Prospective comparison of early and late experience with laparoscopic adrenalectomy

North Pacific Surgical Association Presidential Address 2017- From Cayman to Vancouver: One surgeon's journey

This is the Presidential Address at the 104th Annual Meeting of the North Pacific Surgical Association held in Vancouver, BC, Canada, November 10-11, 2017.

Comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy in a prospective randomized study

PURPOSE

This article reports a prospective, randomized comparison of transperitoneal laparoscopic adrenalectomy (TLA) versus retroperitoneal laparoscopic adrenalectomy (RLA) for adrenal lesions with medium-term follow-up.

SUBJECTS AND METHODS

Between September 2008 and November 2011, 24 patients with surgical adrenal diseases were prospectively randomized to undergo TLA (Group 1, 11 patients) or RLA (Group 2, 13 patients). Study exclusion criteria were patients with a body mass index of >40 kg/m(2), significant prior abdominal surgery, and bilateral adrenalectomy. Mean follow-up was 9 months in both groups.

RESULTS

The groups were matched in regard to patients' age (P=.80), sex (P=.72), body mass index (P=.62), and laterality (P=.72). Median adrenal mass size was 2.92 cm (range, 2-5 cm) in the TLA group and 2.63 cm (range, 2-5 cm) in the RLA group (P=.55). TLA was comparable to RLA in terms of operative time (P=.22), estimated blood loss (P=.83), time to ambulation (P=.21), hospital stay (P=.25), analgesic requirement (P=.40), and postoperative pain (P=.40), whereas time to oral intake resumption (P=.001) and convalescence period (P=.002) were significantly shorter in the RLA group. One case from the RLA group was electively converted to open surgery. During a mean follow-up of 9 months, there were no late complications, and no deaths occurred in any group.

CONCLUSIONS

Laparoscopic adrenalectomy is a viable treatment option for removal of benign adrenal lesions that can be performed safely and effectively by either the transperitoneal or retroperitoneal approach. All operative parameters are similar in the two approaches, except that the convalescence period and time to oral intake resumptions that are significantly shorter with retroperitoneal surgery.

Laparoscopic adrenalectomy by the lateral transperitoneal approach in patients with a history of previous abdominal surgery

Introduction

Even the half of patients undergoing laparoscopic adrenalectomy has history of previous abdominal surgeries. However, it is still uncertain if this fact has an impact on the operation itself as well as the postoperative course.

Aim

To analyze the effects of previous abdominal surgery on surgical outcomes in adrenal tumor patients subjected to laparoscopic adrenalectomy.

Material and methods

This study included 268 patients with adrenal gland tumors operated on by means of laparoscopic lateral transperitoneal adrenalectomy: 1) previously subjected to at least one abdominal surgery (group A, n = 101), or 2) with no history of previous abdominal operations (group B, n = 167).

Results

Groups A and B did not differ in terms of tumor size (p = 0.132), mean operation time (p = 0.456), mean intraoperative blood loss (p = 0.754), or perioperative complication rate (p = 0.833). Dissection of intraperitoneal adhesions was considered difficult in 32 patients from group A (31.6%) and 8 subjects from group B (4.7%, p < 0.001). Conversion was required in three subjects from group A (2.9%) and 3 patients from group B (1.8%, p = 0.529).

Conclusions

Previous abdominal surgery does not constitute a contraindication to laparoscopic transperitoneal adrenalectomy.

Laparoscopic adrenalectomy - ten-year experience

Objectives

The objective of the study is to summarize the authors’ 10-year experience with laparoscopic adrenalectomy and to analyze the intra- and postoperative complications of the procedure.

Material and methods

The records of 80 patients who had undergone laparoscopic adrenalectomy from January 2002 to January 2012 were reviewed retrospectively. There were 51 female and 29 male patients. The average age was 52. In 33 cases the right adrenal gland was affected, in 47 it was the left adrenal gland. Nineteen operations were performed with the retroperitoneal approach, in 61 a transperitoneal access was used. The average size of the tumor was 5 cm. The diagnosis was based on ultrasonography (USG) and computed tomography (CT). The biochemical tests were performed in all cases to assess hormonal activity of the tumor. Pheochromocytoma was diagnosed in 16 cases, Cushing syndrome in 3 cases, and Conn syndrome in 4 cases. All other tumors were hormonally inactive. Six patients were operated on because of adrenal metastases – from renal carcinoma in five cases and from lung carcinoma in one case.

Results

There were three open conversions. The mean operative time was 158 minutes. The mean hospital stay was 5.5 days Blood transfusion was necessary in three patients. Postoperative complications were observed in 11 patients (13.7%).

Conclusions

Laparoscopic adrenalectomy is a safe and effective procedure and should be considered the first – line treatment of benign adrenal masses. Our experience indicates that patients with adrenal metastases are suitable candidates for laparoscopic adrenalectomy, providing a skilled laparoscopic surgeon is involved in operation.

