EXPERIENCE WITH RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY IN 115 PROCEDURES

Safety and feasibility of laparoscopic resection of abdominal neuroblastoma without image-defined risk factors: a single-center experience

OBJECTIVE

To explore the criteria, safety and efficacy of laparoscopic surgery in pediatric neuroblastoma (NB).

METHODS

A retrospective study of 87 patients with NB without image-defined risk factors (IDRFs) between December 2016 and January 2021 at Beijing Children's Hospital was conducted. Patients were divided into two groups according to the surgical procedure.

RESULTS

Between the 87 patients, there were 54 (62.07%) cases in the open surgery group and 33 (37.93%) cases in the laparoscopic surgery group. There were no significant differences between the two groups regarding demographic characteristics, genomic and biological features, operating time or postoperative complications. However, in terms of intraoperative bleeding (p = 0.013) and the time to start postoperative feeding after surgery (p = 0.002), the laparoscopic group was obviously better than the open group. Furthermore, there was no significant difference in the prognosis between the two groups, and no recurrence or death was observed.

CONCLUSION

For children with localized NB who have no IDRFs, laparoscopic surgery could be performed safely and effectively. Surgeons who are skilled in this can help children reduce surgical injuries, speed up postoperative recovery, and obtain the same prognosis as open surgery.

An intra-operative video comparison of laparoscopic versus robotic transabdominal lateral adrenalectomy

BACKGROUND

The aim was to compare intraoperative conduct of adrenalectomy between laparoscopic and robotic approaches.

METHODS

Intraoperative video-recordings of patients who underwent robotic (n = 30) and laparoscopic adrenalectomy (n = 30) were analysed using Mann-Whitney U, chi-square and multivariate regression analyses.

RESULTS

Demographics, indications and outcomes were similar between groups. For all tumour sizes, camera was more engaged to surgical task and exhibited less vision problems in robotic versus laparoscopic group. There was less instrument exchange and restriction of exposure with robotic approach. For dissection, robotic approach allowed for a wider range of instrument reach around adrenal. Robotically, there was an increased ability to do fine dissection, rather than en bloc division with rigid laparoscopic vessel sealers. Bleeding problems were less robotically.

CONCLUSION

Despite similarities in post-operative morbidity and hospital stay, there was a superiority in quality of procedure performed with robotic versus laparoscopic adrenalectomy for both small and large adrenal tumours.

Incidence of adrenal gland tumor as a second primary malignancy: SEER-based study

PURPOSE

Advances in cancer treatment achieved during the past decades have resulted in increased survival of most pediatric and adult patients that suffered from different adrenal tumor types. This article reviews the incidence and survival of adrenal gland tumors as second primary tumors, according to data from the Surveillance, Epidemiology, and End Results (SEER) database.

METHOD

The SEER 13 Registries Database from 1992 to 2013 was used. All primary cancer sites were selected using the Multiple Primary Standardized Incidence Ratios (MP-SIR) session.

RESULTS

Data for a total of 2,887,468 persons with cancer were reviewed. 117 of whom had suffered second primary adrenal tumors. The overall standardized incidence ratio (SIR) of adrenal gland tumor as a second primary was 1.49. A high incidence ratio of the event was also detected in specific primary tumor sites: hypopharynx (Observed/Expected(O/E) = 44.59); other endocrine tissue (including the thymus) (O/E=38.27); chronic myeloid leukemia (O/E=11.15); small intestine (O/E=8.86); liver (O/E=8.74); stomach (O/E=4.95); nodal NHL (O/E=3.79); kidney and renal pelvis (O/E=3.19); and breast (O/E=1.78).

CONCLUSION

The underlying shared mechanisms should be investigated between adrenal tumors and hypopharyngeal, endocrine and other tumors. Racial disparity is an important challenge in cancer treatment at US and should be taken into consideration in the design of cancer prevention programs. This could be achieved through follow-up programs at specialized national cancer networks, especially for rare tumors like adrenal gland.

Comparison of radiofrequency ablation versus laparoscopic adrenalectomy for benign aldosterone-producing adenoma

PURPOSE

To retrospectively compare the safety and efficacy of radiofrequency ablation (RFA) with laparoscopic adrenalectomy (LA) in treating aldosterone-producing adenoma (APA) of the adrenal gland.

MATERIALS AND METHODS

From September 2009 to September 2013, seven patients, diagnosed with unilateral adrenal APA and underwent computed tomography (CT)-guided percutaneous RFA, were recruited in this retrospective study. Eighteen unilateral adrenal APA with the same tumor size (<25 mm) who underwent LA during the same interval were enrolled as control group. Treatment success was defined as complete tumor ablation on follow-up CT scan and normalization of serum aldosterone-to-renin ratio. We also compared "normalization ability" between RFA group and LA group. Normalization ability was defined as reduction in blood pressure, decrease in number of antihypertensive medicine use, reduction in serum aldosterone, and increase in serum potassium level.

