Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases

Comparison of Laparoendoscopic Single-Site Adrenalectomy with the Aid of Intracavitary Retractors and Multiport Laparoendoscopic Adrenalectomy

Objective: To evaluate the operative outcome of the use of intracavitary retractors in transumbilical laparoendoscopic single-site (LESS) adrenalectomy in comparison with the conventional multiport laparoendoscopic procedure. Methods: Between July 2021 and December 2023, 34 patients underwent transumbilical LESS adrenalectomy with intracavitary retractors, while 47 patients underwent conventional multiport laparoscopic adrenalectomy. Comprehensive data were compared, including demographics, intraoperative outcomes, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence. Results: Baseline characteristics were similar between the groups. All procedures were successfully completed without additional access or open conversion. The mean operative time and estimated blood loss for LESS adrenalectomy were comparable with multiport adrenalectomy. The LESS group had significantly shorter incision length (3.07 cm versus 5.16 cm, P < .01), lower postoperative pain scores (3.29 versus 4.91, P < .01), less analgesic drug use (29% versus 53%, P = .03), and better cosmetic scores (9.29 versus 7.28, P < .01). No significant differences were observed in time to resume oral intake, time to ambulation, or postoperative hospital stay. Complication rates were similar between the groups. Conclusion: The utilization of intracavitary retractors in transumbilical LESS adrenalectomy has demonstrated feasibility, effectiveness, and the potential to reduce technical complexities with satisfactory cosmetic effects. This technique enhances visualization of the surgical field without the need for extra ports.

Single-Plane Retroperitoneoscopic Adrenalectomy Guided by Indocyanine Green Dye: An Optimized Step

Background: The objective of this study was to explore the perioperative outcomes of single-plane posterior retroperitoneoscopic adrenalectomy (SPRA) guided by indocyanine green dye (ICG) fluorescence imaging. Methods: A retrospective analysis of patients who underwent SPRA from April to September 2023 in our center was conducted. Patients were divided into the ICG group and the non-ICG group, based on whether they received intraoperative ICG fluorescence guided or not. Baseline and perioperative data were recorded and analyzed by R software (R 4.3.1). Results: A total of 23 patients were enrolled in the study, with 12 in the ICG group and 11 in the non-ICG group. The demographics including age, gender, body mass index, or American Society of Anesthesiologists classification showed no significant differences between groups. There were obvious advantages in shortening adrenal gland localization time and total operative time, as well as reducing estimated blood loss in the ICG group compared with the non-ICG group (5.58 ± 0.36 minutes vs 7.55 ± 0.62 minutes, p < 0.001; 27.50 ± 5.46 minutes vs 45.00 ± 10.99 minutes, p < 0.001; 22.91 ± 7.57 mL vs 54.54 ± 18.90 mL, p < 0.001; respectively). Furthermore, patients in the ICG group exhibited significantly lower visual analog pain scale scores at 24 hours postoperatively and at discharge (p = 0.001 and p = 0.006, respectively). The oral intake intervals, hospital stays, and perioperative complications were comparable between groups. Conclusions: ICG-guided SPRA could be a safe and effective procedure for patients with adrenal tumors. This technique improves the accuracy and efficacy of adrenal gland localization and has shown benefits in perioperative outcomes. The use of ICG fluorescence guidance represents a promising clinical application.

Modified versus three-level technique of retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm: a retrospective, case-controlled study

Objectives

The modified three-level technique for retroperitoneal laparoscopic adrenalectomy (RLA) has proven beneficial in the treatment of adrenal lesions in patients with BMI≥25 Kg/m2. This paper aims to summarize our institution's seven-year experience using this technique for all patients with Adrenal Lesions ≤ 6cm.

Patients and methods

Between January 2016 and December 2022. The patients underwent laparoscopic adrenal surgery were categorized into Zhang's technique (ZT) (Three-level Technique) group and modified technique (MT) group. The fundamental characteristics and perioperative data were analyzed, with statistical significance set at p<0.05.

Results

In total, 731 patients were stratified into two groups: ZT (n=448) and MT (n=283). Statistically significant distinctions were not detected between the two groups regarding sex, BMI, tumor location, tumor size, tumor type, or American Society of Anesthesiologists (ASA) score (p>0.05). The MT group demonstrated superior outcomes compared to the ZT group in terms of operative time, estimated blood loss, drainage volume, diet recovery time, complication rates, and postoperative hospitalization duration (p<0.05). 17 (4.34%) in the ZT group required unplanned adrenalectomy, while there was none in MT group (P<0.05).

Conclusion

MT retroperitoneal laparoscopic adrenalectomy has demonstrated its benefits in the treatment of adrenal lesions across all patients with adrenal lesions ≤ 6cm, serving as a valuable point of reference for the surgical management of adrenal diseases.

Patient summary

We have made modifications to the classic retroperitoneal laparoscopic adrenalectomy and achieved superior surgical outcomes, resulting in a procedure known as modified retroperitoneal laparoscopic adrenalectomy. This technique is suitable for both obese individuals and the general population with adrenal lesions ≤ 6cm.

[Surgical treatment of pheochromocytoma]

This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.

Laparoscopic Adrenalectomy: Tailoring Approaches for the Optimal Resection of Adrenal Tumors

In this study, we investigated the outcomes of laparoscopic approaches for adrenal tumor resection in 67 patients from a single center with a median age of 51 (range 40-79). Predominantly comprising women, the majority of patients were overweight or obese. Adrenal tumors larger than 6 cm were mostly treated using the laparoscopic transperitoneal method (p < 0.001). Our results revealed that patients subjected to the retroperitoneal approach exhibited quicker recovery, as evidenced by faster resumption of oral intake and ambulation, along with reduced intraoperative blood loss and shorter hospitalization (p-value < 0.05). In contrast, patients subjected to the transperitoneal approach experienced minimal complications, though not statistically significant, despite the technique's intricacy and slower recovery. These findings emphasize the significance of tailoring the surgical approach to individual patient characteristics, with particular emphasis on the tumor size. The choice between the retroperitoneal and transperitoneal methods should be informed by patient-specific attributes to optimize surgical outcomes. This study underscores the need for a comprehensive evaluation of factors such as tumor characteristics and postoperative recovery when determining the most suitable laparoscopic approach for adrenal tumor resection. Ultimately, the pursuit of individualized treatment strategies will contribute to improved patient outcomes in adrenal tumor surgery.

It is easy and effective to locate adrenal gland during retroperitoneal laparoscopic left adrenalectomy by the landmark of left PFSV

To evaluate the feasibility and clinical significance of the left perinephric fat sac vein (PFSV) as an anatomical landmark in locating left adrenal gland (LAD) during retroperitoneal laparoscopic left adrenalectomy (RLLA). In this study, a total of 36 patients who underwent RLLA were enrolled from February 2019 and March 2021. By following a vein vessel on the internal surface of perinephric fat sac (PFS), known as PFSV, LAD was searched finally along the upper edge of this vein. The demographic and clinical characteristics of these patients were acquired, including tumor features and perioperative outcomes (operating time, estimated blood loss, complications). The operations were successfully completed in all the 36 patients without conversion to open surgery. In addition, the LAD was successfully found along the upper edge of PFSV in 34 patients. For all operations, the mean operative time was 75 min (range 60-95) and the estimated blood loss was 20 ml (range 10-50). The median oral intake was 20.7 h (range 6-39). The median hospital stay was 6.3 days (range 4-9), and the median follow-up was 12.3 months (range 9-17). Moreover, no intraoperative complications were observed and no residual tumors were detected after 9 to 15 months follow-up. It may be a safe and efficient procedure to use PFSV as a landmark for searching LAD during RLLA, especially for beginners. However, more studies with larger sample size are need to be conducted to further evaluate the outcomes of this method and the significance of PFSV in searching LAD during RLLA.