Secondary arterial hypertension: improvements in diagnosis and management in the last 10 years

The diagnosis and management of secondary hypertension has improved in the last decade as a result of the advances in the acknowledgment of some physiopathologic mechanisms and mainly by the development of new diagnostic methods. Furthermore, the treatment of some types of secondary hypertension may be solved by noninvasive techniques. Hypertension of renal and renovascular origin, coarctation of the aorta, primary hyperaldosteronism, and adrenal medullary tumors are analyzed. The main results of some relevant studies on diagnostic and treatment of those diseases are presented. Also, some experimental methods are mentioned, taking into account the possibility of clinical use in the near future.

Has experience changed the scenario in laparoscopic adrenalectomy?

BACKGROUND

Laparoscopic adrenalectomy (LA) is a relatively uncommon operation performed by surgeons with a specific interest in endocrine surgery as well as advanced laparoscopic surgery. LA is technically difficult and it is recommended to tackle small glands first till adequate experience is reached [1]. A minimum of 30 cases are required to master the technique [2]. The present study reviews data of 60 laparoscopic adrenalectomies comparing the later results with the first 30 cases.

MATERIAL AND METHODS

Starting 2001, patients diagnosed to have adrenal disorders were subjected to laparoscopic approach in a graded manner. A database was maintained with respect to age, sex, duration of symptoms, co-morbid conditions, diagnosis, size of tumor, weight of tumor, blood loss, duration of surgery, conversion to open, in-hospital stay, referral pattern, morbidity (both early and late) and mortality. The database was divided into two groups. First 30 patients constituted Group A, Group B constituted the next 30 adrenalectomies and deviation in the two was noted. Statistical analysis was performed to determine the importance of deviation of factors.

RESULTS

Sixty adrenalectomies were performed in 49 patients (11 being bilateral) between February 2001 and July 2008. Age group varied from 12-54 years with mean of 30.73 years, Twenty four were males. Thirty-one right and 29 left LA were performed. The comparison of factors in relation to the two groups (Group A and B respectively) revealed an increase in number of adrenalectomies performed (0.4 v/s 0.76) in relation to timeline, increased incidence of pheochromocytoma (6 v/s 18) and incidentalomas (zero v/s 8), larger tumor size (4.17 cm v/s 6.6 cm), comparable blood loss (72 cc v/s 98.3 cc) and duration of surgery (122 min v/s 112 min), increased conversion to open surgery (1 v/s 6) leading to increased in-hospital stay (2.8 days v/s 3.37 days) but a comparable morbidity (2 v/s 1) and no mortality.

CONCLUSION

Though technically difficult, with increasing experience and focused approach, laparoscopic skills in adrenalectomy improves. The spectrum of indications broadens, thus making laparoscopic interventions for vascular and large adrenal glands safe and patient friendly.

Laparoscopic adrenalectomy after prior abdominal surgery

BACKGROUND

Compared with the open procedure, laparoscopic adrenalectomy (LA) is associated with decreased operative time, perioperative complications, and hospital stay. Some regard prior abdominal surgery as a contraindication to LA or suggest a retroperitoneoscopic approach. We studied the effect of prior abdominal surgery on the feasibility and safety of transabdominal LA.

METHODS

We retrospectively analyzed 246 consecutive LAs performed at four academic centers from 2002 to 2006. Cases were grouped according to prior abdominal surgery (PAS) (n=92, 37%) or no prior surgery (NPS) (n=154, 63%). Statistical power was greater than 0.90 to detect the following differences in endpoints: conversion 2%, operating time 22%, and complications 2%.

RESULTS

Mean tumor size was 3.3 cm, 8.1% of tumors were larger than 7 cm, and 20% were pheochromocytomas. Prior operations were upper abdominal (37%), lower abdominal (48%), or laparoscopic (15%). There were nine conversions (3.7%), one in the PAS group and eight in the NPS group (p=0.14), with conversions related to large tumor size and pheochromocytoma (both p<0.01). Operating time was 158+/-59 min across groups. The subgroup with prior upper abdominal surgery had nonsignificantly longer operating times compared with the NPS group (183 vs. 165 min, p=0.16). Operative blood loss was 67+/-84 ml and the perioperative complication rate was 12.2%, with no differences between groups.

CONCLUSION

Prior abdominal surgery does not impede transabdominal LA. More than one-third of patients requiring adrenalectomy will have had prior abdominal surgery, and these patients should not be denied the benefits of a laparoscopic procedure.

Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases

OBJECTIVE

To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5cm.

METHODS

Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods.

RESULTS

All 112 operations were completed without any mortality or reoperation. Mean operative time was 151min and mean blood loss was 30ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147+/-5.1min, mean+/-standard error of mean) was significantly shorter than that of the initial 12 cases (183+/-8.8min, p=0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushing's adenomas, 12 pheochromocytomas, and 20 incidentalomas).

CONCLUSION

The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.

Outcomes of laparoscopic adrenalectomy. Clinical experience with 68 patients

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.