RESULTS

There was no statistically significant demographic difference in both groups. The mean tumor size was 18 (8-25) mm in RFA and 19 (11-25) mm in LA groups, respectively. There was only one intra-procedure hypertensive crisis in the RFA group. No other complications needed further management in both groups. During an interval of 3-6 months of follow-up, the treatment success rate reached 100 % in the RFA group versus 94.4 % in the LA group. Normalization ability was statistically equivalent in the RFA and the LA group. Comparing with LA group, RFA group demonstrated with less post-operative pain (visual analog scale, 2.0 ± 1.16 vs. 4.22 ± 1.44, p < 0.001) and shorter operative time (105 ± 34 vs. 194 ± 58 min, p < 0.001).

CONCLUSIONS

CT-guided percutaneous RFA is effective, safe and is a justifiable alternative for patients who are reluctant or unfit for laparoscopic surgery for the treatment of APA.

Past and present in abdominal surgery management for Cushing's syndrome

INTRODUCTION

Data on specific abdominal surgery and Cushing's syndrome are infrequent and are usually included in the adrenalectomy reports. Current literature suggests the feasibility and reproducibility of the surgical adrenalectomies for patients diagnosed with non-functioning tumours and functioning adrenal tumours including pheochromocytoma, Conn's syndrome and Cushing's syndrome.

DISCUSSION

Medical treatment for Cushing's syndrome is feasible but follow-up or clinical situations force the patient to undergo a surgical procedure. Laparoscopic surgery has become a gold standard nowadays in a broad spectrum of pathologies. Laparoscopic adrenalectomies are also standard procedures nowadays. However, despite the different characteristics and clinical disorders related to the laparoscopically removed adrenal tumours, the intraoperative and postoperative outcomes do not significantly differ in most cases between the different groups of patients, techniques and types of tumours. Tumour size, hormonal type and surgeon's experience could be different factors that predict intraoperative and postoperative complications. Transabdominal and retroperitoneal approaches can be considered. Outcomes for Cushing's syndrome do not differ depending on the surgical approach. Novel technologies and approaches such as single-port surgery or robotic surgery have proven to be safe and feasible.

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery. Single-port access and robotic surgery can be performed but more data are required to identify their correct role between the different surgical approaches. Factors such as surgeon's experience, tumour size and optimal technique can affect the outcomes of this surgery.

[Adrenal tumors. Principles of diagnostics and operative treatment]

Adrenal masses are very heterogeneous and comprise benign or malignant tumors, unilateral or bilateral masses and variable endocrine activity. Because of these attributes adrenal gland masses are a clinical challenge. This article gives a summary of diagnostic steps and indications for adrenal surgery including perioperative management.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy has become an accepted method for removing benign lesions of the adrenal gland. There are few contraindications to the laparoscopic approach, and the transperitoneal and retroperitoneal techniques yield excellent results. Virtually all benign lesions and select malignant lesions can be removed laparoscopically. Laparoscopic adrenalectomy has been shown to be a safe and effective approach to many forms of adrenal pathologic conditions. It should be considered the standard of care in the management of benign lesions of the adrenal gland that require surgical removal.

Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years

INTRODUCTION

The aim of this study is to review 10 years experience of retroperitoneoscopy procedures.

METHODS

A total of 600 patients treated between 1995 and 2007 by retroperitoneoscopy (nephrectomy, partial and total nephrectomy, adrenalectomy, pyeloplasty, renal cyst, calyceal diverticulectomy) were reviewed for per, peri and postoperative complications including patients in the learning curve.

RESULTS

The mean blood loss was 159 mL. Conversion to open surgery was required in 28 patients (4.6%) primarily due to technical problems during dissection (elective). There were 32 (5.3%) surgical complications, including bleeding or hematomas in 12 cases and 2 of them required reintervention, urinomas in 8 which were treated by installation of a ureteral drainage (JJ stent). Wound or deep abscesses happened in four, urinary fistula in one and pancreatic fistula in another. Evisceration (hernias) was seen in three patients. Intestinal injury occurred in two. The complication rate depended on the difficulty of the procedure and learning curve of the surgeon. A total of 28 patients (4.6%) presented medical postoperative complications (hyperthermias, deep venous thrombosis, pyelonephritis, pulmonary superinfections, pulmonary atelectasia and transient vascular ischemic accident). Mean postoperative hospital stay was 6.2 days (ranged from 2 to 20).

