Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: bilateral step-by-step technique

Comparison of Perioperative Outcomes Between Single-Port and Multi-Port Robotic Adrenalectomy

Background

Single-port (SP) robotic surgery has been utilized in several surgical procedures. We aim to describe our institution’s approach and perioperative experience with SP robotic adrenalectomy and compare it to the traditional multi-port (MP) approach.

Methods

We retrospectively reviewed all patients who underwent robotic adrenalectomy by a single surgeon between March 2019 and March 2020. Patient demographic, perioperative factors, and pathologic outcomes were recorded and analyzed using t-tests, chi-square, or Fisher’s exact tests.

Results

Thirty-six patients underwent SP (n = 11) and MP (n = 25) robotic adrenalectomy. Age, body mass index, gender, operative time, major Clavien-Dindo complications, and margin status showed no differences. Patients undergoing SP adrenalectomy had a lower estimated blood loss (18.1 ± 13.0 vs 65.6 ± 95.0 cc, P = .02) and smaller lesion size (2.8 ± 1.3 vs 4.1 ± 1.8 cm, P = .04) compared to those undergoing MP.

Conclusions

SP adrenalectomy appears to be a feasible approach in select adrenal masses. Further studies are needed to establish its safety and cost effectiveness.

Laparoendoscopic single-site adrenalectomy versus multi-port laparoendoscopic adrenalectomy: A systemic review and meta-analysis

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.

Safety and feasibility of reduced-port site surgery for robotic posterior retroperitoneal adrenalectomy

BACKGROUND

Minimally invasive surgery, such as laparoscopic adrenalectomy and robotic adrenalectomy, has become a treatment of choice for benign adrenal tumors. Efforts are ongoing to minimize the invasiveness of the procedure and to reduce the number of port sites. The primary endpoint of this study was the safety and feasibility of a reduced-port site technique for robotic posterior retroperitoneal adrenalectomy (RPRA).

METHODS

This study retrospectively analyzed 74 RPRAs performed by a single surgeon, including 30 conventional three-port site early-phase RPRAs, 30 three-port site late-phase RPRAs, and 14 reduced-port site RPRAs. Reduced-port site RRPA was defined as using two port sites: one for a multi-glove port and one for an additional side port. The clinicopathological features and surgical outcomes were compared in these three groups.

RESULTS

No major complications were observed following RPRA in the three groups of patients. Operation time, pain score, and hospital stay did not differ significantly among these three groups.

CONCLUSIONS

RPRA using a reduced-port site system was safe and feasible and may be a good alternative to conventional three-port site RPRA for benign adrenal tumors in certain situations.

Surgical Indications and Techniques for Adrenalectomy

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.