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Kook Y, Choi HR, Kang SW, Kim JK, Lee CR, Lee J, Jeong JJ, Nam KH, Chung WY. Laparoscopic adrenalectomy: comparison of outcomes between posterior retroperitoneoscopic and transperitoneal adrenalectomy with 10 years' experience. Gland Surg 2021; 10:2104-2112. [PMID: 34422581 DOI: 10.21037/gs-21-178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/17/2021] [Indexed: 11/06/2022]
Abstract
Background Laparoscopic adrenalectomy is widely used for treating various adrenal tumors. Posterior retroperitoneoscopic adrenalectomy was introduced after transperitoneal laparoscopic adrenalectomy. The comparability and superiority of posterior retroperitoneoscopic adrenalectomy have been widely investigated. We aimed to compare the outcomes of posterior retroperitoneoscopic adrenalectomy and transperitoneal laparoscopic adrenalectomy using 10 years' data. The changes in outcomes over time were also analyzed. Methods This was a retrospective observational study. A total of 505 patients who underwent laparoscopic adrenalectomy between 2009 and 2018 were included. The patients were divided into two groups: transperitoneal (n=114) and retroperitoneal (n=391) groups. Patients who underwent posterior retroperitoneoscopic adrenalectomy were further classified into sub-groups (sub-group 1: 2009-2012; sub-group 2: 2013-2015; and sub-group 3: 2016-2018) based on time periods. Clinicopathological factors and postoperative outcomes were retrospectively reviewed and analyzed. Results The retroperitoneal group showed significantly shorter operation time, diet initiation time, and hospital stay compared to the transperitoneal group (P=0.000, 0.000 and 0.000, respectively). Analgesics were used less frequently in the retroperitoneal group than in the transperitoneal group (P=0.048). In the retroperitoneal group, the time to postoperative diet initiation shortened over time (P=0.000). Conclusions Posterior retroperitoneoscopic adrenalectomy is a favorable surgical method that results in patient outcomes that are comparable to those of conventional transperitoneal laparoscopic adrenalectomy, without compromising patient safety.
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Affiliation(s)
- Yoonwon Kook
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ryeon Choi
- Department of Surgery, Eulji Medical Center, Seoul, Korea
| | - Sang-Wook Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jandee Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Hyun Nam
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Youn Chung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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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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Bhat HS, Tiyadath BN. Management of Adrenal Masses. Indian J Surg Oncol 2017; 8:67-73. [PMID: 28127186 PMCID: PMC5236029 DOI: 10.1007/s13193-016-0597-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022] Open
Abstract
An adrenal mass can be either symptomatic or asymptomatic in the form of adrenal incidentalomas (AIs) in up to 8 % in autopsy and 4 % in imaging series. Once a diagnosis of adrenal mass is made, we need to differentiate whether it is functioning or nonfunctioning, benign, or malignant. In this article, we provide a literature review of the diagnostic workup including biochemical evaluation and imaging characteristics of the different pathologies. We also discuss the surgical strategies with laparoscopy as the mainstay with partial adrenalectomy in select cases and adrenalectomy in large masses. Follow-up protocol of AIs and adrenocortical carcinoma is also discussed.
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Affiliation(s)
- Hattangadi Sanjay Bhat
- Department of Urology and Renal transplantation, Rajagiri Hospital, Munnar Rd Chunagamvely Aluva, Kochi, Kerala 683112 India
| | - Balagopal Nair Tiyadath
- Department of Urology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita lane elmakkara, Kochi, Kerala 682041 India
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Xu W, Li H, Ji Z, Yan W, Zhang Y, Zhang X, Li Q. Retroperitoneal Laparoscopic Management of Paraganglioma: A Single Institute Experience. PLoS One 2016; 11:e0149433. [PMID: 26885838 PMCID: PMC4757081 DOI: 10.1371/journal.pone.0149433] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/30/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore the feasibility and safety of retroperitoneal laparoscopic resection of paraganglioma (RLPG) in a large study population. METHODS In a six-year period, 49 patients with primary retroperitoneal paragangliomas (PG) underwent retroperitoneal laparoscopic surgery in a single center. Medical records were reviewed, and collected the following data, which were clinical characteristics, perioperative data (operative time, estimated blood loss, intraoperative hemodynamic changes, intraoperative and postoperative complications, and open conversions), and follow-up data (recurrence or distant metastases). RESULTS All PGs were removed with negative tumor margin confirmed by postoperative histopathology. The operative time of RLPG was 101.59±31.12 minutes, and the estimated blood loss was 169.78±176.70ml. Intraoperative hypertensive and hypotensive episodes occurred in 25 cases and 27 cases, respectively. Two open conversions occurred. Two intraoperative complications occurred but were successfully managed endoscopically. Postoperative complications were minor and unremarkable. No local recurrence or distant metastasis were observed during the follow-up period. CONCLUSIONS Our experience indicates the feasibility and safety of resection of PGs in a relatively large study population.