CONCLUSION

Retroperitoneoscopy can be the technique of choice for accessing and carrying out all the surgery of the upper urinary tract respecting the principles of oncological surgery. After experience with 600 cases during the last 10 years the technique has become safe, simplified, reproducible and effective although not easy. Most complications are minor and easily managed.

Intraoperative complications of laparoscopic adrenalectomy

A laparoscopic or retroperitoneoscopic access to the adrenal gland is the standard of care for adrenalectomy in most cases. Although in laparoscopic adrenalectomy the approach is minimally invasive, the procedure is challenging. This is reflected in the scope of possible complications. The surgeon must consider complications related to the anatomical topography of the adrenal gland, which typically encompasses the complications known from open surgery and complications related to the minimal invasive access. In this topic paper we will address the most frequently encountered complications of adrenalectomy: vascular injuries, injuries of the bowel, pleural tears, and injuries to the liver, spleen and pancreas. Fortunately, these complications occur rarely. However, many of these complications can have devastating consequences. Therefore, it's the surgeon's obligation to be aware of the possible complications he might encounter during laparoscopic adrenalectomy. This awareness is essential for their prevention and it helps the laparoscopic surgeon to identify complications intraoperatively.

Flank approach versus anterior sub-mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study

BACKGROUND

Laparoscopy is commonly recognized as the gold standard in adrenal surgery. The most used surgical access is at present the so-called flank approach. The aim of this study was to compare the flank approach and the anterior sub-mesocolic access carrying out left laparoscopic adrenalectomy (LA).

METHODS

From January 2003 to January 2006 50 eligible left LAs were randomized to the flank (n = 25, group A) or sub-mesocolic transperitoneal approach (n = 25, group B). The two groups were similar concerning patient and lesion features. Comparing the two approaches, the main parameters analyzed, adjusted for tumor size and histology, were operating time (OpT), complication rate, and hospital stay.

RESULTS

There were no converted procedures. Mean overall OpT was 76.4 min (54-96 min) versus 65.6 min (45-95 min) in group A and B, respectively (p = 0.001), while the OpT required to tie the adrenal vein was 42.8 min (26-55 min) and 24.5 min (16-41 min) (p = 0.000). Oral feeding resumed within 12-24 h in both groups. Mean hospital stay was 3 and 2.4 days in groups A and B, respectively (p = 0.04). Mean tumor size was similar in group A and B: 3.6 cm (1.5-6.5 cm) and 3.8 cm (2-6 cm), respectively. Definitive histology in groups A and B were: Cushing adenoma (6 and 4), Conn adenoma (5 and 6), pheochromocytoma (4 and 9), and incidentaloma (8 and 5, respectively). A myelolipoma and an adrenogenital adenoma were observed in group A and one carcinoma was observed in group B.

CONCLUSIONS

Sub-mesocolic approach provides a statistically significant shorter OpT and hospital stay. Identification and early closure of the adrenal vein by means of a really minimal dissection and no-touch gland technique resulted in the main benefits of this approach.

Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for aldosteronoma. We evaluated the retroperitoneal approach with regard to safety, efficacy, invasiveness and cost-benefit ratio in patients with primary aldosteronism.

METHODS

Between July 1999 and June 2005, we carried out a total of 195 retroperitoneoscopic adrenalectomies (RA) in one hospital, including 108 on the left and 87 on the right, in 78 men and 113 women aged 20-78 years (mean age 48.2 years) with aldosteronoma. Average adrenal tumor size was 16 mm (range 10-32 mm). The 195 operations were divided into 10 groups of 20 operations each, and the mean duration and estimated blood loss for each group were compared.

RESULTS

The mean operating time and intraoperative blood loss in RA were 93.2 +/- 37.4 (45-210) min and 68.5 +/- 53.2 (5-210) mL, respectively. Compared to group 1 (cases 1-20), a statistically significant decrease in operative time and estimated blood loss were seen in and after group 4 (>or= case 61, 94.5 +/- 30.3 vs 139.2 +/- 44.7 min, P < 0.01), and in and after group 5 (>or= case 81, 67.5 +/- 50.5 vs 120.5 +/- 60.9 mL, P < 0.01), respectively. No differences were found in duration of surgery and estimated blood loss between left and right sided tumors (P > 0.05). The mean postoperative hospital stay was 4.5 +/- 1.2 days. Postoperative complications, including hematoma and wound infection, occurred in 4.1% of patients.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy for aldosteronoma is a safe, effective, and minimally invasive approach with an advantageous cost-benefit ratio. With accumulated experience, it can expedite the learning curve for RA.

Laparoscopic resection of abdominal neuroblastoma

BACKGROUND

Since indications for laparoscopic adrenalectomy have progressively expanded to pediatric surgery, preliminary reports have studied the laparoscopic approach for abdominal neuroblastoma (NB). We aimed to report on the indications and the results of laparoscopic resection in a large series of abdominal NBs.

