Laparoscopic adrenalectomy: retroperitoneal approach

Subdiaphragmatic phrenic nerve supply: A systematic review

OBJECTIVE

The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve.

MATERIALS AND METHODS

A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included.

RESULTS

A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure.

CONCLUSIONS

This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.

Retroperitoneal laparoscopic adrenalectomy for large adrenal tumors-analysis of tumor size and adverse events: a retrospective single-center study

Introduction

Adrenal tumors are relatively common, and adrenalectomy is the third most common endocrine surgery. Patients with adrenal tumors were categorized into two groups for analysis: those with intermediate (4-6 cm, Group 1) and large (>6 cm, Group 2) tumors undergoing Retroperitoneal Laparoscopic Adrenalectomy (RLA). The primary outcome is to compare the surgical outcomes between these two groups. The secondary outcome involves analyzing the relationship between tumor characteristics and the incidence of adverse events.

Methods

Data from 76 patients who underwent RLA for tumors of size ≥4 cm between 2005 and 2022 at a single tertiary referral center were analyzed retrospectively. Variables, including patients' age, hormone function, operation time, conversion to open approach, perioperative complications, and adverse surgical events (blood loss >500 cc, conversion to open approach, and perioperative complications), were assessed.

Results

No significant differences were observed between the two groups in terms of functional and histopathologic analysis, gender distribution, functioning factors, perioperative complications, and estimated blood loss. However, patients in Group 2 were younger (median age 50, IQR: 40-57, P = 0.04), experienced longer operative times (median 175 min, IQR: 145-230 min, P = 0.005), and had a higher rate of conversion to open surgery (12%, P = 0.033). For every 1 cm increase in tumor size, the odds ratio for adverse surgical events increased by 1.58.

Conclusions

RLA is a safe and feasible procedure for adrenal tumors larger than 6 cm. While intraoperative and postoperative complications are not significantly increased in either group, larger tumors increase surgery times and are more likely to require conversion to open surgery. Therefore, caution and preparedness for potential adverse events are recommended when dealing with larger tumors. A tumor size of 5.3 cm may serve as a guide for risk stratification and surgical planning in large adrenal tumor management.

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.

Recovery of Surgical Training Through Extended Laparoscopic Simulation Training

Introduction The coronavirus disease 2019 (COVID-19) pandemic has adversely affected surgical training internationally. Laparoscopic surgery has a steep learning curve necessitating repetitive procedural practice. We evaluate the efficacy of short- and long-duration simulation training on participant skill acquisition to support the recovery of surgical training.  Methods A prospective, observational study involving 18 novice medical students enrolled in a five-week course. Nodal timed assessments involved three tasks: hoop placement, stacking of sugar cubes and surgical cutting. One month post-completion, we compared the ability of six novice course participants to that of six surgical trainees who completed a smaller portion of the course curriculum. Results Course participants (n=18) completed tasks 111% faster on their third and last course attempt. The surgical trainee group (n=6) took 46% longer to complete tasks compared to the six re-invited course participants, whose ability continued to advance on their fourth effort with a combined 154% earlier completion time compared to try one. Conclusions This study supports the adoption of a structured, extended, regular and spaced-out simulation course or curriculum to cultivate greater skill acquisition and retention amongst surgical trainees, and improve patient care.

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.

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.

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.

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.

Laparoscopic adrenalectomy - ten-year experience

Objectives

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

Material and methods

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

Results

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

Conclusions

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

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.

Laparoscopic adrenalectomy for beginners without open counterpart experience: initial results under staged training

OBJECTIVES

To develop a staged laparoscopic training program for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility.

METHODS

From January 2002 to October 2007, 5 beginners (postgraduate years 1-5) without previous experience in open adrenalectomy were selected randomly to receive the staged laparoscopic training, including box-trainer, animal model, and mentor-initiated clinical training. During the clinical training, the trainees acted as the camera holder first, and then selectively performed simple operations, such as laparoscopic renal cyst unroofing. Finally, they performed 30 LAs independently under the mentor's supervision using the technique of anatomic retroperitoneoscopic adrenalectomy. The clinical data of the 30 LAs performed by each the trainees (150 LAs total) were collected and compared with the data from the initial 30 LAs of the mentor.

RESULTS

All LAs were completed successfully. No procedure required conversion to open surgery. The median operative time of the trainees was 82.3 minutes (range 59-133), which was obviously shorten than the mentor's (median operative time 131.5 minutes, range 73-230, P < .001). The learning curve among the trainees was shorter compared with that of the mentor. No major complications were observed. The minor intraoperative and postoperative complication rate for the trainees was 0.67% and 6.7%, respectively, not significantly different from those of the mentor (0% and 3.3%, respectively; both P > .05). All complications developing in patients treated by the trainees required only conservative therapy.