Comparison of lateral transperitoneal versus retroperitoneal laparoscopic adrenalectomy for pheochromocytoma: a single-centre retrospective study

Laparoscopic adrenalectomy (LA) has became the standardized treatment for pheochromocytoma. The aim of this study was to evaluate outcomes of lateral transperitoneal and retroperitoneal LA for pheochromocytoma. Between January 2011 and December 2021, 142 patients with pheochromocytoma underwent LA via lateral transperitoneal (123 patients) or retroperitoneal (19 patients) approaches. Data of these patients were assessed to investigate the differences in perioperative outcomes and intraoperative haemodynamic parameters between the two procedures. Clinical parameters at presentation were comparable between the two groups, except for tumour size, which was larger in the transperitoneal group (50 [10-115] mm vs 35 [7-110] mm, P = 0.012). There were no significant differences between the two groups in terms of operation time, estimated blood loss, intraoperative transfusion rate, incidence of complications, conversion to open surgery, postoperative analgesic requirement, time to first oral intake, or mean hospital stay. Intraoperative haemodynamic parameters of the two groups were similar. After adjusting for tumour size using propensity score matching, both perioperative outcomes and haemodynamic parameters were still comparable. Lateral transperitoneal and retroperitoneal laparoscopic adrenalectomies provide similar perioperative and haemodynamic outcomes for surgical resection of pheochromocytoma.

Mayo adhesive probability score is associated with perioperative outcomes in retroperitoneal laparoscopic adrenalectomy

BACKGROUNDS

This study aimed to determine whether the Mayo adhesive probability score (MAP), which evaluated adherent perinephric fat (APF), is useful in evaluating the difficulty of retroperitoneal laparoscopic adrenalectomy (RLA), and to analyse the correlation between MAP and perioperative parameters.

METHODS

Clinical data of 104 patients with adrenal adenoma who underwent RLA were collected for retrospective analysis. According to the CT images obtained before surgery, patients were divided into two groups: High MAP group (2-5 points) and Low MAP group (0-1 points). Comparison of the general clinical characteristics and the perioperative data between the two groups was made.

RESULTS

There were more male patients (73.7% versus 34.3%), more patients with a smoking history (24.3% versus 7.5%), higher BMI (25.7 versus 23.2, kg/m² ), and bigger (23.8 versus 18.5, mm) neoplasm in the high MAP group (P < 0.05). Significant difference was observed in operative time (128.8 versus 102.3, min), estimated blood loss (47.2 versus 25.2, ml) and drainage tube removal time (4.0 versus 3.2, d) between the two groups (P < 0.05). A high MAP score (P < 0.001) and the size of tumour (P = 0.024) were independent risk factors for extended operative time. A higher BMI (OR = 1.525, P < 0.001) and larger tumour size (OR = 2.862, P = 0.004) were independent risk factors for a high MAP score.

CONCLUSIONS

MAP score was associated with the perioperative outcomes of RLA. BMI and tumour size were better indicators of MAP score, which can influence the difficulty of RLA.

The Adhesive Perinephric Fat Score is Correlated with Outcomes of Retroperitoneal Laparoscopic Adrenalectomy for Benign Diseases

Background

Retroperitoneal laparoscopic adrenalectomy (RLA) possessing unique superiority with minimal abdominal interference is complicated by the status of periadrenal fat, including its quantity and texture. We hypothesized that an adherent perinephric fat predictor, the Mayo Adhesive Probability score (Mayo score), is associated with the perioperative outcomes of RLA.

Methods

This retrospective study included consecutive patients who underwent RLA for the diagnosis of benign adrenal tumors at our institution between 2017 and 2020. Medical records were reviewed to evaluate the association between Mayo scores obtained from preoperative computed tomography imaging and surgical outcomes as well as complications. Factors independently related to perioperative results were analyzed using multivariable regression models.

Results

In total, 186 RLA were included. According to their Mayo scores, the patients were divided as follows: 0 (n = 51, 27.4%), 1 (n = 34, 18.3%), 2 (n = 45, 24.2%), 3 (n = 29, 15.6%), 4 (n = 16, 8.6%) and 5 (n = 11, 5.9%). Longer operative time (92.0 ± 25.0 vs. 114.7 ± 30.6 vs. 137.4 ± 27.1 min, P < 0.001), higher estimated blood loss (42.2 ± 28.1 vs. 70.5 ± 44.9 vs. 132.6 ± 63.4 mL, P < 0.001) and greater decline of hemoglobin (0.7 ± 0.4 vs. 1.0 ± 0.4 vs. 1.3 ± 0.6 g/dL, P < 0.001) were significantly associated with elevated Mayo score risks. No difference in complication rates was found. The score was identified as a unique, independent risk factor for perioperative outcomes on multivariable analysis.

Conclusions

The Mayo score is a vital outcome predictor of RLA. It may be utilized in the preoperative planning for patients undergoing RLA.

Experience in identifying the variant adrenal venous anatomy during modified retroperitoneoscopic adrenalectomy

Background:

Adrenal vein plays an important role in performing laparoscopic adrenalectomy successfully. However, it often presents with a multitude of venous anatomical variants. Hence, having a thorough knowledge on the variant types is crucial to reduce operative complications. This study aims to present our experience in identifying adrenal vein variation in adrenalectomy through modified retroperitoneal approach.

Patients and Methods:

A total of 187 patients underwent modified retroperitoneoscopic adrenalectomy between July 2017 and February 2019. Perioperative data and adrenal vein variants were recorded and analysed.

Results:

Variant adrenal veins were encountered in seven patients. On the right side, two cases were drained by two adrenal veins; one case had a common trunk of adrenal vein and an accessory hepatic vein and one case had an adrenal vein joined with the opening of the right renal vein. On the left side, two cases of anatomic variations were described as follows: one vein converged with the left inferior phrenic vein and joined with the left renal vein, whereas the other vein directly joined with the left renal vein. One case had two adrenal veins that joined with the left renal vein.

Conclusions:

Accurate identification and proper handling of the anatomical variation in the drainage of adrenal vein are crucial to safe LA. It is helpful to anticipate and avoid bleeding, especially in large adrenal tumours.

Retroperitoneoscopic renal and adrenal specimen resection surgery in children

Introduction

The most common indication for retroperitoneoscopy in children is poorly functioning kidney, related to reflux or obstruction. Few pediatric urologists attempt to conduct a mass resection operation under retroperitoneoscopy, especially in infants with oncological diseases.