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Affiliation(s)
- Weifeng Xu
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
- * E-mail:
| | - Zhigang Ji
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Weigang Yan
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xuebin Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qian Li
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Assessment of postoperative changes in antihypertensive drug consumption in patients with primary aldosteronism using the defined daily dose. Asian J Surg 2014; 37:190-4. [DOI: 10.1016/j.asjsur.2014.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 01/14/2014] [Indexed: 11/23/2022] Open
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Myśliwiec P, Marek-Safiejko M, Łukaszewicz J, Safiejko K, Kozlowski R, Wojskowicz P, Dadan J. Videoscopic adrenalectomy - when does retroperitoneal seem better? Wideochir Inne Tech Maloinwazyjne 2014; 9:226-33. [PMID: 25097691 PMCID: PMC4105681 DOI: 10.5114/wiitm.2014.41636] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/02/2013] [Accepted: 08/31/2013] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Videoscopic adrenalectomy is the gold standard for the surgical treatment of benign adrenal tumours. The two most common approaches are the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). So far it has not been established which is the preferable one. The choice depends primarily on the surgeon's preference and contraindications for a particular approach in individual cases. AIM To compare the two most common approaches for videoscopic adrenalectomy, LTA and PRA, based on a literature review and our own experience. MATERIAL AND METHODS We reviewed the literature (PubMed and Cochrane 1990 - current) and analysed retrospectively our own patients who underwent videoscopic adrenalectomy between 2009 and 2013. The analysis covered patient features, tumour characteristics, reasons for qualification for each approach, operative time and postoperative complications. RESULTS Out of 71 videoscopic adrenalectomies, 50 were performed using PRA and 21 using LTA. Patients in the PRA group on average were older, but had smaller tumours. There was no significant difference in perioperative morbidity between PRA and LTA. Mean blood loss and total operative time were smaller/shorter for the PRA group in comparison to the LTA group. Time to first oral intake and the average postoperative hospital stay were shorter for PRA than LTA. CONCLUSIONS Videoscopic adrenalectomy is a safe and efficient technique performed using both LTA and PRA approaches. The choice of technique should be guided, most of all, by surgeon experience, patient characteristics, tumour size and location. Our preferable approach is PRA, especially for small (< 6 cm) benign tumours. We find LTA advantageous for tumours of larger size, with suspected malignant character (either primary or secondary), in ectopic position, as well as in patients lacking an ipsilateral kidney or when a simultaneous abdominal operation is planned.
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Affiliation(s)
- Piotr Myśliwiec
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Poland
| | - Magda Marek-Safiejko
- Department of Oncological and General Urology, Bialystok Sniadecki Memorial Provincial Hospital, Bialystok, Poland
| | - Jerzy Łukaszewicz
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Poland
| | - Kamil Safiejko
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Poland
| | - Robert Kozlowski
- Department of Oncological and General Urology, Bialystok Sniadecki Memorial Provincial Hospital, Bialystok, Poland
| | - Piotr Wojskowicz
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Poland
| | - Jacek Dadan
- 1 Department of General and Endocrinological Surgery, Medical University of Bialystok, Poland
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Yuan X, Wang D, Zhang X, Cao X, Bai T. Retroperitoneal Laparoendoscopic Single-Site Adrenalectomy for Pheochromocytoma: Our Single Center Experiences. J Endourol 2014; 28:178-83. [PMID: 24004249 DOI: 10.1089/end.2013.0488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Xiaobin Yuan
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Dongwen Wang
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuhui Zhang
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaoming Cao
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Tao Bai
- Department of Pathology, First Hospital of Shanxi Medical University, Taiyuan, China
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Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy? World J Urol 2013; 32:723-8. [PMID: 23907661 DOI: 10.1007/s00345-013-1139-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/20/2013] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm. METHODS A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery. RESULTS The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery. CONCLUSIONS Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.