METHODS

A retrospective multicenter study included 45 children with abdominal NBs (28 localized, 11 stage 4, 6 stage 4s) and laparoscopic resection of their abdominal primary tumor. Primary site of the tumor was the adrenal gland in 41 cases and retroperitoneal space in 4. The median age at surgery was 12 months (1-122); median tumor size was 37 mm (12-70). Resection was performed through transperitoneal laparoscopy (n = 38) or retroperitoneoscopy (n = 7).

RESULTS

Complete macroscopic resection was achieved in 43 of 45 children (96%). The median duration of pneumoperitoneum was 70 min (30-160), and the length of hospital stay was 3 days (2-9). Four procedures (9%) were converted to open surgery, and tumor rupture occurred in three cases. Of the 28 children with localized disease, there was a 96% overall survival (OS) rate after a median follow-up of 28 months (4-94). There was one local relapse in this subgroup, with subsequent complete remission. For the entire 45-children cohort, four children died and three presented a recurrence resulting in OS, disease-free survival, and event-free survival rates of 84% +/- 8.1, 84% +/- 8.2, and 77% +/- 9.1 respectively.

CONCLUSION

Laparoscopic resection of abdominal primary allows effective local control of the disease in a wide range of clinical situations of neuroblastoma, with an acceptable morbidity.

Clinical outcomes and learning curve of a laparoscopic adrenalectomy in 103 consecutive cases at a single institute

OBJECTIVE

We examined the clinical outcomes and the learning curve for a laparoscopic adrenalectomy (LA) in 103 consecutive cases performed by three surgeons at our institute, according to the type of adrenal disorder.

PATIENTS AND METHODS

One hundred and three patients with adrenal tumors, including 38 cases of primary aldosteronism, 33 cases of Cushing syndrome (including preclinical Cushing syndrome), 15 cases of pheochromocytoma, and nine cases of non-functioning adenoma were evaluated, while focusing on the approaches, intraoperative and postoperative data, and the learning curve of LA, according the type of adrenal disorder.

RESULTS

There was no significant difference in the operation time, estimated blood loss, incidence of conversion to open surgery and blood transfusion, or postoperative recovery among the patients treated by LA for aldosteronoma, Cushing adenoma, pheochromocytoma, and non-functioning adenoma. In the cases of aldosteronoma and Cushing adenoma, the learning curve for the operation time and blood loss in each operator tended to decrease as the number of operations increased. On the other hand, in the cases treated by LA for pheochromocytoma, no trends in either the operation time or blood loss were observed. However, there has been neither any conversion to open surgery nor blood transfusion in cases treated by LA since 1998 (our 42nd case), even after the changes in the operators.

CONCLUSIONS

Our results clearly indicate that LA is becoming safer than before, probably due to improvements in the technique, education, and training of surgeons, in addition to the increased number of cases now treated by LA.

Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas: results of 161 tumors in 126 patients

BACKGROUND

Laparoscopic and retroperitoneoscopic excisions of pheochromocytomas and retroperitoneal paragangliomas are challenging surgical procedures because of extensive intraoperative catecholamine release, extreme vascularization, and demanding localization.

MATERIALS

In a prospective clinical study 161 chromaffine neoplasias (134 pheochromocytomas, 27 paragangliomas) were removed endoscopically in 126 patients (67 males, 59 females, age 41.7 +/- 16.4 years; 130 operations). Six patients showed multiple (2-5) tumors. Tumor size ranged from 0.5 to 12 cm (mean 3.5 +/- 1.9 cm). Forty-two patients suffered from hereditary diseases. Twenty-four patients had bilateral adrenal diseases; in 14 patients pheochromocytomas were removed on both sides synchroneously. Ten neoplasias were local or loco-regional recurrences (7 pheochromocytomas, 3 paragangliomas). The laparoscopic route was chosen in 16 operations; the retroperitoneoscopic technique was performed in 128 others. Partial adrenalectomies were performed in 57 operations (in all but one of the patients with bilateral disease). High-dosage alpha-blockade with phenoxybenzamine was routinely used.

RESULTS AND DISCUSSION

Conversion to open surgery occurred once. Perioperative complications were minor (17%); mortality was zero. Operating time for unilateral retroperitoneoscopically removed primary pheochromocytomas (n = 113) was 82 +/- 49 minutes (range: 20-300 minutes) and depended on tumor size (< 3 cm vs. > or = 3 cm; P < 0.05) and gender (P < 0.001), but not on extent of resection (partial vs. total, P = 0.266). Operating time for paragangliomas ranged from 55 to 600 minutes. Median blood loss was 20 ml. Median duration of postoperative hospitalization was 4 days. In 22 of 24 patients with bilateral disease, complete preservation of cortical function was achieved. Locoregional and/or distant metastatic recurrence were found in 5 patients.