Aim

In this study, we describe our experience in a series of resection operations under retroperitoneoscopy to demonstrate its safety and efficacy in children, especially in the treatment of pediatric urology tumor.

Material and methods

A retrospective review of 18 consecutive retroperitoneoscopic resection operations from December 2017 to July 2019 was made. Then a comparison study between retroperitoneoscopy and transperitoneal laparoscopy for exclusively oncological patients was conducted.

Results

Retroperitoneoscopic surgery was successfully performed on 18 patients, 11 having solid tumors, 2 with cysts, and 5 with nonfunctioning or poorly functioning kidneys. The mean age was 69.5 ±46.9 months. The mean operative time was 138.6 ±57.7 min, while the mean size of the mass was 6.4 ±3.8 cm in the largest diameter. Two patients were converted to open surgery because of large diameter of the mass. The 11 solid tumors which were operated on by retroperitoneoscopic surgery were then compared with 13 consecutive oncological patients undergoing transperitoneal laparoscopy. Retroperitoneoscopy has a lower transfusion rate (p < 0.05) and faster recovery (p < 0.01) compared to transperitoneal laparoscopy.

Conclusions

This study demonstrates that the resection operation of a renal or adrenal specimen under retroperitoneoscopy is feasible and safe in children. It is useful not only to treat patients with benign diseases but also in oncological patients. Retroperitoneoscopy is a recommended surgical approach for children.

Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges

Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intra-operative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2-60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: [Table: see text] There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes.

Experience in the application of laparoscopic anatomical adrenalectomy via the renal cortex surface monolayer

Objective:

To discuss the clinical application of laparoscopic anatomical adrenalectomy via the renal cortex surface in the operation of adrenal masses.

Methods:

A retrospective analysis was performed on 231 patients with adrenal masses who were received and cured in the urology department of the Affiliated Hospital of Hebei University from July 2016 to January 2019. All patients received retroperitoneal adrenalectomy by means of laparoscopic anatomical adrenalectomy via the renal cortex surface. Operation duration, bleeding volume, postoperative complications, retention time of the drainage tube were measured and analyzed, and postoperative follow-up surveys were administered.

Results:

All cases were successfully operated. Two cases were converted to open surgery due to the presence of large adrenal tumors, and the patients suffered no significant complications. The mean operation duration, bleeding volume and retention time of the drainage tube were 31 minutes, 20 mL and 1.2±0.6 d, respectively. In terms of the postoperative pathology of adrenal tumors, 183 cases were shown to have adenomas, 34 had pheochromocytomas, nine had schwannomas, 3 had metastases from lung cancer, and two had sarcomas. A total of 174 patients were followed up for three to 18 months. Only one case with sarcoma that relapsed within half a year of the operation.

Conclusion:

In the treatment of adrenal masses, laparoscopic anatomical adrenalectomy via the renal cortex surface has many advantages including the large operation space, clear view of anatomical markers, little bleeding, small trauma, few postoperative complications, simple operational procedures and short learning curves. This technique needs clinical promotion.

Comparison of surgical outcomes between lateral and posterior approaches for retroperitoneal laparoscopic adrenalectomy: A single surgeon's experience

Purpose

To compare surgical outcomes between the lateral and the posterior approach for retroperitoneal laparoscopic adrenalectomy (RLA).

Materials and Methods

We retrospectively reviewed the records of 130 patients who underwent RLA for adrenal tumors by a single surgeon between January 2015 and December 2018. Patient characteristics and perioperative outcomes were analyzed and compared between two surgical groups: lateral approach (n=56) and posterior approach (n=74).

Results

There were no significant differences in perioperative outcomes between the two groups except for operative time (lateral approach, 105.4±41.21 minutes vs. posterior approach, 71.5±31.51 minutes; p=0.001). In the lateral approach group, two patients (3.6%) underwent open conversion, but there were no major complications in either group (Clavien-Dindo classification ≥3). Male sex was associated with an operative time of ≥90 minutes in the univariate analysis (p=0.019), but this effect did not remain significant in the multivariate analysis. In the multivariate analysis, large tumor size (>5 cm; p=0.020) and preoperative diagnosis of malignancy (p=0.043) were significantly associated with an operative time of ≥90 minutes.

Conclusions

Both the lateral and posterior approaches for RLA were performed safely with similar operative outcomes and are therefore comparable options for the treatment of adrenal tumors. In addition, large tumor size and preoperative diagnosis of malignancy are associated with longer operative times.

Lateral retroperitoneoscopic adrenalectomy: advantages and drawbacks

Lateral retroperitoneoscopic adrenalectomy (LRA) is performed mostly by urologists. It is gaining popularity among general surgeons because of the direct access to the adrenal gland. However, the management of large tumors remains controversial. We report our experience and discuss the advantages and the drawbacks of this approach. Between December 2011 and April 2015, 89 consecutive patients underwent LRA for adrenal tumors. Conversion to open surgery, operative time, blood loss, hospital stay, intra-operative complications, early and late postoperative complications, and mortality were analyzed. The entire group was divided into patients with large tumors (> 5 cm) and patients with small tumors (≤ 5 cm), which were further compared. The conversion rate was 1.1%. The mean operative time was 107.4 ± 27.95 min, the mean blood loss 33.15 ± 25.45 ml. The mean hospital stay was 4.7 ± 2.05 days. Most of the complications were minor. There was zero mortality. Concerning the size of the tumor, we found statistically significant difference in operative time (p = 0.001), hospital stay (p = 0.020), incidence of early postoperative complications (p = 0.049), and conversion rate to open surgery (p = 0.037). LRA is a feasible, effective and safe procedure that offers additional advantages over the standard transabdominal approach because of its direct access to the adrenal gland. However, malignancy, large tumor size, bilateral pathology, and concomitant intra-abdominal pathology may represent a potential setback for this approach.

Modified three-level techniques of retroperitoneal laparoscopic procedures to treat adrenal lesions for patients with BMI ≥ 25 Kg/m2

Objective: To evaluate the modified Zhang's 'three-level' technique of retroperitoneal laparoscopic adrenalectomy (RLA) to treat adrenal lesions for patients with BMI of 25-30 Kg/m². Methods: A retrospective analysis was performed in all patients with BMI of 25-30 Kg/m² in our hospital from January 2014 to December 2019. Those who underwent laparoscopic adrenal surgery were divided into two groups on the basis of the technique used: the Zhang's technique (the ZT group) and the modified technique (the MT group). Results: Herein, 170 operations were included (ZT, 91 patients; MT, 79 patients). RLA was successfully performed in all of them. Compared with the ZT group patients, the MT group patients showed shorter operation time (p = 0.007), lesser intraoperative blood loss (p = 0.023), shorter operation time, earlier postoperative diet recovery (p < 0.001), shorter postoperative drainage time (p < 0.001) and shorter postoperative hospitalization period (p = 0.001). It was also worth noting that the unplanned total adrenalectomy rate was significantly less in the MT group than in the ZT group (0% vs. 10.8%, p = 0.020). There was no significant difference in the complications between the two groups (3.3% vs. 2.5%, p = 0.567). Conclusions: We found that MT was a beneficial retroperitoneal laparoscopic treatment for adrenal lesions in patients who had a BMI of 25-30 Kg/m². It may provide a reference for the treatment of adrenal surgical diseases in such patients.

