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Sebastian M, Rudnicki J. Recommendation for laparoscopic ultrasound guided laparoscopic left lateral transabdominal adrenalectomy. Gland Surg 2020; 9:689-694. [PMID: 32775258 DOI: 10.21037/gs.2020.03.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Left sided adrenalectomy may be associated with intraoperative bleeding and conversion or injury of the pancreatic tail leading to postoperative fistula. Another problem may be the identification of adrenal mass in the case of previous upper abdominal surgery. Intraoperative laparoscopic ultrasound (LUS) enables the safe plane of dissection, identification of key structures and reduction of conversion and complication rate to the minimum. Methods Laparoscopic left lateral transabdominal adrenalectomy (LTA) was performed in 94 patients. LUS was performed in 50 patients with identification of adrenal mass, its vascularization and surrounding anatomical planes. Results Laparoscopic left LTA with LUS was associated with significant shorter operating time, smaller rate of conversions and intraoperative bleeding in comparison to the group without intraoperative ultrasound. Conclusions Intraoperative ultrasound during laparoscopic left LTA is a very effective method of navigation and its use should be taken into consideration especially in cases when the visualization and possibility of safe dissection are reduced.
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Affiliation(s)
- Maciej Sebastian
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy Rudnicki
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
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Laparoscopic Approach to the Adrenal Masses: Single-Center Experience of Five Years. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:52-57. [PMID: 32377134 PMCID: PMC7192254 DOI: 10.14744/semb.2019.40225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/30/2019] [Indexed: 12/27/2022]
Abstract
Objectives: Currently, laparoscopic adrenalectomy is the gold standard technique for suitable patients with adrenal masses. In this study, we aimed to assess the postoperative results of patients who underwent laparoscopic adrenalectomy. Methods: Between January 2014 and October 2019, 76 cases were operated and retrospectively evaluated. Laparoscopic transabdominal adrenalectomy was applied to the patients. Demographic profiles, preoperative indications, intraoperative and postoperative complications, mortality and length of hospital stay were evaluated. Results: Seventy-six patients (30 male, 46 female) with a mean age of 47.2±11.7 (range 22-71) years underwent laparoscopic adrenalectomy. Thirty-nine of the patients had right; 33 of the patients had left adrenal masses. Three patients had bilateral adrenal cortical hyperplasia. One patient was operated for paraganglioma. Conversion to open adrenalectomy was observed in four patients (5.26%). Nine patients (11.8%) experienced intraoperative and postoperative complications. Intraoperative and postoperative complications were bleeding from spleen (2 cases) and upper pole of kidney (1 case), renal artery injury (1 case), bleeding from liver parenchyma (2 cases), ischemia of spleen and pancreas (1 case), small intestinal injury (1 case) and incisional hernia (1 case). The complication rate is acceptable and comparable with other studies in the literature. Conclusion: Laparoscopic adrenalectomy can be safely applied in suitable patients with acceptable complications and low conversion rates.
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Kim LT, Solórzano CC. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1338-1347. [PMID: 32112213 DOI: 10.1245/s10434-020-08221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/10/2023]
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy]. Surg Endosc 2020; 34:5421-5427. [PMID: 31953726 PMCID: PMC7644518 DOI: 10.1007/s00464-019-07337-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 12/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate. METHODS Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed. RESULTS We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively. CONCLUSION A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.