CONCLUSIONS

It was safe and feasible for beginners without previous open counterpart experience to perform LA using staged training.

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.

Retroperitoneoscopic adrenalectomy: lateral versus dorsal approach

BACKGROUND

For tumours of the adrenal gland different surgical retroperitoneal approaches have been established, including the lateral and the dorsal approach. It is still unclear if the lateral or the dorsal approach should be preferred.

PATIENTS AND METHODS

A retrospective comparison between 21 patients who underwent retroperitoneoscopic adrenalectomy in lateral position (LRA) and 24 patients who underwent a retroperitoneoscopic adrenalectomy in dorsal position (DRA).

RESULTS

There were no significant differences with regard to the age, sex, tumour localisation, and the size of the tumour. The body-mass-index as well as the operation time was significantly higher of patients who underwent surgery in lateral position. Complications were comparable in both groups.

CONCLUSION

The dorsal and the lateral retroperitoneal approach are ideal approaches for patients having had an intraabdominal surgery before. Due to the missing intraabdominal pressure the lateral approach is advantageous for patients with high body-mass-index (>35) and is indicated for patients with a tumour >6 cm due to the small retroperitoneal space.

Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheochromocytoma

PURPOSE

We compared the clinical outcomes of retroperitoneoscopic and open adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Clinical data on 56 patients who underwent retroperitoneoscopic lateral adrenalectomy were retrospectively compared with those on 50 who underwent open adrenalectomy for pheochromocytoma, including patient demographic data, perioperative indexes and clinical outcomes.

RESULTS

Demographic data on patients were similar in the 2 groups. In the retroperitoneoscopic group such perioperative indexes were significantly different from those of the open group (each p <0.05), including operative time (mean +/- SD 52 +/- 22 vs 120 +/- 42 minutes), estimated blood loss (74 +/- 34 vs 187 +/- 64 ml), resumption of oral intake (1 vs 2 days), postoperative hospital stay (5.2 +/- 1.7 vs 8.3 +/- 1.8 days), incidence of intraoperative hypertension (17.0% or 9 of 53 patients vs 36.0% or 18 of 50) and number of patients requiring blood transfusion(1.8% or 1 of 53 vs 16.0% or 8 of 50). The incidence of systemic inflammatory response syndrome was much less in the retroperitoneoscopic group (20.8% or 11 of 53 patients vs 42.0% or 21 of 50, p <0.05). However, the duration of systemic inflammatory response syndrome and postoperative complications were similar in the 2 groups (p >0.05). Blood pressure returned to normal 3 months after the operation in 81% of the patients in the retroperitoneoscopic group and in 84% in the open group. During the followup of 5 to 36 months no tumor recurrence and/or metastasis developed.

CONCLUSIONS

Compared with open surgery retroperitoneoscopic lateral adrenalectomy for pheochromocytoma is a safe, minimally invasive and effective procedure.

Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases

PURPOSE

To our knowledge we introduce the technique of anatomical retroperitoneoscopic adrenalectomy.

MATERIALS AND METHODS

From February 2000 to October 2005 anatomical retroperitoneoscopic adrenalectomy was performed in 800 consecutive patients with adrenal lesions using a 3 port lateral retroperitoneal approach. After incising Gerota's fascia 3 relatively bloodless planes were entered consecutively to expose and separate the adrenal gland. When entering the first dissection plane between the perirenal fat and anterior renal fascia located at the superomedial side of the kidney, the adrenal could be identified at the initial stage of the operation. The following dissections proceeded in the plane between the posterior renal fascia and the lateral aspect of perirenal fat, and then in the avascular plane located on the parenchymal surface of the upper renal pole. The adrenal vein was dealt with at the final stage. Operative time was defined as the time from skin incision to skin closure.

RESULTS

Mean +/- SE operative time was 45 +/- 19.1 minutes (range 25 to 230) and mean estimated blood loss was 25 +/- 10.6 ml (range 5 to 200). Average time to oral intake and ambulation were 1.2 and 1.0 day, respectively. Minor postoperative complications occurred in 12 patients (1.5%). Major complications and perioperative mortality were not observed. The procedures resulted in marked clinical improvements in patients with a hormone secreting tumor, except in 6 with idiopathic adrenal hyperplasia.

CONCLUSIONS

Anatomical retroperitoneoscopic adrenalectomy is a safe, effective, technically efficient procedure for surgical adrenal diseases.