The safety and efficiency of retroperitoneal laparoscopic adrenalectomy via extra and intra perinephric fat approaches: a retrospective clinical study

Background

This retrospective clinical study is to evaluate the safety and efficiency of two different approaches in retroperitoneal laparoscopic adrenalectomy and provide experience and basis for the treatment of adrenal tumors through retroperitoneal approach.

Methods

From July 2015 to February 2018, 112 patients with adrenal lesions underwent retroperitoneal laparoscopic adrenalectomy (RLA) using a 3-port method. Among them, 56 patients underwent RLA via the extra perinephric fat approach (EPFA), 56 patients underwent RLA via the intra perinephric fat approach (IPFA). Clinical data, including preoperative, operative and postoperative management were recorded.

Results

All surgeries were successfully completed, and there was no single patient who died during these surgeries. There was no statistically significant difference between the two groups in blood loss, postoperative complications, vena cava injury, renal cortex injury, peripheral organ injury, and post operation hospital stay. Peritoneum injury occurred more frequently in the EPFA group when compared with the IPEA group (p = 0.042). The average surgery time of the IPEA group is significantly shorter when compared with that of the EPEA group (p < 0.001). Due to serious saponification of the perinephric fat and heavy adhesion to renal fascia, three cases in IPFA group were converted to the EPFA surgery.

Conclusion

RLA is a safe and effective procedure both via extra perinephric fat and intra perinephric fat approaches. IPEA is superior to EPEA in terms of peritoneal injury and duration. The choice may mainly depend on the experience of the surgeon, the characteristics of the adrenal tumor and the nature of the perinephric fat.

Posterior retroperitoneoscopic adrenalectomy for pediatric adrenal tumors

BACKGROUND/AIMS

Posterior retroperitoneoscoic adrenalectomy has been reported as an option for adrenal tumor resection but is not commonly performed in children owing to the extreme semikneeling position advocated to flatten the lumbar lordosis in order to achieve adequate retroperitoneal space. As children have smaller lordosis angles, flattening of the lordosis and creation of optimal retroperitoneal space may be achieved with less hip flexion. We used pediatric lumbar lordosis measurements to develop a modified prone jackknife position and report our experiences with this setup for posterior retroperitoneoscopic adrenalectomy for adrenal tumors.

METHODS

Lordosis angles were measured on sagittal computed tomography (CT) and magnetic resonance imaging (MRI) studies of patients with adrenal tumors and compared to normal references. The data were used to develop our modified prone jackknife position. Selected patients with adrenal tumors underwent posterior retroperitoneoscopic adrenalectomy in this position. Patient demographics, diagnoses, operative times, complications, postop analgesia requirements, and length of hospitalization were analyzed.

RESULTS

CT and MRI studies were analyzed for 20 patients with adrenal tumors diagnosed in our institution from 2012 to 2017; median lordosis angle was 27.84° (range: 15.50°-36.48°) - less than reference lordosis angles of respective age groups, and flexion angles of common operating tables. Five patients underwent retroperitoneoscopic adrenalectomy between June 2016 and June 2018. Histological diagnoses were neuroblastoma, adrenal hyperplasia, pheochromocytoma, and adrenal angiomatoid fibrous histiocytoma. Median age was 4 years [range: 1-11]. Median operating time was 137 min [range 111-181 min]. No conversions to open surgery were required. One patient had intraoperative bleeding from the adrenal vein. Only 1 patient required postoperative opioids for analgesia. Median length of hospitalization after surgery was 2 days (range: 2-3 days).

CONCLUSIONS

Pediatric patients can achieve flattening of lumbar lordosis with less extreme positioning. Posterior retroperitoneoscopic adrenalectomy in a modified prone jackknife position is a feasible operation for pediatric patients with small adrenal masses.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level III.

Comparison of retroperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: a single-center retrospective study

Background

It remains unclear whether retroperitoneal laparoscopic adrenalectomy (RLA) is safe and effective for the treatment of large pheochromocytoma (PHEO). This retrospective study aimed to identify the advantages and disadvantages of RLA compared to open adrenalectomy (OA).

Methods

This study included 147 patients who underwent RLA (n = 101) or OA (n = 46) for PHEO larger than 5 cm. Groups were balanced by propensity score matching (PSM) into 46 pairs. Perioperative variables and long-term follow-up results were compared between the two groups.

Results

After PSM, patients in the RLA group had a shorter operative time (218 vs. 245 min, P = 0.040), quicker bowel recovery (2 vs. 3 days, P = 0.046), and a shorter hospital stay (8 vs. 9 days, P = 0.010) compared to the OA group. The results of multiple linear regression analyses showed that the operative method (OA vs. RLA) had an influence on the above three postoperative variables (β = 31.84, P = 0.046; β = 0.76, P = 0.044; and β = 1.25, P = 0.025, respectively). There was no significant difference in the proportion of patients with improved blood pressure (82.61% vs. 69.57%, P = 0.143) between the two groups.

Conclusions

Both RLA and OA provide similar perioperative and long-term outcomes for the surgical management of large PHEO. RLA is an efficacious and safe surgical method for patients with PHEO larger than 5 cm in diameter.

Comparison of transperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: A retrospective propensity score-matched cohort study

BACKGROUND

Surgical resection is the main treatment strategy for pheochromocytoma. Whether laparoscopic techniques are feasible for large pheochromocytoma treatments is controversial. The aim of this study was to evaluate the feasibility and safety of transperitoneal laparoscopic adrenalectomy (LA) compared with open adrenalectomy (OA).

METHODS

We retrospectively studied 182 patients with radiographic tumor sizes ≥ 6 cm who underwent adrenalectomy at our center between 1 January 2007 and 31 December 2017. After propensity score-matching to balance baseline variables, 82 patients treated with LA and 100 patients treated with OA were grouped into 64 pairs. Patient demographics, and extensive peri-operative and oncologic data were recorded and compared.

RESULTS

In the matched group, the incidence of intra-operative hemodynamic instability, transfusion rate, prolonged hypotension, and cardiovascular morbidity in the LA group were lower than the OA group (25.0% vs. 48.4%, 29.7% vs. 46.9%, 4.7% vs. 23.4%, and 14.1% vs. 37.5%, respectively). The estimated blood loss was less (100 ml vs. 300 ml) and bowel recovery was quicker (1.9 d vs. 2.3 d) in the LA group. The proportion of patients in whom blood pressure returned to normal (P = 0.184), had recurrences (P = 0.197), and survived (P = 0.763) were equivalent. The surgical approach (OA vs. LA) was an independent risk factor for IHD, prolonged hypotension, cardiovascular morbidity, and longer bowel recovery.

CONCLUSIONS

This propensity score-matched cohort study showed that LA was feasible, safe, and superior to OA for patients with large pheochromocytoma, meanwhile LA had comparable oncological outcomes compared with OA after a lengthy follow-up.

Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: Comparative outcomes

OBJECTIVES

To evaluate operative and oncological outcomes of laparoscopic adrenalectomy through a transperitoneal approach and retroperitoneal approach for large (>5 cm in diameter) pheochromocytomas.

