Laparoscopic adrenalectomy. A review of 30 initial cases

Laparoscopic left and right adrenalectomy from an anterior approach - is there any difference? Outcomes in 176 consecutive patients

Introduction

Traditionally, in open surgery, right adrenalectomy is considered technically more demanding than its left-sided counterpart. This belief is supposed to be attributable mainly to different anatomic characteristics of the adrenal veins. Whether this opinion is also correct for laparoscopic adrenalectomy remains elusive.

Aim

To compare the outcomes of left versus right laparoscopic adrenalectomy from an anterior approach.

Material and methods

Retrospective statistical analysis of a prospectively compiled database of consecutive patients undergoing laparoscopic adrenalectomy in a single center with focus on potential differences in the left- versus right-sided procedure in terms of demographic parameters, tumor size, operating time, occurrence of serious intraoperative complications, conversion, length of hospital stay and re-operation rate.

Results

One hundred seventy-six patients underwent elective laparoscopic adrenalectomy – 80 left-sided (45.45%) and 96 right-sided (54.55%). No significant difference was found between the groups in terms of age (54.09 ±11.2 vs. 56.27 ±11.6; p = 0.2), tumor size (3.39 ±1.86 vs. 3.26 ±1.66; p = 0.64), operating time (71.84 ±22.33 vs. 72.06 ±30.99; p = 0.95), occurrence of serious intraoperative complications (7.5% vs. 10.4%; p = 0.5), conversion (1.25% vs. 1.04%; p = 0.9), length of hospital stay (4.52 ±1.30 vs. 4.37 ±1.91; p = 0.55) or reoperation rate (5% vs. 1%; p = 0.11). There was no mortality.

Conclusions

No significant difference was found between the left and right laparoscopic adrenalectomy in terms of operating time, occurrence of serious intraoperative complications, conversion rate or postoperative outcome. Therefore, the opinion that the right-sided procedure is more difficult does not seem to be justified for laparoscopic adrenalectomy from the anterior approach.

[Development and evolution of laparoscopic adrenalectomy in an specialized team: from the beginning to the outpatient setting]

BACKGROUND

After the first reports in 1992, laparoscopic adrenalectomy (LA) has evolved technically until becoming the standard approach for the treatment of most of the adrenal gland diseases.

MATERIAL AND METHODS

Retrospective and descriptive study of 67 patients who underwent 68 LA between January-1998 and December-2008 in the Laparoscopic Surgery Unit of the General and Digestive Surgery Service in a third level hospital (only one case of bilateral LA). The group was divided in 2 periods, P-1 (1998-2003, 22 cases) and P-2 (2004-2008, 45 cases), which have been compared to evaluate the evolution of the LA technique.

RESULTS

Indications for LA were: 19 incidentalomas, 19 primary hyperaldosteronism, 18 pheocromocitoms, 5 cases of symptomatic and non-functioning adrenal masses, 4 Cushing adenomas and 2 metastases. There was no mortality, only 4 patients had minor complications (6%) and conversion rate was only 3% (2 cases). Mean size of adrenal glands resected was 3.83 cm and the mean operative time was 86 minutes. Mean postoperative hospital stay was 3 days and in P-2 seventeen patients were discharged on an outpatient basis (hospital stay less than 23 hours).

CONCLUSIONS

In our experience, LA for the treatment of adrenal diseases has shown to be safe, effective and reproducible with low complications and excellent tolerance by patients. When the learning curve is overcome, hospital stay and operative time clearly decrease. As a consequence, LA can be planned in selected cases as outpatient surgery with good results.

Laparoscopic adrenalectomy: 100 resections with clinical long-term follow-up

BACKGROUND

The operative results of 100 laparoscopic adrenal resections in 94 patients and the subsequent impact on postoperative antihypertensive therapy are presented.

METHODS

Clinical and follow-up data for resections performed between 1995 and 2003 were obtained from medical records, patient questionnaires, and telephone interviews.

RESULTS

The diseases included Conn's syndrome (27 patients), Cushing's syndrome (30 patients), pheochromocytoma (11 patients), and Other tumors (26 patients). Antihypertensive therapy was eliminated or reduced for Conn's syndrome (75%), Cushing's syndrome (27%), pheochromocytoma (88%) and patients with Other tumors (54%). Clinical improvement was observed by 12 months for pheochromocytoma patients as compared with 35 to 45 months for the other groups (p < 0.05). Multivariate analysis showed that pheochromocytoma patients were more likely to experience improvement or cure than the Other tumor group (hazard ratio, 4.87; 95% confidence interval, 1.61-14.7).

CONCLUSIONS

Laparoscopic adrenalectomy continues to be safe and efficacious for benign adrenal diseases. Although patients with functional tumors can expect improvement or cure, the time until improvement may be longer than previously recognized.

Transperitoneale oder retroperitoneale Adrenalektomie

INTRODUCTION

The aim of this prospective study was to evaluate the optimal surgical approach to endoscopic adrenalectomy.

PATIENTS AND METHODS

Between March 1997 and February 2003, we performed 221 endoscopic adrenalectomies in 202 patients (right side 83, left side 100, bilateral 19), with an conversion rate of 2,5%. In 197 patients endoscopic adrenalectomy was carried out via retropertioneal approach 128 times and via transperitoneal approach 88 times.

RESULTS

Endoscopic adrenalectomy was performed in 98% of the total number patients. No statistically significant influence ( P=0.05) was found for the parameters intraoperative blood loss, rate of postoperative complications, or duration of hospitalization in regard to the procedure. The operative time and learning curve were significantly longer with the retroperitoneal approach. Multivariate analysis identified surgical approach, tumor size (5 cm), and body mass index (25) as independent factors for operative time.