Laparoscopic Adrenalectomy: A Single-Center Experience of 43 Cases

PURPOSE

To evaluate the surgical feasibility of laparoscopic adrenalectomy and what laparoscopy offers for the surgeon and the patient.

PATIENTS AND METHODS

From March 1996 to June 2004, 43 transperitoneal laparoscopic adrenalectomies were performed for various pathological states. Functioning adrenal masses and solid masses>5 cm were the most common indications. The mean size of the masses on abdominal CT was 6.8 cm in the largest diameter. All patients were assessed regarding the operative time, blood loss, complications, and conversion to open surgery. The postoperative course was reported with special attention to the complications and hospital stay.

RESULTS

The mean operative time was 125 minutes with a mean blood loss of 60 mL. Intraoperative complications occurred in 3 cases (6.9%), necessitating conversion to open surgery in 2 to control bleeding from the avulsed right adrenal vein. A third case of conversion was elective because of difficult dissection of a large left pheochromocytoma from the renal hilum, so there was a 6.9% rate of conversion to open surgery. All patients showed early ambulation, early start of eating, and a short hospital stay (mean 2.6 days).

CONCLUSION

Laparoscopic adrenalectomy is surgically feasible and can be applied for different adrenal pathologies. The procedure can be performed with a reasonable operative time, minimal blood loss, and an acceptable rate of complications. Laparoscopic adrenalectomy provides excellent postoperative recovery and convalescence with a short hospital stay.

Laparoscopic adrenalectomy for primary and secondary malignant adrenal tumors

Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tumors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasible procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.

Laparoscopic Adrenalectomy for Large Adrenal Tumors

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy remains a controversial procedure for large tumors. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions.

PATIENTS AND METHODS

A total of 178 patients underwent laparoscopic adrenalectomy, of whom 29 patients had large (>or =5 cm) tumors. Their mean age was 47.9 years (range 21-72 years), and the mean tumor size was 6.5 cm (range 5.0-11.0 cm). They were compared with patients whose adrenal tumors were <5 cm.

RESULTS

The large-tumor group had a mean operating time of 176 +/- 48 minutes (range 84-278 minutes) and a mean blood loss of 136.6 mL (range 10-800 mL) and required a mean of 1.8 days before starting oral intake. None of these values is significantly different from the results in the control group (P > 0.05). The length of recovery was significantly longer in the large-tumor group (5.4 v 4.5 days; P < 0.05), but this was not true if a patient with a 23-day postoperative stay is excluded. The overall incidence of complications was 12% in the large-tumor group, which was not significantly different from that in the control group (P > 0.05).

CONCLUSIONS

The operating time, blood loss, and incidence of complications after laparoscopic adrenalectomy did not differ between the patients with large and small adrenal tumors, indicating that experienced surgeons can safely and effectively use laparoscopy for larger tumors. However, it is necessary to consider carefully whether laparoscopic surgery is indicated for tumors that show infiltration on preoperative imaging or for patients who have undergone previous upper-retroperitoneal surgery.

Anatomical reconsideration to renal area: lessons learned from radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib

BACKGROUND

To perform radical nephrectomy or adrenalectomy through a minimal incision over the 12th rib and to compare this with the traditional supracostal or transcostal approach. We review and clarify the related surgical anatomy through close observation.

METHODS

We performed radical nephrectomy in six patients with upper urinary tract carcinoma through a minimal incision over the 12th rib and in five patients with renal cell carcinoma through a medium-sized incision, and adrenalectomy in five patients (bilaterally in one) again through a minimal incision over the 12th rib. During surgery, special points were noted to find out the differences between the new minimal-incision approach and the conventional approach.

RESULTS

The procedures were accomplished smoothly with no complications through either a minimal or medium-sized incision. From our observation, it is clear that most of the procedures involved in the minimal-incision approach were and should be carried out within the space created in the retroperitoneum beneath the lateroconal fascia.

CONCLUSION

Entering the correct anatomical planes posteriorly and anteriorly in the renal fasciae is a prerequisite for full mobilization of the kidney, together with the perinephric fat. To perform this, recognition of the lateroconal fascia and incising it along the correct lines are of the utmost importance for minimal-incision radical nephrectomy and adrenalectomy. Furthermore, this anatomical approach is also important for the conventional open approach and laparoscopic approach.