CONCLUSIONS

Endoscopic removal of solitary, bilateral, multiple, and recurrent pheochromocytomas and retroperitoneal paragangliomas is feasible and safe, but surgeons need extensive experience in minimally invasive techniques, as well as in endocrine surgery.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Dispelling inhibition for laparoscopic surgery in younger children with Cushing's syndrome. Case report and literature review

Laparoscopic adrenalectomy (LA) is now the gold standard for the treatment of small, benign adrenal tumors in adults. In Cushing's syndrome (CS), LA is difficult and seldom done, especially in younger children. A 6-year-old girl was diagnosed with CS due to a juxtaadrenal tumor. She underwent LA and made an uneventful recovery. The histopathology was reported as paraganglioma which is a very rare cause of CS. LA is seldom done in younger children with CS owing to extreme obesity, abundant perinephric fat and a high incidence of pre- and postoperative complications.

Malignant adrenal tumors

Adrenal tumors, apart from neuroblastoma, are relatively rare in infancy and childhood. Most adrenal lesions are benign, and both benign and malignant tumors may be hormonally active thus, making accurate preoperative diagnosis difficult. The two main malignant tumors are adrenocortical carcinoma and pheochromocytoma. In both tumors, it may be difficult to determine benign from malignant and the biologic behavior and degree of invasion may portend a more malignant course. Surgical excision is the primary therapy for both tumors, including excision of metastatic and recurrent tumor. An open procedure should be considered for invasive adrenocortical carcinoma and in pheochromocytomas in which preoperative imaging demonstrates metastatic nodal disease. A laparoscopic approach is preferred for lesions in which preoperative imaging demonstrates a localized lesion. Chemotherapy, although without proven efficacy, is utilized in some children with metastatic or unresectable disease.

Cirugía laparoscópica en el tratamiento de enfermedades adrenales: experiencia en 200 casos

OBJECTIVE

We report our experience in laparoscopic adrenalectomy, after adopting the laparoscopic technique for 10 years as a primary option for suprarenal surgery.

METHODS

We included 200 laparoscopic adrenal surgeries performed consecutively in 183 patients with surgical adrenal pathology between November 1994 and November 2005. Sixty-seven (36.6%) patients were male and 116 (63.4%) were female, with an average age of 49.1 years (age range 8 months to 78 years).

RESULTS

The most frequents clinical diagnosis were hyperaldosteronism (17.5%), metastatic cancer (15.8%), pheochromocytoma (15.3%), Cushing syndrome (7.1%), adrenal cyst (4.9%) and myelolipoma (2.7%). A total of 164 total adrenalectomies, 29 partial adrenalectomies and 7 marsupializations of adrenal cysts were performed. Mean surgical time was 82.6 minutes (range 25 to 240 minutes) and mean hospitalization time was 2.5 days (range 1-10 days). The size of the suprarenal gland and/or tumor varied between 1 and 14 cm (average 5.6 cm). The rate of complication was 6%. In 8 of the patients, there was another laparoscopic procedure besides the adrenal surgery: cholecystectomies (2), marsupialization of a renal cyst (2), block nephrectomy (2), partial nephrectomy for a tumor (1) and pancreatic cystectomy (1). One patient underwent a right laparoscopic adrenalectomy and an ipsilateral percutaneous nephrolithotomy.

CONCLUSION

The accumulated experience with 200 laparoscopic adrenal procedures has allowed the management of endocrine pathologies, such as, aldosteroma, pheochromocytoma, Cushing syndrome and rare entities, such as, cysts, myelolipomas in a suitable manner. Additionally, it has permitted us to extend the benefits of a minimally invasive procedure for large adrenal masses and selected oncology cases.

Ten Years of Laparoscopic Adrenalectomy: Lesson Learned from 104 Procedures

The purpose of this study was to evaluate the short- and long-term results of 104 consecutive laparoscopic adrenalectomies performed during a period of 10 years in two specialist centers. One hundred four patients underwent laparoscopic adrenalectomy in two specialist centers in Italy between 1994 and 2003. Indications to laparoscopic adrenalectomy were aldosterone-secreting adenoma (20%), pheochromocytoma (24%), cortisol-secreting adenoma (11.5%), incidentaloma (26.9%), multiple endocrine neoplasia (MEN) type 2A (2.8%), adrenal metastases from lung cancer (3.8%), adrenal cyst (6.7%), and angiomyolipoma (3.8%). Transperitoneal anterior and lateral approaches were adopted in 17 and 84 patients, respectively. Retroperitoneal approach was adopted in three patients. Mean operative time was 108 ± 39.1 minutes (range, 40–300 minutes). There was no correlation between adrenal tumor diameter and operative time. Mean intraoperative blood loss was 106 mL (range, 40–600 mL). Intraoperative complication rate and conversion rate were 4.8 per cent (5 cases). Laparoscopic adrenalectomy is a safe procedure. After a relatively short learning curve, it can be performed successfully by any surgeon with low operative morbidity and mortality. The size of the adrenal tumor should not be considered a contraindication to this procedure.

