Single-Incision Retroperitoneoscopic Adrenalectomy and Single-Incision Laparoscopic Adrenalectomy

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

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

Laparoendoscopic Single-Site Retroperitoneoscopic Adrenalectomy Versus Conventional Retroperitoneoscopic Adrenalectomy in Obese Patients

OBJECTIVE

To compare the operative outcomes of obese patients undergoing laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy or standard laparoscopic (LAP) retroperitoneoscopic adrenalectomy.

METHODS

Between September 2011 and April 2015, 51 obese patients underwent LESS retroperitoneoscopic adrenalectomy and their operative outcomes were compared with 65 obese patients who underwent standard retroperitoneoscopic adrenalectomy by the same surgeon. In the LESS group, a single-port access was positioned in the lumbar incision. The standard retroperitoneal adrenalectomy technique was performed with a combination of conventional and curved LAP instruments. The following parameters were adopted: patient demographics, surgical details, perioperative complications, postoperative outcome data, and short-term outcomes.

RESULTS

The LESS group was comparable with the LAP group in terms of total operative time (70.4 ± 21.3 vs 65.5 ± 24.8 minutes, p = 0.26), hospital length of stay (5.7 ± 1.2 vs 6.1 ± 1.5 days, p = 0.12), and incidence of complications (4/51 vs 5/65, p = 0.98) for patients with similar baseline demographics. The LESS group had significantly shorter surgical incisions (2.8 ± 0.3 vs 5.3 ± 0.6 cm, p < 0.0001), lower in-hospital analgesic requirement (7.6 ± 3.3 mg morphine equivalent vs 10.5 ± 6.2 mg, p = 0.003), and significantly superior scar satisfaction score (9.3 ± 0.7 vs 7.6 ± 1.4, p < 0.0001) than the LAP group. Although estimated blood loss was greater in the LESS group (28.1 ± 10.6 vs 16.9 ± 7.2 mL in the LAP group, p < 0.0001), <50 mL overall blood loss was not clinically significant. During a mean follow-up of 20.2 months, no recurrences or deaths were documented in either group.

CONCLUSIONS

In properly selected patients, LESS retroperitoneoscopic adrenalectomy for obese individuals is technically feasible and safe in experienced hands, offering perioperative outcomes comparable with those of the conventional multiport approach, but with a superior cosmetic outcome.

Transumbilical laparoendoscopic single-site surgery versus conventional laparoscopy for the resection of retroperitoneal paragangliomas

OBJECTIVES

To compare transumbilical laparoendoscopic single-site surgery with conventional laparoscopy for the resection of retroperitoneal paragangliomas.

METHODS

In the present case-control study, we compared 11 transumbilical laparoendoscopic single-site surgery procedures with 22 conventional laparoscopy procedures carried out to treat retroperitoneal paragangliomas between June 2004 and October 2013 at Peking Union Medical Hospital, Beijing, China. Operative time, estimated intraoperative blood loss, blood transfusions, intraoperative hypertension, intraoperative hypotension, highest intraoperative systolic blood pressure, lowest intraoperative systolic blood pressure, postoperative fatigue time, postoperative systematic inflammation reaction syndrome, 24-h postoperative visual analog scale scores, postoperative hospital stay duration, and postoperative complications were recorded and analyzed.

RESULTS

There were no significant differences in patient characteristics. All surgical procedures were successfully completed in both groups. Minor complications occurred in one case in the laparoendoscopic single-site surgery group and in two cases in the conventional laparoscopy group. In the laparoendoscopic single-site surgery group, the operative time was longer than that in the conventional laparoscopy group (P = 0.001). There were no significant differences in terms of intraoperative hypertension, intraoperative hypotension, highest intraoperative systolic blood pressure, lowest intraoperative systolic blood pressure, estimated blood loss, postoperative fatigue time, postoperative hospital stay or systematic inflammation reaction syndrome between the two groups. The 24-h postoperative visual analog scale score was lower in the laparoendoscopic single-site surgery group (P = 0.002). No recurrence or metastases were observed over the duration of the postoperative follow up.

CONCLUSIONS

In properly selected patients, transumbilical laparoendoscopic single-site surgery is a feasible, safe and effective procedure for the surgical treatment of retroperitoneal paragangliomas.