METHODS

We retrospectively compared the results of a transperitoneal approach with those of a retroperitoneal approach in 22 patients (mean age 57.5 years, range 38-76 years) with unilateral large pheochromocytomas (12 right, 10 left). The mean body mass index, operation time, pneumoperitoneum time, estimated blood loss, fluctuation in blood pressure and complication rate were compared between the two approaches.

RESULTS

The mean tumor diameter (range) was 7.0 cm (range 5.2-15.5 cm), and no significant differences were observed between the transperitoneal approach and retroperitoneal approach in any baseline clinical parameter. For right-sided procedures, significant differences were found for operation time (113 vs 85 min), pneumoperitoneum time (93 vs 64 min) and estimated blood loss (96 vs 23 mL; P < 0.05, transperitoneal approach and retroperitoneal approach, respectively). No open conversion or recurrence was reported, but one right transperitoneal approach case required blood transfusion. No difference in these parameters was noted on the left side.

CONCLUSIONS

For right side procedures, the retroperitoneal approach is feasible, safer and faster than the transperitoneal approach for large pheochromocytomas. Early transection of the feeding artery is beneficial for managing the tumor and reducing the risk of bleeding.

Surgical management of large adrenal tumors: impact of different laparoscopic approaches and resection methods on perioperative and long-term outcomes

Background

The indication of retroperitoneal laparoscopic adrenalectomy (RLA) was extended with the retroperitoneal approach and has been wildly accepted and technologically matured. However, the management of large adrenal tumors via this approach still remains controversial. The aim of this study was to perform a comprehensive analysis on the minimally invasive surgical management of larger adrenal tumors.

Methods

A total of 78 patients with large adrenal tumors (> 5 cm) and 97 patients with smaller adrenal tumors (< 5 cm) were enrolled in this study. The patient characteristics were preferentially analyzed. The intra-operative and postoperative indicators were compared between those who underwent RLA and those who underwent transperitoneal laparoscopic adrenalectomy (TLA); the intra-operative and postoperative indicators were also compared between the large tumor group and smaller tumor group of those who underwent RLA. Furthermore, the analyses of partial RLA were focused on the perioperative indicators and follow-up results.

Results

RLA was superior to TLA in terms of operation time (98.71 ± 32.30 min vs. 124.36 ± 34.62 min, respectively, P = 0.001), hospitalization duration (7.43 ± 2.82 days vs. 8.91 ± 3.40 days, respectively, P = 0.04), duration of drain (4.83 ± 0.37 days vs. 3.94 ± 2.21 days, respectively, P = 0.02), first oral intake (2.82 ± 0.71 days vs. 1.90 ± 0.83 days, respectively, P < 0.001) and time to ambulation (3.89 ± 1.64 days vs. 2.61 ± 1.42 days, respectively, P < 0.001). Further analyses of the RLA patients demonstrated that the larger tumor (> 5 cm) group showed superior results for the intraoperative indicators than the smaller tumor (< 5 cm) group (P < 0.05), while the results for the postoperative indicators between the two tumor size groups were similar (P > 0.05). Data confirmed that the partial resection method was superior to the total resection method from the perspective of the hormone supplement (0% vs. 48.15%, P = 0.002). The 2-year recurrence-free rates were 92.60 and 92.86% for the total and partial RLA resection methods, respectively (P = 0.97). The partial RLA resection method had a similar complete remission rate as the total RLA resection method (96.30% vs. 100%, respectively, P = 0.47).

Conclusion

Both RLA and TLA seem to provide similar effects for the surgical management of large adrenal tumors. However, partial RLA resection should be considered for the management of benign tumors to reduce the hormone supplement.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0349-0) contains supplementary material, which is available to authorized users.

Single-plane retroperitoneoscopic adrenalectomy: a new operative procedure for benign adrenal disease

To evaluate the therapeutic effect of single-plane retroperitoneoscopic adrenalectomy. From February 2014 to March 2017, 251 patients underwent single-plane retroperitoneoscopic adrenalectomy, and their operative outcomes were compared with those of 98 patients who underwent anatomical three-plane retroperitoneoscopic adrenalectomy. Among 35 patients with a body mass index (BMI) of ≥30 kg/m², their operative outcomes were compared between two operative procedures. The demographic data and perioperative outcomes of the patients were statistically analysed. The single-plane and three-plane groups were comparable in terms of estimated blood loss, time to oral intake, hospital stay, and incidence of complications among patients with similar baseline demographics. The single-plane group had a significantly shorter operation time (46.9 ± 5.8 vs 54.8 ± 7.0 mins, P < 0.0001) and lower analgesia requirement (56/251 vs 33/98, p = 0.03). For obese patients with a BMI of ≥30 kg/m², single-plane adrenalectomy was also associated with a significantly shorter operation time(48.1 ± 6.2 vs 64.1 ± 5.1 mins, p < 0.0001). Single-plane retroperitoneoscopic adrenalectomy is feasible, safe, and effective in the treatment of adrenal masses <5 cm in size and provides a shorter operation time and better pain control than anatomical retroperitoneal adrenalectomy, especially in obese patients.

Mineralocorticoid receptor antagonism protects the aorta from vascular smooth muscle cell proliferation and collagen deposition in a rat model of adrenal aldosterone-producing adenoma

The number of patients with adrenal aldosterone-producing adenomas (APAs) has gradually increased. However, even after adenoma resection, some patients still suffer from high systolic blood pressure (SBP), which is possibly due to great arterial remodeling. Moreover, mineralocorticoid receptors (MRs) were found to be expressed in vascular smooth muscle cells (VSMCs). This study aims to determine whether MR antagonism protects the aorta from aldosterone-induced aortic remolding. Male rats were subcutaneously implanted with an osmotic minipumps and randomly divided into four groups: control; aldosterone (1 μg/h); aldosterone plus a specific MR antagonist, eplerenone (100 mg/kg/day); and aldosterone plus a vasodilator, hydralazine (25 mg/kg/day). After 8 weeks of infusion, aortic smooth muscle cell proliferation and collagen deposition, as well as the MDM2 and TGF-β1 expression levels in the aorta, were examined. Model rats with APAs were successfully constructed. Compared with the control rats, the model rats exhibited (1) marked SBP elevation, (2) no significant alteration in aortic morphology, (3) increased VSMC proliferation and MDM2 expression in the aorta, and (4) enhanced total collagen and collagen III depositions in the aorta, accompanied with up-regulated expression of TGF-β1. These effects were significantly inhibited by co-administration with eplerenone but not with hydralazine. These findings suggested that specific MR antagonism protects the aorta from aldosterone-induced VSMC proliferation and collagen deposition.

Lateral retroperitoneoscopic adrenalectomy for complicated adrenal tumor larger than 5 centimeters

BACKGROUND

The role of lateral retroperitoneoscopic adrenalectomy (LRA) for complicated tumor with large diameter remains controversial, this study aimed to evaluate the effectiveness of this procedure on the management of tumor larger than 5cm in diameter.