[Laparoscopic adrenalectomy--experience of 10 years]

INTRODUCTION

The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan and North America. We reviewed our 10-year experience with laparoscopic adrenal surgery.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was carried out in 113 patients, 77 females and 36 males, between January 1994 and January 2004. The age ranged from 1 to 76 years (43.1 +/- 16.2 years). Ten (8.8%) patients were 20 years old or younger, 19 (16.8%) patients had unilateral tumor larger than 4 cm, 25 (22.1%) patients had Body Mass Index > or = 30 kg/m2, and 13 (11.5%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (3.3 +/- 1.6 cm). One hundred and sixteen operations were performed, of which 109 were unilateral and 7 were bilateral, adding up to a total of 123 adrenalectomies. Among the 116 procedures, the lateral transperitoneal approach was employed in 113 cases, whereas lateral retroperitoneal approach enabled 3 adrenalectomies.

RESULTS

Unilateral procedures lasted 107 +/- 33.7 min (45-250 min); bilateral procedures lasted 180 +/- 90.6 min (100-345 min); 5 (4.3%) cases were converted to open surgery. Twenty (17.7%) patients suffered complications, being 8 (7.0%) intraoperative and 12 (10.6%) postoperative complications. Six (5.3%) cases were considered major complications. No deaths occurred due to the surgical procedures. Blood transfusion rate was 3.5%. Hospital stay was 5.7 +/- 15.0 days (1-140 days). Follow-up period was 23 +/- 12.8 months (1-60 months) and all these patients were followed for a minimum of 6 months.

CONCLUSIONS

Laparoscopic adrenalectomy is feasible and has excellent results in selected patients.

Retroperitoneal laparoscopic adrenalectomy

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of the adrenal gland. Since the initial report of laparoscopic adrenalectomy in 1992, it has evolved into a feasible and reproducible minimally invasive procedure for benign adrenal tumors. Transperitoneal and retroperitoneal approaches are the two principal laparoscopic routes to the adrenal gland. Both have proven to be safe and effective when compared with open adrenalectomy, offering the benefits of decreased blood loss, less postoperative pain, shorter hospital stay, rapid convalescence, and improved cosmetic effect. Although the transperitoneal approach is used more widely, the retroperitoneal approach offers distinct advantages that make it a valuable alternative route to the adrenal gland. This article describes retroperitoneal laparoscopic adrenalectomy including indications, operative technique, and a review of the literature.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

The clinically inapparent adrenal mass: update in diagnosis and management

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

Justification of extraperitoneal laparoscopic access for surgery of the upper urinary tract

Laparoscopic surgery was originally developed by gynecologists and general surgeons. Based on their experience, the first successful laparoscopic procedures in urology were performed transperitoneally. However, this novel technique transformed traditionally retroperitoneal procedures into transperitoneal procedures, giving free rein to distinct intraperitoneal complications. Retroperitoneal laparoscopy was a later development in urology. This approach has gained increasing popularity throughout the years and has challenged the transperitoneal laparoscopic route in many aspects. This review focuses on the advantages of retroperitoneal laparoscopic surgery of the upper urinary tract.

One Hundred Laparoscopic Adrenalectomies: A Single Surgeon’s Experience

BACKGROUND

Since the first laparoscopic adrenalectomy was performed in 1992, it has quickly gained acceptance as the standard of care for the treatment of benign adrenal neoplasms. We report a single surgeon's experience with 100 consecutive laparoscopic adrenalectomies.

METHODS

The records of all patients having adrenalectomy at the Johns Hopkins Hospital from 1993 until 2000 were reviewed. We examined the length of stay, time to diet resumption, perioperative morbidity, operative cost, and total cost of 100 consecutive laparoscopic adrenalectomies. These data are compared with those of 20 patients within our institution having open adrenalectomy and with 428 patients statewide having all forms of adrenalectomy during the same time period.