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Rowe SP, Lugo-Fagundo C, Ahn H, Fishman EK, Prescott JD. What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques. Abdom Radiol (NY) 2019; 44:140-153. [PMID: 29967985 DOI: 10.1007/s00261-018-1669-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Adrenalectomy is the standard of care for management of many adrenal tumor types and, in the United States alone, approximately 6000 adrenal surgeries are performed annually. Two general approaches to adrenalectomy have been described; (1) the open approach, in which a diseased adrenal is removed through a large (10-20 cm) abdominal wall incision, and (2) the minimally invasive approach, in which laparoscopy is used to excise the gland through incisions generally no longer than 1-2 cm. Given these disparate technique options, clear preoperative characterization of those specific disease features that inform selection of adrenalectomy approach is critically important to the surgeon. Because most of these features are directly assessed via preoperative abdominal imaging, in particular computed tomography (CT) scanning, a clear mutual understanding among surgeons and radiologists of those adrenal tumor features impacting operative approach selection is vital for planning adrenal surgery. In this context, we review the preoperative CT imaging features that specifically inform adrenalectomy approach selection, provide illustrative examples from our institution's imaging and surgical archives, and provide a stepwise guide to both the open and laparoscopic adrenalectomy approaches.
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Affiliation(s)
- Steven P Rowe
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21231, USA
| | - Carolina Lugo-Fagundo
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21231, USA
| | - Hannah Ahn
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21231, USA
| | - Elliot K Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD, 21231, USA
| | - Jason D Prescott
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD, 21287, USA.
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Lateral laparoscopic adrenalectomy in patients with previous abdominal surgery - single-center experience. Wideochir Inne Tech Maloinwazyjne 2018; 13:283-287. [PMID: 30302139 PMCID: PMC6174173 DOI: 10.5114/wiitm.2018.77706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/27/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Lateral transabdominal adrenalectomy (LTA) is the most common minimally invasive technique used to treat patients with adrenal tumors. Aim To analyze intra-operative and post-operative complications and reasons for conversion to open surgery in patients who underwent LTA and had previous abdominal surgery. Material and methods Five hundred and nineteen patients underwent LTA in our center between 2005 and 2016. We identified a study group of 150 patients, with previous abdominal surgery. We analyzed the frequency of intra-operative and post-operative complications and the reasons for conversion from laparoscopic to open adrenalectomy. Results The patients’ mean age was 58; they underwent LTA due to hormonally active tumors (n = 79, 53%) and non-functioning adrenal tumors (n = 71, 47%). The size of adrenal lesions ranged from 20 mm to 90 mm. Seventy-eight (52%) adrenal lesions were found in the right adrenal gland, and 72 (48%) lesions in the left adrenal gland. The mean operating time was 130 min. The mean stay in hospital was five days. The intra-operative complications included blood pressure fluctuations (n = 32), abnormal vascular supply of the adrenal glands causing difficulties with dissections (n = 3), and respiratory problems (n = 1). Two (1.3%) patients had post-operative bleeding at the site of removed adrenal glands; 1 patient had an exacerbation of asthma postoperatively. Of the 150 patients analyzed, 3 (2%) required conversion to open adrenalectomy. The conversions were not caused by abdominal adhesions. Conclusions Lateral transabdominal adrenalectomy is feasible and safe in patients with previous abdominal surgery. In our study, conversion from laparoscopic to open adrenalectomy was not caused by abdominal adhesions.
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Natkaniec M, Dworak J, Pędziwiatr M, Pisarska M, Major P, Dembiński M, Winiarski M, Budzyński A. Patients criteria determining difficulty of the laparoscopic lateral transperitoneal adrenalectomy. A retrospective cohort study. Int J Surg 2017; 43:33-37. [PMID: 28528215 DOI: 10.1016/j.ijsu.2017.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Identification of patients in whom adrenalectomy may be more difficult, can help in decision making in borderline and doubtful cases. The aim of the study was to determine patients criteria influencing difficulty of laparoscopic lateral transperitoneal adrenalectomy (LTA). MATERIAL AND METHODS The study enrolled 275 patients who underwent LTA. We analyzed the impact of gender, age, history of previous abdominal surgery, body mass index, risk of anesthesia measured as ASA scale, size, localization (left/right), and histological type of the tumor on parameters reflecting the level of difficulty of the procedure: operative time, intraoperative blood loss, conversion rate and intraoperative complications rate. RESULTS Multivariate logistic regression showed that following factors were associated with longer operative time: gender, tumor size and malignant lesions. In another model it was shown that age, size of the tumor and malignancy were associated with more excessive blood loss. Moreover, it was shown, that tumor size predictive factor for conversion. Univariate analysis showed a relation with malignancy, but multivariate analysis revealed no significance. CONCLUSIONS Patient age, gender, size and histological type of the tumor are criteria influencing parameters reflecting the level of difficulty. This criteria could be considered as predictors of the difficulty of LTA. Surgery in case of patients with combination of this risk factors should be handled by surgeon with sufficient experience to minimalize the risk of adverse events.