METHODS

A retrospective comparison was conducted of 67 patients with large complicated adrenal tumor (>5cm). 41 patients received LRA, and 26 received open adrenalectomy (OA) in our hospital between January 2011 and June 2015. Basic characteristics regarding mean age, gender, body mass index (BMI), tumor size, tumor side, previous abdominal surgery, resection method, pathology were preferentially analyzed. Operative indicators regarding operation time, estimated blood loss (EBL), conversion to ICU, complications, post-operative hospitalization, duration of drain, time to first oral intake and ambulation were compared between groups.

RESULTS

There were no significant differences between the two groups in the basic characteristics. The mean operation time for LRA was shorter than OA (98.7±32.3 min vs 152.7±72.3 min, P = 0.001). EBL was 31.9±20.0 ml for LRA and 590.0±1181.1 ml for OA (P = 0.03). There was no complication in LRA group and one patient in OA group had complications, but this difference was not significant (P = NS). The post-operative hospitalization in LRA was 7.4±2.8 days, and shorter than 9.8±2.7 days in OA group (P = 0.00). The time to first oral intake and ambulation for LRA was shorter than OA (first oral intake, 1.9±0.8 days vs 3.1±1.3 days, P = 0.00; time to ambulation, 2.6±1.4 days vs 4.2±1.6 days, P = 0.00). While the difference between groups were not significant in terms of ICU conversion (3/41 vs 4/26, P = NS) and duration of drain (3.9±2.2 days vs 4.7±1.9 days, P = NS).

CONCLUSION

Our study shows that LRA can be performed safely and effectively for complicated adrenal tumors larger than 5 cm in diameter, but it remains technically demanding.

Transperitoneal laparoscopic adrenalectomy: a review and single-center experience

Background: Laparoscopic adrenalectomy (LA) is the preferred approach to adrenal gland tumors.

Objective: To evaluate the perioperative and functional outcomes of transperitoneal LA.

Methods: We retrospectively reviewed data of all consecutive patients who underwent transperitoneal LA at our institution between April 2000 and December 2011.

Results: Two hundred two patients with mean age of 46 years were included in the study. There were 109 left, 89 right, and 4 bilateral tumors. Preoperative diagnosis included 126 aldosterone-producing adenomas (APA), 33 patients with Cushing syndrome, 19 pheochromocytomas, 20 nonfunctional tumors, and 4 adrenal metastases. Mean tumor size was 3.3 cm (range 0.4-22 cm). Mean operative time was 109 min and estimated blood loss 90 mL for unilateral adrenalectomy; and 195 min and 300 mL for bilateral adrenalectomy. Four patients with pheochromocytoma required transfusion and 2 required conversion to an open approach. Seven intraoperative complications and 18 30-day postoperative complications occurred. These included 5 major complications (Clavien-Dindo grade 3-5). Ninety-seven percent of APA patients had normal serum potassium levels after surgery. Among the patients with functioning endocrine tumors, complete resolution rate from secondary hypertension was significantly higher in the pheochromocytoma group compared with those with APA or Cushing syndrome (82% vs. 48% vs. 68% respectively, p = 0.02). Mean follow up was 35.2 months.

Conclusion: LA is the treatment of choice for most adrenal gland tumors with excellent outcomes and low complication rates. There was a high chance for complete resolution of secondary hypertension after surgery for pheochromocytoma.

Comparison of Modified Retroperitoneal Adrenalectomy With the Gold Standard for Benign Adrenal Tumors

OBJECTIVES

To compare our modified retroperitoneoscopic adrenalectomy with the standard procedure.

METHODS

A total of 68 patients underwent modified retroperitoneoscopic adrenalectomy. Simultaneously, another 23 patients were treated using the standard procedure. The demographic data and perioperative outcomes of the patients were obtained for statistical analysis.

RESULTS

No significant differences in age, evaluated blood loss, oral intake, and hospital stay were observed. The mean operation time in the modified group was shorter than that in the standard group (58.3±16.4 vs. 79.5±23.6 min, P<0.05). The median total length of incision was shorter in the modified group than in the standard group (4.5±0.8 vs. 6.4±1.1 cm, P<0.05). The modified group also showed significantly better pain control (3 vs. 6 diclofenac sodium use, P<0.05) and cosmetic outcome (score, 9.1±1.8 vs. 8.2±2.1, P<0.05) than the standard group.

CONCLUSIONS

Our modified retroperitoneoscopic adrenalectomy is a safe and alternative procedure for adrenal tumors. This procedure offers superior cosmetic outcome, better pain control, and shorter operation time compared with the standard retroperitoneal adrenalectomy.

Posterior retroperitoneoscopic approach to the adrenal arteries

BACKGROUND

Differently from transperitoneal adrenalectomy, with the posterior retroperitoneoscopic approach adrenal arteries are dissected first [1, 2]. Knowledge of their position is pivotal as they are covered by peri-adrenal fat [3, 4].

METHODS

Four posterior retroperitoneoscopic adrenalectomies were selected, in which adrenal arteries are dissected to show their path and how they can be localized among peri-adrenal fat.

RESULTS

A video is presented herein, which focuses on surgical anatomy of adrenal arteries when approached during a posterior retroperitoneoscopic adrenalectomy. Details about relative positions between adrenal arteries and adjacent structures are considered and shown during their dissection.

CONCLUSIONS

The posterior retroperitoneoscopic approach offers a direct view of adrenal arteries and allows for their exposure and safe division in the early steps of adrenalectomy.

Evaluation of PADUA Score as Predictor of Warm Ischemia Time (WIT) during Laparoscopic Partial Nephrectomy (LPN)

Objective

To evaluate the efficacy of Preoperative Aspects and Dimension Used for an Anatomical (PADUA) classification in the prediction of Warm Ischemia Time (WIT) during Laparoscopic Partial Nephrectomy (LPN).

Methods

Single centre retrospective study on 402 patients who underwent LPN between January 2011 and October 2013. WIT was correlated with each characteristics of the PADUA classification. Univariate and multivariate analysis were used to evaluated the independent predictive risk factors of WIT >20 minutes.

Results

The median WIT was 19.8 minutes (IQR 15-25). The PADUA risk groups (High vs Low: OR: 2.804; 95% CI 1.155-6.806; p-value <0.001; Intermediate vs Low: OR 0.971; 95% CI 0.185-5.092 p-value <0.001) and PADUA score as continuous variable (OR: 1.512; 95% CI 1.043-2.194; p-value <0.001) were the best independent risk factors of WIT >20 minutes. Another important factor related with WIT >20 minutes was a CKD stage 3 (p-value: 0.047; OR: 0.528; 95% CI:0.282-0.990).

Conclusions

This study reveal that tumor’ anatomical aspects may influence the WIT. The use of the nephrometry scoring systems should to be use by the surgeon in the planning of nephron sparing surgery (NSS) and should be considered for its inclusion in international guidelines.

Retroperitoneoscopic Adrenalectomy in Obese Patients: Is It Suitable?

BACKGROUND

The aim of this study was to evaluate the suitability of posterior retroperitoneoscopic adrenalectomy for patients with morbid obesity.