Videoendoscopic surgery by extraperitoneal access

Laparoscopic surgery in urology is definitely incorporated to the techniques of minimally invasive treatment for urogenital diseases. Though the classic access to organs in the urinary tract is extraperitoneal, this access has not been prioritized when the videoendoscopic technique is used. In Brazil, few groups use this approach and little has been discussed about its true practical applicability. The authors intended to discuss the main technical aspects and criteria for indication, reported though the improvement achieved in a 5-year period with 150 operated cases. A review of the literature shows that the worldly acceptance of the extraperitoneal endoscopic approach is increasing. Nevertheless, there are no evidences that the extraperitoneal access is superior to the transperitoneal route. Thus, the choice depends basically on the surgeon's preference. Major advantages are the immediate access to the renal hilum and isolation of peritoneal structures. Employing this access is useful when one suspects that significant peritoneal adherences could prevent the surgical act or when one wishes to preserve the integrity of the peritoneal cavity.

Laparoscopic surgery for malignant adrenal tumors

This paper outlines the indications and techniques of laparoscopic surgery for malignant adrenal tumors. Laparoscopic surgery is not indicated for adrenal tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. When laparoscopic surgery is performed for a tumor without invasion that has a maximum diameter of more than 6 cm or a tumor that is considered potentially malignant from preoperative imaging or endocrine studies, it is important to inform the patient and family that the tumor may be malignant and that conversion to open surgery may be necessary. The transperitoneal approach is appropriate for primary adrenal malignancies. For metastatic cancer, the transperitoneal approach is suitable for radical surgery and the extraperitoneal approach for histological diagnosis by partial resection or tumor biopsy. In either case, it is important for the surgeon to have a sufficiently wide working space, to remove the tumor and surrounding fat en bloc, to never grasp the tumor or adrenal tissue, and to carefully handle the ultrasonically activated scalpel or ultrasonic aspirator so that it does not touch the tumor surface due to the risk of tumor cell dissemination. It is also essential not to unreasonably persist with laparoscopic procedures, but to immediately switch to open surgery when laparoscopic surgery becomes difficult.

Retroperitoneal laparoscopic adrenalectomy

Retroperitoneoscopic adrenalectomy is currently performed either by lateral flank approach or posterior lumbar approach. The retroperitoneal laparoscopic adrenalectomy avoids invading the intraperitoneal cavity and possible injury to the abdominal organs. The posterior lumbar approach allows direct access to the main adrenal vascular supply before the gland is manipulated. Retroperitoneal laparoscopic adrenalectomy by the posterior approach is technically feasible and most effective as regards the simplicity of vascular control. The lateral flank approach allows a more spacious working cavity, but a large tumor obscures the surgical plane to the adrenal vessels. The transection of the adrenal vein is performed at the end of the procedure. The operating time, perioperative morbidity and cost have been reduced with these retroperitoneal approaches. The retroperitoneal approach to the adrenal gland is technically simple and can be performed quickly, with a low postoperative morbidity and should be regarded as the routine approach for relatively small adrenal benign tumors that are less than 5 cm in diameter.

Retroperitoneoscopic adrenal surgery with reusable instruments

BACKGROUND AND PURPOSE

Retroperitoneoscopic surgery has proven advantages over open surgery in terms of cosmesis, reduced postoperative pain, hospital stay, and early return to work. This is particularly true for surgery of the adrenal gland that otherwise entails a large surgical incision. One of the drawbacks of this surgery is the additional cost attributable to the disposable instruments. We present our cost-reductive retroperitoneoscopic techniques to tackle a variety of adrenal pathologies.

PATIENTS AND METHODS

Beginning March 1995, 17 patients underwent cost-reductive retroperitoneoscopic adrenal surgery for various indications including 12 pheochromocytomas, 3 myelolipomas, 2 adrenal cortical adenomas, and two adrenal cysts. Two patients underwent simultaneous bilateral procedures for pheochromocytoma. A cost-reductive technique using minimal disposable equipment was employed.

RESULTS

The procedure was completed in 18 of 19 cases (94%). One patient undergoing an adrenalectomy for pheochromocytoma was converted to open surgery because of nonprogress of the dissection. The largest tumor removed measured 10 cm. The mean operative time was 133 minutes, the average blood loss 169 mL, NSAID doses 3.56, and hospital stay 4.6 days. There were two major and two minor complications with no deaths.

CONCLUSIONS

Cost-reductive retroperitoneoscopy is a feasible option for the management of a variety of adrenal pathologies. It should be considered a difficult procedure and be undertaken only by surgeons proficient in laparoscopy.

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.

Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis

PURPOSE

To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches.

MATERIALS AND METHODS

From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40.

RESULTS

To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive.

CONCLUSIONS

Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.