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Affiliation(s)
- Michał Natkaniec
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland.
| | - Jadwiga Dworak
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Marcin Dembiński
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Marek Winiarski
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University, Kraków, Poland
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Pędziwiatr M, Major P, Pisarska M, Natkaniec M, Godlewska M, Przęczek K, Dworak J, Dembiński M, Zub-Pokrowiecka A, Budzyński A. Laparoscopic transperitoneal adrenalectomy in morbidly obese patients is not associated with worse short-term outcomes. Int J Urol 2016; 24:59-63. [PMID: 27734531 DOI: 10.1111/iju.13241] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/19/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the impact of obesity and morbid obesity on short-term outcomes after laparoscopic adrenalectomy. METHODS The study included 520 consecutive patients undergoing laparoscopic adrenalectomy for adrenal tumor. The entire study group was divided depending on the body mass index: group 1 (normal weight), <25 kg/m2 ; group 2 (overweight), 25-30 kg/m2 ; and group 3 (obese) 30-40 kg/m2 . Additionally, group 4 (morbidly obese) was distinguished. Study end-points were: operative time, intraoperative blood loss, total length of hospital stay, morbidity rate and 30-day readmission rate. RESULTS The mean operative times were 88.8, 94.7, 93.5, and 99.9 min in groups 1, 2, 3 and 4, respectively (P = 0.1444). Complications were comparable between groups (12.8% vs 8.8% vs 8.2% vs 11.5%, P = 0.5295). The mean intraoperative blood loss was 66.8 versus 78.3 versus 60.7 versus 92.4, P = 0.1399. There were no differences in conversion rate between groups. CONCLUSIONS Obesity has no influence on short-term outcomes of laparoscopic transperitoneal adrenalectomy. This procedure is feasible regardless of the body mass index. Therefore, it can be offered to all patient groups including those morbidly obese individuals in whose case preoperative weight loss seems unnecessary.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Michał Natkaniec
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Godlewska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Krzysztof Przęczek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Jadwiga Dworak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Dembiński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Anna Zub-Pokrowiecka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
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Abstract
Minimally invasive adrenalectomy has become the gold standard for removal of benign adrenal tumors. The imaging characteristics, biochemical evaluation, and patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic approaches are discussed with details of surgical technique for both procedures.
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Affiliation(s)
- Azadeh A Carr
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Oltmann SC, Chen H. The transabdominal minimally invasive approach to the isolated adrenal mass. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tumor size, previous abdominal operation, medical comorbidities and surgeon skill set are factors to determine if a minimally invasive approach is feasible for patients with benign adrenal pathology, as patient outcomes are far superior with this approach. Laparoscopic techniques have largely replaced the open operations, and are often viewed as the standard of care for many general surgery operations. For this reason, general surgeons are very familiar with the anatomy within the peritoneal cavity. Often, the skill set from one advanced laparoscopic procedure may translate to another, potentially allowing a low volume adrenal surgeon but high volume laparoscopic surgeon to safely perform transabdominal laparoscopic adrenalectomy.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, TX 75390-9092, USA
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, 600 Highland Ave., Madison, WI 53792, USA
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Riedinger CB, Tobert CM, Lane BR. Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach. World J Clin Urol 2014; 3:54-65. [DOI: 10.5410/wjcu.v3.i2.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/07/2014] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.
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