CONCLUSION

The lateral transperitoneal approach is the optimal procedure for endoscopic adrenalectomy.

The clinically inapparent adrenal mass: update in diagnosis and management

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

Primary Hyperaldosteronism in the Era of Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy has been recommended as the standard method for removing an aldosteronoma. To assess our surgical experience with primary hyperaldosteronism in the era of laparoscopic adrenalectomy a 6-year retrospective review of 30 consecutive patients was done. The 20 men and 10 women ranged in age from 35 to 78 with a mean of 51.2 years. All patients were hypertensive and hypokalemic with a mean serum potassium of 2.9 ± 0.32 (standard deviation) mmol/L. Serum aldosterone was elevated in 28 of 30 (94%) patients and normal in the remaining two. Serum renin was suppressed in all patients. CT correctly localized the tumor in all 30 patients. Twenty-eight patients had histologically documented adenomas and two had associated cortical hyperplasia on pathology. Mean adenoma size was 2.0 ± 1.12 cm. Twenty-four patients underwent left laparoscopic adrenalectomies, whereas right laparoscopic adrenalectomies were performed in five. One was converted to an open left adrenalectomy. Mean operative time was 183 minutes. The mean hospital stay for laparoscopic adrenalectomy was 2.2 days.

The patients were followed from one to 63 months (mean 26.1 months). Twenty-nine of 30 (95%) patients were rendered normokalemic. The remaining patient takes a potassium-wasting diuretic. Persistent hypertension was present in 10 of 30 (33%) patients. Blood pressure in nine of 10 patients was controlled with less medical therapy. The other patient's blood pressure remained difficult to control despite multiple medications. Duration of hypertension before surgery was a significant risk factor for persistent hypertension ( P < 0.05). Gender ( P < 0.05) and age ( P < 0.05) at the time of surgery were not statistically significant predicators for persistent hypertension. There were two reported trocar site hernias. We conclude that primary hyperaldosteronism due to aldosterone-producing tumors can be diagnosed and accurately localized with preoperative measurements of serum aldosterone, renin, and CT scanning. Laparoscopic adrenalectomy is safe and effective for the treatment of primary hyperaldosteronism with minimal associated morbidity and a short hospital stay. Hypokalemia may be cured by surgical treatment, although persistent hypertension still occurs. Duration of hypertension before surgery is a risk factor for persistent hypertension whereas age and sex are not.

Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy is now regarded as the procedure of choice for treatment of small or benign adrenal tumors, including pheochromocytoma. However, long-term outcomes have not been critically assessed. We report here 3 cases of pheochromocytomatosis recurring 3 to 4 years after laparoscopic adrenalectomy. We postulate laparoscopic-induced seeding of tumor as the mechanism of recurrence.

METHODS

We retrospectively reviewed the cases of 3 patients with documented biochemical and radiolabeled metaiodobenzylguanidine evidence of recurrent pheochromocytoma after prior presumed curative laparoscopic adrenalectomy.

RESULTS

Original pheochromocytomas were 5.5 to 6.5 cm in diameter. At the time of laparoscopic adrenalectomy, tumors were not believed to be malignant, based on clinical or histopathologic data. However, on 3- to 4-year follow-up, each patient developed symptoms, elevated urinary catecholamine levels, and metaiodobenzylguanidine imaging consistent with recurrence. At reoperation, multiple small tumor nodules were found in the adrenal bed near the site of the initial laparoscopic resection. The original operative notes suggested some possible method of local seeding: tumor fragmentation and spillage or excessive tumor manipulation.

CONCLUSIONS

Pheochromocytoma recurrence may occur as a result of local spillage of tumor during laparoscopic adrenalectomy. The relative risk of recurrence between open and laparoscopic resection needs to be assessed. Long-term follow-up will continue to be important, regardless of operative approach.

Adrenal masses in neoplastic patients: the role of laparoscopic procedure

BACKGROUND

The incidence of complications resulting from fine-needle biopsy of adrenal masses in patients already treated by radical procedures for primitive neoplasms of the lungs and kidneys substantiates our opinion concerning laparoscopy as both a diagnostic and therapeutic procedure.

METHODS

We performed 70 laparoscopic adrenalectomies from April 1995 to December 1999. In five patients, the adrenal mass appeared at follow-up evaluation in patients submitted to surgery for a spinocellular lung cancer. One patient underwent surgery for renal adenocarcinoma. In two patients, the adrenal mass was present already at the time primitive lung tumor was diagnosed, so adrenalectomy was performed at the first lung surgery in one patient and 2 weeks before lung surgery in the other patient. All the patients were placed in a lateral position for a transperitoneal approach. Right adrenal masses were present in seven patients, whereas one patient had an adrenal mass in a left location.

RESULTS

No laparotomy was required. The average surgical time was 160 min. (range, 115-120 min). No morbility or mortality occurred, and the average hospital stay was 4 days (range, 3-11 days). All the patients had a complete removal of their masses, which averaged 4.5 cm (range, 2.5-6 cm) in size. Histology confirmed the metastatic origin of the mass in five of seven patients with primary lung cancer, and in one patient with previous kidney cancer. At this writing, three patients were disease free and still alive respectively at 3, 5, and 18 months. Three patients died of brain metastases respectively at 16, 36, and 36 months. An adenoma was proved in the other two cases.

CONCLUSIONS

Laparoscopic adrenalectomy allows us to propose a much more aggressive approach to adrenal masses demonstrated at follow-up evaluation or in patients with primary lung or kidney cancer and no masses at other locations. Nevertheless a much larger study is required for definitive conclusions on a survival rate. We believe that a mini-invasive procedure such as laparoscopy may allow us to replace a rational surgical approach with a more certain pathologic diagnosis.