METHODS

This retrospective clinical cohort study included patients who underwent elective posterior retroperitoneoscopic adrenalectomy. Intraoperative (operative time, blood loss, intraoperative complications, conversion rate) and postoperative (hospital stay, morbidity, mortality) parameters were compared between the two study subgroups: obese (body mass index [BMI] ≥30 kg/m(2)) and non-obese patients (BMI <30 kg/m(2)).

RESULTS

A total of 137 subsequent patients were enrolled in the study (41 obese and 96 non-obese patients). Mean tumour size was 5.2 ± 2.2 cm; aldosteronism and incidentaloma were the most frequent indications. Operative time was significantly longer (87 vs. 65 min; P = 0.0006) in obese patients. There was no difference in operative blood loss. One conversion was necessary. Overall, the 30-day postoperative morbidity was significantly higher in obese patients (26.8 vs. 11.5 %; P = 0.025). The hospital stay was significantly longer in obese patients (3.1 vs. 2.5 days; P = 0.003).

CONCLUSIONS

Dorsal retroperitoneoscopic adrenalectomy can be safely performed in morbidly obese patients, maintaining the advantages of minimally invasive surgery. Avoiding an abdominal approach is beneficial for patients. There is a more favourable postoperative course, shorter hospital stay, better cosmetic outcome and quicker recovery with dorsal retroperitoneoscopic adrenalectomy. The prolonged operative time, longer hospital stay and higher risk of postoperative complications that occurred in obese patients were acceptable in light of the generally higher risk associated with surgeries performed in obese patients.

Modified retroperitoneoscopic port sites for surgery of upper urinary tract

BACKGROUND AND OBJECTIVES

Our objective was to introduce our experience using modified retroperitoneoscopic port positions for operations of the upper urinary tract.

METHODS

We designed different trocar positions or incisions according to different surgical procedures and specimen sizes. A total of 116 patients, comprising patients with common adrenal, kidney, and ureter diseases, underwent retroperitoneoscopic operations by use of modified incisions. These patients comprised 23 with adrenal diseases, 84 with kidney diseases, and 9 with ureter diseases. The specimen was retrieved, as much as possible, through a transverse incision to produce a hidden scar after recovery. By contrast, 143 patients underwent the same or similar procedures using classical 3-port incisions. The operative time was defined as the time from skin incision to skin closure.

RESULTS

There were no significant differences in age, estimated blood loss, oral intake, and hospital stay between groups. A significant difference in favor of the modified group was noted with respect to analgesia use (diclofenac sodium, 50 mg vs 100 mg; P<.05) in all 3 modified methods, as well as in cosmetic outcome in the groups undergoing the first modification (score, 8.9±2.2 VS 7.3±2.8; P<.05) and second modification (score, 8.7±2.5 VS 7.1±2.4; P<.05). In addition, the mean operative time in patients undergoing ureter operations was shorter than that in the conventional group using classical 3-port positions (55±11 minutes vs 70±15 minutes, P<.05).

CONCLUSIONS

Our modified retroperitoneoscopic incision is a safe, cosmetic alternative procedure for operations of the upper urinary tract. Different diseases and specimen sizes can be treated with the personalized or suitable incisions that we have introduced.

The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves

PURPOSE

The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs).

METHODS

Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers.

RESULTS

Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as "the urogenital-hypogastric sheath." Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs.

CONCLUSION

The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.

Retroperitoneoscopic Anatomical Necrosectomy

Background. Video-assisted retroperitoneal necrosectomy is a minimally invasive surgical technique for the treatment of severe acute pancreatitis. This study evaluated the safety and feasibility of a modified single-stage video-assisted retroperitoneal necrosectomy, retroperitoneoscopic anatomical necrosectomy (REAN). Methods. Between September 2010 and May 2012, a total of 17 patients with infected necrotizing pancreatitis underwent REAN. The surgical procedures were similar to retroperitoneoscopic pancreatectomy, in which 3 trocars are utilized. Briefly, the perirenal space was entered through the posterior pararenal space. Dissection proceeded from posterior to anterior direction to expose the dorsal side of the perirenal fascia. This was opened to reach the anterior perirenal space, where the peripancreatic abscess was located. Necrotic tissue was then debrided and catheter drainage was performed in a single stage. Results. Operating time ranged from 45 to 100 minutes with minimal blood loss. All patients recovered except for one who died. Major perisurgical complications included peritoneal injury (1 patient), splenic vein injury (1 patient), retroperitoneal infection with paralytic ileus (1 patient), hydrothorax and atelectasis (2 patients), and subcutaneous cellulitis beneath the incision (3 patients). Two patients required additional percutaneous catheter drainage, and 1 patient required a laparotomy to debride the remaining necrotic tissue. Postoperative hospital stay ranged from 21 to 64 days. Conclusions. This study demonstrates that REAN, a modified single-stage video-assisted retroperitoneal approach, was safe and feasible for the treatment of infected necrotizing pancreatitis. The advantages of this procedure include direct access with shorter operating time, complete necrotic tissue debridement, easy hemostasis, simple manipulation, and easy drainage.

Is laboratory training essential for beginners in learning laparoscopic adrenalectomy?

The aim is to develop a staged clinical laparoscopic training program (without laboratory trainings) for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility. Five beginners with no previous experience in adrenalectomy were randomly selected to receive the staged clinical laparoscopic training, including open retroperitoneal adrenalectomy or radical nephrectomy and mentor-initiated clinical laparoscopic training. The clinical data of the 15 LAs performed by each the trainees were collected and compared with the data from the initial 15 LAs of the mentor. All LAs were completed successfully, and no procedure required conversion to open surgery. The median operative time of the trainees was obviously less than the mentor's. The learning curve of the trainees was shorter compared with that of the mentor. The perioperative complication rate was similar between trainees and mentor. Beginners without laboratory trainings could perform LA safely and effectively after they participated in staged clinical laparoscopic training.

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

PURPOSE

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

METHODS

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

RESULTS

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.

Modified anatomical retroperitoneoscopic adrenalectomy for adrenal metastatic tumor: technique and survival analysis

BACKGROUND

In a previous experience, anatomical retroperitoneoscopic adrenalectomy (ARA) was proven safe, effective, and technically efficient for surgical adrenal diseases. However, laparoscopic adrenalectomy for adrenal metastasis is controversial. We evaluated the safety, effectiveness, and efficiency of modified ARA technique for adrenal metastasis and predicted survival factors.

METHODS

From 2000 to 2010, a consecutive series of 75 patients with adrenal metastases underwent 78 ARAs (three bilateral ARAs). Three modifications and one key procedure were specified in this study. Medical records and follow-up data were retrospectively studied. Then, the surgery data of ARA were compared with those of other approaches to evaluate its safety, effectiveness, and efficiency. Additionally, univariate and multivariate analyses were used to predict the risk factors for survival.

RESULTS

The most common primary tumor was renal cell carcinoma (RCC, n = 26), followed by non-small-cell lung carcinoma (NSCLC, n = 23), and hepatocellular carcinoma (HCC, n = 12). A total of 76 successful ARAs and two conversions to open surgery were performed, with a median operation time of 53 (range, 40-250) min and median estimated blood loss of 25 (range, 10-700) mL. The local recurrence rate was 5.3 %, and the median survival was 24 months. These data were comparable with or even better than other approaches in previous studies. The independent prognostic factors of survival were body mass index (BMI, p < 0.001), tumor type (p < 0.001), tumor size (≥ 4 cm vs. <4 cm, p = 0.017), and margin status (negative vs. positive, p = 0.011).

