LESS-A (mean difference [MD] 15.46, 95% confidence interval [CI] 11.18 to 19.74), estimated blood loss (MD 4.72, 95% CI 12.08 to 21.52) and the time to resume oral intake (MD -0.04, 95% CI -0.19 to 0.11) were similar; LESS-A presented a shorter postoperative stay in hospital (MD -0.60, 95% CI -0.86 to -0.35) and lower VAPS score (MD -1.21, 95% CI -1.44 to -0.97). Besides, the risk of minor postoperative complications (risk ratio [RR] 1.74, 95% CI 0.78 to 3.87) was similar. The postoperative analgesia demand in total (RR 0.65, 95% CI 0.52 to 0.81) together with the analgesia usage lasting more than 24 hours after surgery (RR 0.35, 95% CI 0.21 to 0.58) were associated with lower risk in LESS-A, however. CONCLUSIONS Based on current evidence, the operative time seems to be longer in LESS-A; however, operative blood loss and complications are similar. In addition, LESS-A presents a shorter hospital stay after surgery and more acceptable perception of pain than conventional LA.
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Affiliation(s)
- Qingfeng Hu
- Department of Urology and Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai, China
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Tran GB, Nguyen TD, Le KV. Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital. Asian J Endosc Surg 2013; 6:33-8. [PMID: 22989250 DOI: 10.1111/j.1758-5910.2012.00157.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 08/09/2012] [Accepted: 08/16/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy. METHODS Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port. RESULTS The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days). CONCLUSION Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.
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Affiliation(s)
- Giang Binh Tran
- Department of General Surgery, Viet Duc University Hospital, Hanoi, Vietnam.
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Hattori S, Miyajima A, Maeda T, Hasegawa M, Takeda T, Kosaka T, Kikuchi E, Nakagawa K, Oya M. Does laparoendoscopic single-site adrenalectomy increase surgical risk in patients with pheochromocytoma? Surg Endosc 2012; 27:593-8. [DOI: 10.1007/s00464-012-2495-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 07/09/2012] [Indexed: 12/16/2022]
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Bittner JG, Brunt LM. Evaluation and management of adrenal incidentaloma. J Surg Oncol 2012; 106:557-64. [PMID: 22623268 DOI: 10.1002/jso.23161] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/29/2012] [Indexed: 12/14/2022]
Abstract
Adrenal incidentaloma is the most common adrenal neoplasm encountered in clinical practice. The timely, accurate, and cost-effective evaluation and management of adrenal lesions found incidentally can be challenging for clinicians. Evaluation begins with biochemical screening and additional imaging. Management strategies vary by patient factors and tumor characteristics. Adrenalectomy is indicated for lesions that are hormonally active, larger than 4-5 cm, symptom-related, and have an imaging appearance that is atypical of a benign lesion.
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Affiliation(s)
- James G Bittner
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Abstract
Nowadays, minimally invasive operating techniques are an essential part of adrenal gland surgery. Meanwhile four different methods are being used: laparoscopically in the supine or lateral position or retroperitoneoscopically as a prone or lateral method. Ideal indications for endoscopic adrenalectomy are adrenal hyperplasias and benign, hormonally active adrenal gland tumors up to 5 cm in diameter. In comparison to the conventional operating procedures, the endoscopic methods have the advantage of less blood loss and minimized postoperative pain as well as shortening of hospital stay. Yet in contrast, the operating time of these procedures is prolonged. To date, it is not evident whether laparoscopy or retroperitoneoscopy should be preferred. Laparoscopy offers a familiar anatomical exposure but requires 5-6 trocars. For the retroperitoneoscopic methods only 3 trocars are needed, but orientation in the operating field is more difficult. All endoscopic procedures on the adrenal gland are technically difficult. They require a extended experience in minimally invasive surgery as well as special knowledge in endocrine surgery.
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Affiliation(s)
- M K Walz
- Abteilung für Allgemeine Chirurgie, Zentrums für Chirurgie, Universitätsklinikum Essen
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