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Lee CR, Walz MK, Park S, Park JH, Jeong JS, Lee SH, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS. A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors. Ann Surg Oncol 2012; 19:2629-34. [PMID: 22526902 DOI: 10.1245/s10434-012-2352-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of small adrenal tumors. However, several approach routes, such as the transperitoneal (TP), lateral retroperitoneal, and the posterior retroperitoneal (PR) approaches are being used based on surgeon's preference. The PR approach has several benefits compared with the others. Recently, the authors used the PR approach to treat several adrenal tumors and here describe the methods used in detail and the preliminary results obtained. METHODS From January 2009 to July 2010, 58 patients underwent adrenalectomy. Open adrenalectomy and robotic adrenalectomy were performed in 5 and 10 patients. Also, 43 patients underwent laparoscopic adrenalectomy, and the TP and PR approaches were used in 26 and 17 patients, respectively. Clinicopathologic data and surgical outcomes were evaluated and compared retrospectively. RESULTS There were no significant differences between the TP and PR groups in terms of age, sex, BMI, lesion side, volume of blood loss, or tumor size (3.86 ± 3.83 in TP approach, 2.64 ± 1.61 in PR approach). Mean operative time and average oral intake time using the PR approach were shorter than for the TP approach. Less analgesia use was required in patients who underwent PR approach. CONCLUSIONS This study shows that posterior retroperitoneoscopic adrenalectomy is a safe procedure and the operative time is comparable to transperitoneoscopic adrenalectomy. The use of the PR approach for small adrenal tumor can provide very favorable surgical outcomes compared with the TP approach.
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Affiliation(s)
- Cho Rok Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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Kazaryan AM, Marangos IP, Røsok BI, Rosseland AR, Edwin B. Impact of Body Mass Index on Outcomes of Laparoscopic Adrenal Surgery. Surg Innov 2011; 18:358-367. [DOI: 10.1177/1553350611403772] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective. The aim of this article is to define the relationship between body mass index (BMI) and outcomes of laparoscopic adrenalectomy. Method. A total of 172 patients were eligible for inclusion in the study. The patients were divided into 3 groups: group I, normal weight; group II, overweight; and group III, obesity. Perioperative outcomes were compared between the groups. Results. The median operative time was 72, 75, and 90 minutes in groups I, II, and III, respectively. The median blood loss was <50 mL in all groups. There were no intraoperative blood transfusions. There was no statistical difference in the rate of intraoperative incidences and postoperative complications. Moderately increased operative time was the only perioperative parameter that statistically differed from nonobese patients. The regression analysis found significant but weak correlation between BMI and operative time. The BMI did not correlate with other surgical outcomes. Conclusions. Laparoscopic adrenal surgery for obese patients can be done as safely as for nonobese patients.
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Affiliation(s)
- Airazat M. Kazaryan
- Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- Vestre Viken, Drammen Hospital, Drammen, Norway
| | - Irina Pavlik Marangos
- Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Bård I. Røsok
- Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | - Bjørn Edwin
- Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Li QY, Li F. Laparoscopic adrenalectomy in pheochromocytoma: retroperitoneal approach versus transperitoneal approach. J Endourol 2011; 24:1441-5. [PMID: 20367115 DOI: 10.1089/end.2010.0065] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate outcomes of transperitoneal and retroperitoneal approaches in laparoscopic adrenalectomy (LA) for pheochromocytoma. METHODS We retrospectively compared the results of transperitoneal LA (TLA) with that of retroperitoneal LA (RLA) in 99 patients with unilateral pheochromocytoma (<6 cm in diameter). Age of patients ranged from 20 to 63 years (42 men and 57 women; 56 in right and 43 in left). The mean operation time, blood loss, mean hospital stay after operation, fluctuation range of blood pressure, blood pressure after operation, complication, mortalities, and recurrences were considered. RESULTS There were significant differences between RLA and TLA in terms of duration of surgery 84 ± 17 minutes versus 117 ± 24 minutes (p < 0.05), intraoperative blood loss 200 ± 22.5 ml versus 340 ± 41.7 ml (p < 0.05), mean hospital stay after operation 4.8 ± 1.6 days versus 7.8 ± 2.2 days (p < 0.05), and complication 12.5% versus 6.7% (p < 0.05). There was no significant difference between RLA and TLA in terms of fluctuation range of blood pressure (p > 0.05) and blood pressure after operation (p > 0.05). There were no mortalities or recurrences of tumors in all patients during follow-up. CONCLUSIONS Compared with TLA, RLA is safer, more quick, and effective for patients with unilateral pheochromocytoma (< 6 cm in diameter).
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Affiliation(s)
- Qing Yuan Li
- Department of Urology and Transplantation, First Affiliated Hospital, Binzhou Medical University, Binzhou City, Shandong Province, China.
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Strebel RT, Müntener M, Sulser T. Intraoperative complications of laparoscopic adrenalectomy. World J Urol 2008; 26:555-60. [PMID: 18481069 DOI: 10.1007/s00345-008-0272-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 04/19/2008] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Raeto T Strebel
- Department of Urology, Kantonsspital Graubünden, Loëstr. 170, 7000, Chur, Switzerland.
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