RESULTS

A total of 93 patients had unilateral laparoscopic adrenalectomy and 7 had bilateral procedures. The mean age was 49 years (11 to 70). Indications were aldosteronoma (n = 40), pheochromocytoma (n = 22), glucocorticoid-producing adenoma (n = 14), nonfunctioning adenoma (n = 12) Cushing's disease (n = 5), and others (n = 7). The median length of stay for this series was 1.0 day. Average length of stay and time to resumption of diet were 1.8 and 1.0 days, respectively. Patients having open procedures during this same time period had an average length of stay of 6.5 days.

CONCLUSIONS

Laparoscopic adrenalectomy provides clear advantages over open adrenalectomy. Patients having laparoscopic adrenalectomy have decreased length of stay, shorter time to resumption of diet, and lower total hospital charges when compared with those having open adrenalectomy.

Laparoscopic adrenal surgery for neuroblastomas in children

PURPOSE

The role of laparoscopy in children with neuroblastomas has not been fully defined. The laparoscopic approach to the adrenal gland is already largely used in adults and a few cases have been reported in children. We report the experience of a single surgical team center with laparoscopic adrenal surgery for neuroblastomas in children.

MATERIALS AND METHODS

Between September 2000 and October 2002 laparoscopic adrenalectomy for neuroblastoma was performed in 9 patients (6 girls and 3 boys) with a mean age of 38 months (range 2 months to 9 years). Two tumors were detected prenatally and 7 postnatally. Preoperative diagnosis was neuroblastoma stage I in 4 cases and stage IV in 3 cases, and nondetermined suprarenal calcified masses in 2 cases. A 4 or 5-trocar transperitoneal approach was used in all cases. The adrenal tumors were completely excised, placed into a plastic bag and removed through the umbilical trocar site.

RESULTS

All of the adrenal tumors were well encapsulated and completely excised. One of the 9 procedures was converted to open surgery because of adhesions to renal vessels. In 1 case a second hepatic localization was removed simultaneously, and in 3 cases 1 or more lymph nodes were resected. Average operative time was 85 minutes (range 45 to 170). There were no deaths. There were no postoperative complications, except 1 port site infection that was treated locally. Blood transfusion was not required. Average hospital stay was 4.5 days (range 2 to 10). Histological analysis of the 9 specimens (maximum length 6 cm) confirmed the diagnosis of neuroblastoma. N-myc status was studied in 8 of the 9 resected neuroblastomas and was amplified in 2 cases (both stage IV with preoperative biopsy). Average postoperative followup was 15 months (range 1 to 25). There was no local recurrence or metastasis, except in the case that required conversion to open surgery (local recurrence 7 months later).

CONCLUSIONS

Laparoscopic adrenalectomy for neuroblastoma is safe and feasible in children, with good results. Experience with advanced laparoscopic surgery is required to achieve this result in optimal oncological conditions. Our short-term results must be reevaluated at long term, and further studies are needed to compare laparoscopy to open surgical techniques.

Laparoscopic Adrenalectomy: A Worthwhile Procedure Performed in a General Surgery Department

A laparoscopic procedure is considered the treatment of choice for adrenalectomy. We report the experience of a nonreferring unit for adrenal pathology; we have evaluated its safety and feasibility in a series of 40 patients. From 1994 to 2001, forty consecutive patients underwent laparoscopic adrenalectomy, 37 with transperitoneal and 3 with retroperitoneal approach. The mean operative time was 129 ± 51.7 minutes (range 60–300): 107 ± 29 minutes (range 60–100) for the right-sided transperitoneal adrenalectomy and 144 ± 62 minutes (range 90–300) for the left-sided transperitoneal adrenalectomy. The mean intraoperative blood loss was 90 mL (range 40–200). The procedure laparoscopic was converted to open in one case for the presence of a voluminous angiolipoma arising from the retroperitoneal fat strictly adherent to the adrenal gland. The postoperative morbidity rate was 5.1 per cent. Pain medication was required for a mean period of 1.6 ± 0.6 days (range 1–3). The patients were able to resume solid food after an average time of 1.8 ± 0.7 days (range 1–4). Postoperative hospital stay was 3 ± 1.4 days (range 2–8). We believe that laparoscopic adrenalectomy is safe and effective in removing benign functioning or nonfunctioning adrenal masses and also in a general surgery department.

Laparoscopic adrenal surgery in a Brazilian center

BACKGROUND AND PURPOSE

The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan, and North America. We reviewed our 7-year experience with laparoscopic adrenal surgery. This is the first large series presented from Latin America.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was carried out in 61 female and 33 male patients between January 1994 and February 2001. Their ages ranged from 1 to 72 (42.8 +/- 16.4 years) years. Ten patients (10.6%) were 20 years or younger, 10 (10.6%) had unilateral tumors >4 cm, 22 (23.4%) had a Body Mass Index >/= 30, and 10 (10.6%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (2.9 +/- 4 cm). Ninety-seven operations were performed, of which 91 were unilateral and 6 were bilateral, adding up to 103 adrenalectomies. Among the 97 procedures, the lateral transperitoneal approach was employed in 94 cases, whereas a lateral retroperitoneal approach enabled 3 adrenalectomies.