CONCLUSIONS

ARA is a safe and effective approach for the management of adrenal metastasis in selected patients. BMI, tumor type, tumor size, and margin status may independently predict survival.

Retroperitoneal laparoscopic hepatectomy: a novel approach

PURPOSE

Retroperitoneal laparoscopic surgery has been widely used for kidney and adrenal gland resection. However, there have not been any reports of laparoscopic hepatectomy performed using a retroperitoneal approach. Herein, we report on a successful case of laparoscopic hepatectomy using a retroperitoneal approach. Further, we discuss the key technical points, feasibility, and indications of this method.

METHODS

A 48-year-old male patient with multiple hepatic metastases of the left lateral and right posterior segments of the liver following radical colon carcinoma resection underwent laparoscopic partial hepatectomy of the right posterior segment using a retroperitoneal approach, followed by laparoscopic hepatic left-lateral segmentectomy using a transabdominal approach.

RESULTS

The operation time was 120 minutes and the blood loss volume was 150 mL. The patient was discharged at nine days post-surgery. There were no complications, including hemorrhage and bile leakage.

CONCLUSIONS

The results of this case study provide evidence that a retroperitoneal approach is a novel, rapid, and safe method for laparoscopic hepatectomy that can be applied to the partial resection of small and superficial tumors of the right posterior segment of the liver.

Minimally invasive adrenalectomy in children

PURPOSE

Minimally invasive adrenalectomy (MIA) is the criterion standard for removal of small adrenal tumors in adults. The purpose of this review was to determine the place of MIA in children.

METHODS

The authors conducted a systematic review of the pediatric and adult literature about MIA, focusing on the technique and indications.

RESULTS

Minimally invasive adrenalectomy appears superior to open adrenalectomy for small tumors. The potential advantages of MIA are appealing for postoperative pain, risk of intestinal obstruction, and quality of scars. The most common approach is the transperitoneal lateral laparoscopy, which allows for a large working space. For small tumors or for bilateral adrenalectomy, the prone retroperitoneoscopy is a promising new technique. In children, the learning curve is an issue because the indications are rare. The most common indication is neuroblastoma without image-defined surgical risk factors. The incidence of local recurrence is low, but the follow-up is short in most cases.

CONCLUSIONS

Minimally invasive adrenalectomy is promising for removal of small adrenal tumors. Long-term follow-up is required to evaluate the efficacy of MIA in neuroblastomas. Benign diseases are excellent candidates for this minimally invasive technique.

The anterior approach to retroperitoneoscopic adrenalectomy in children: technique

PURPOSE

Very limited literature exists on minimally invasive adrenalectomy in children. Retroperitoneoscopic adrenalectomy (RPA) has the advantage of avoiding intra-abdominal organ retraction, but concerns have been expressed regarding RPA on the right side. Herein, we describe the second reported experience with the anterior approach to RPA in children, which appears to overcome the limitations previously ascribed to right RPA.

MATERIALS AND METHODS

Two children, aged 8 and 14-years, presented with incidental right adrenal masses. Both patients were placed in the lateral decubitus position with lumbar hyper-extension. A 5-mm, 3-port approach was used, as demonstrated in the video.

RESULTS

Pathology revealed a 7-cm ganglioneuroma and a 5-cm pheochromocytoma with intact surgical margins. Operative time with these large masses and first experience with this technique was 5 h in the first case and 3.5 h in the second. No intraoperative or postoperative complications were noted, with minimal blood loss and a hospital stay of 36 h in both cases.

CONCLUSION

The anterior approach to RPA is feasible even in children with a smaller retroperitoneal space and a large adrenal mass. It provides excellent exposure of the adrenal gland and vein, even on the right side.

Retroperitoneoscopic adrenalectomy in pheochromocytoma

Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.

Anatomic retroperitoneoscopic adrenalectomy for selected adrenal tumors >5 cm: our technique and experience

OBJECTIVES

To introduce our experience in using anatomic retroperitoneoscopic adrenalectomy (ARA) for adrenal tumors >5 cm and evaluate this procedure's safety and efficiency.

METHODS

Of the 1400 ARAs performed in the past 8 years, 110 were performed on patients who had adrenal tumors with a diameter >5 cm. The perioperative indexes of these patients were retrospectively collected and analyzed.

RESULTS

The mean tumor size on postoperative pathologic examination was 7.2 ± 2.1 cm (range 5-14). Only 1 patient with right-sided adrenal pheochromocytoma (7.8 cm diameter) required conversion to open surgery owing to the tumor's severe adhesions to the liver and inferior vena cava. The mean operative time and evaluated blood loss was 70.8 ± 18.6 minutes and 81.3 ± 46.1 mL, respectively. The average postoperative interval to oral intake and drainage withdrawal was 2.1 and 2.2 days, respectively. No patient died during the operation. Major intraoperative complication (ie, injury to the vena cava) occurred in 1 patient, necessitating open surgery. Minor complications during the perioperative period occurred in 10 patients (9.1%).

CONCLUSIONS

When performed by experienced surgeons, ARA is a safe and feasible procedure for large adrenal masses with a diameter >7 cm; however, this procedure results in a longer operation time and greater blood loss compared with ARA performed on smaller masses. Open surgery is indicated when the tumor adheres to, or has infiltrated, the surrounding tissues.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy: first clinical experience

BACKGROUND

This study aimed to describe the initial clinical experience of transvaginal natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopic adrenalectomy (TNLA) and to evaluate its feasibility and efficacy.

METHODS

Between May and December 2010, 11 consecutive women were subjected to TNLA for adrenal tumors at the authors' center. With the patient under general anesthesia, a 5-mm trocar and a 10-mm trocar were inserted in the umbilical edge for conventional operating apparatus, and a 10-mm trocar was inserted in the posterior vaginal fornix for a conventional 30º laparoscope. Dissection was performed according to the method of a standard laparoscopic adrenalectomy. The adrenal gland, its tumor, or both were put into a homemade bag and then removed via the incision of the posterior vaginal fornix after complete resection.

RESULTS

A total of 11 TNLAs were performed in this series. Only one conversion to open surgery was performed for one patient with Cushing disease, who was subjected to a splenectomy synchronously for an injury of the spleen. Except for this patient, no patients required a blood transfusion. The median operative time was 102 min (range 80-310 min), and the median estimated blood loss was 80 ml (range 30-800 ml). The median size of the mass in terms of the largest diameter was 4.7 cm (range 2.2-6.6 cm). There was no difference between pre- and postoperative median Female Sexual Function Index (FSFI) total scores (P = 0.102). All the patients except the one who had conversion to open surgery were very satisfied with the cosmetic result.

CONCLUSIONS

The findings show TNLA to be a feasible and effective surgical technique that results in excellent cosmesis. It may be an alternative technique for the treatment of properly selected female patients with adrenal tumor.