RESULTS

Unilateral procedures lasted 117 +/- 43.7 minutes (range 45-250 minutes); bilateral procedures lasted 186 +/- 91.6 minutes (range 100-345 minutes). Five operations (5.1%) were converted to open surgery. Twenty patients (21.3%) suffered complications, 8 (8.5%) being intraoperative and 12 (12.8%) postoperative. Six cases (6.4%) were considered major complications. No deaths occurred. The blood transfusion rate was 4.2%. The hospital stay averaged 6.1 +/- 15.3 days (range 1-140 days). The follow-up period was 17 +/- 12.6 months (range 1-60 months).

CONCLUSIONS

Laparoscopic adrenalectomy is feasible and has excellent results in properly selected patients.

Laparoscopic management of primary hyperaldosteronism: clinical experience with 212 cases

PURPOSE

Laparoscopy is now widely used to remove benign adrenal tumors. We assessed the value of transperitoneal partial or total adrenalectomy for primary hyperaldosteronism.

MATERIALS AND METHODS

From September 1994 to October 2001, 212 consecutive patients with a mean age of 48 years who presented with primary hyperaldosteronism and related arterial hypertension underwent transperitoneal laparoscopic adrenalectomy (193) or tumor enucleation (20) performed by a single surgeon, including 1 who underwent bilateral adrenalectomy. In all cases preoperatively high plasma and urine aldosterone was associated with low plasma renin and hypokalemia.

RESULTS

Mean followup was 44 months. Conversion to open surgery was necessary in 30 patients (14%) due to bleeding or adhesion and a procedure duration of greater than 3 hours. Mean operative time was 102 minutes (range 30 to 260). Six patients (2.8%) required blood transfusion. No deaths occurred. Postoperatively complications were observed in 10% of patients and the most frequent one was electrical myocardial ischemia without infarction. Mean postoperative pain medication was 17 mg. morphine sulfate equivalents (range 0 to 60). Mean and median hospital stay was 3.6 and 2.9 days, respectively (range 2 to 20). Postoperatively blood pressure was normal in 58% of patients without any drug, while treatment was decreased in the remainder. Kalemia was normalized in all cases.

CONCLUSIONS

Although some complications can occur, mostly at the beginning of the learning curve, laparoscopic transperitoneal adrenalectomy is effective treatment for primary hyperaldosteronism.

Laparoscopic adrenalectomy: alternative or new standard?

Laparoscopy has become a standard approach for adrenalectomy because of its safety, low invasiveness, and less demanding technical nature and the readily removable size of tumor through trocar incision. Comparative studies between open and laparoscopic adrenalectomy document less blood loss, shorter hospital stay, and lower incidence of complication. These reports also show that the patients have less pain, use fewer narcotics postoperatively, and have quicker resumption of oral intake after surgery with the laparoscopic approach. The techniques for laparoscopic adrenalectomy started with the transperitoneal approach and developed into the retroperitoneal approach. Further technical development and recognition yielded three transperitoneal and two retroperitoneal approaches. Characteristics of each approach are discussed. Due to technical developments and experiences in laparoscopic surgery, application of the laparoscopic approach has been expanded to include excision for adrenal cancer and laparoscopic partial adrenalectomy for bilateral pheochromocytoma in certain cases and in selected institutes.

Surgical strategy in adrenal masses

OBJECTIVE

Endoscopic adrenalectomy represents the "New Golden Standard" in the surgical treatment of benign adrenal lesions up to 6 cm. Open adrenalectomy is recommended for patients with suspected malignant disease and tumors larger than 6 cm.

METHODS AND MATERIAL

The surgical technique of trans- and retroperitoneal adrenalectomy is described. Reviewing literature the importance of the endoscopic approach and its role in the surgical treatment of adrenal lesions is analyzed.

RESULTS

As in open adrenalectomy different endoscopic approaches to the adrenals were developed: adrenal tumors can be removed endoscopically using a transperitoneal (patient in a supine or lateral decubitus position) or extraperitoneal route (patient in a lateral decubitus or prone position). Reviewing literature the endoscopic transperitoneal adrenalectomy is documented in 1425 patients. 4.6% (66 patients) had to be converted to an open procedure. Five hundred and forty-four tumors were removed by an extraperitoneal access. The conversion rate was 4.4% (24 patients).

CONCLUSION

The basis of excellent results are careful patient selection, evaluation and preoperative preparation in a center with experience in the open techniques and at least 20 endoscopic adrenalectomies per year.