Comparison of Retroperitoneoscopic and Transperitoneal Laparoscopic Adrenalectomy for Right-Sided Benign Tumors: A Single-Institute Experience

<b><i>Introduction:</i></b> There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for right-sided laparoscopic adrenalectomy. The aim of this study was to determine whether there is any difference between right-sided transperitoneal laparoscopic adrenalectomy (TLA) and retroperitoneal laparoscopic adrenalectomy (RLA). <b><i>Material and Methods:</i></b> Our surgery database was reviewed to identify patients who underwent right-sided laparoscopic adrenalectomy with a retroperitoneal or transperitoneal approach since 2000. Fifty-five patients were enrolled (31 RLA and 24 TLA). Patient characteristics, as well as operative and perioperative details, were compared between the two groups. <b><i>Results:</i></b> There was no difference in patient characteristics between the groups. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient's BMI was >26. There was no significant difference in operative time, conversion to open surgery, length of hospitalization, or time to oral intake between the groups. <b><i>Conclusions:</i></b> Right-sided laparoscopic adrenalectomy can be performed safely and effectively via either RLA or TLA. Surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach.

Laparoscopic trans- and retroperitoneal adrenal surgery for large tumors

BACKGROUND

Laparoscopic adrenalectomy for tumors larger than 6 cm is currently a matter of controversial discussion because of difficult mobilization from surrounding organs and a possible risk of capsule rupture.

MATERIALS AND METHODS

Data of consecutive patients undergoing laparoscopic adrenalectomy between 1/1994 and 7/2012 were collected and analysed retrospectively. Intra- and postoperative morbidity in patients with tumors ≤6 cm (group 1, n = 227) were compared to patients with tumors >6 cm, (group 2, n = 52).

RESULTS

Incidence of adrenocortical carcinoma was significantly higher in group 2 patients (6.3% vs. 0.4%, P = 0.039) whereas the incidence of aldosterone-producing adenoma was lower (2% vs. 25%, P = 0.001). Mean duration of surgery was longer (105 min vs. 88 min, P = 0.03) and the estimated blood loss was higher (470 mL vs. 150 mL) in group 2 patients. Intraoperative bleeding rate (5.7% vs. 0.8%, P = 0.041), and the conversion rate were significantly higher (5.7% vs. 1.3%, P = 0.011) in group 2. Also, postoperative complication rate was significantly higher in group 2 (11.5% vs. 3.0%, P = 0.022). However, only two major complications occurred, one in each group.

CONCLUSION

Minimally invasive adrenal surgery can be performed by an experienced surgeon even in patients with large tumors (>6 cm) with an increased but still acceptable intra- and postoperative morbidity.

The Optimal Approach for Laparoscopic Adrenalectomy through Mono Port regarding Left or Right Sides: A Comparative Study

Introduction. Several studies have shown the feasibility and safety of both transperitoneal and posterior retroperitoneal approaches for single incision laparoscopic adrenalectomy, but none have compared the outcomes according to the left- or right-sided location of the adrenal glands. Materials and Methods. From 2009 to 2013, 89 patients who received LAMP (laparoscopic adrenalectomy through mono port) were analyzed. The surgical outcomes attained using the transperitoneal approach (TPA) and posterior retroperitoneal approach (PRA) were analyzed and compared. Results and Discussion. On the right side, no significant differences were found between the LAMP-TPA and LAMP-PRA groups in terms of patient characteristics and clinicopathological data. However, outcomes differed in which LAMP-PRA group had a statistically significant shorter mean operative time (84.13 ± 41.47 min versus 116.84 ± 33.17 min; P = 0.038), time of first oral intake (1.00 ± 0.00 days versus 1.21 ± 0.42 days; P = 0.042), and length of hospitalization (2.17 ± 0.389 days versus 3.68 ± 1.38 days; P ≤ 0.001), whereas in left-sided adrenalectomies LAMP-TPA had a statistically significant shorter mean operative time (83.85 ± 27.72 min versus 110.95 ± 29.31 min; P = 0.002). Conclusions. We report that LAMP-PRA is more appropriate for right-sided laparoscopic adrenalectomies due to anatomical characteristics and better surgical outcomes. For left-sided laparoscopic adrenalectomies, however, we propose LAMP-TPA as a more suitable method.

EAU guidelines on robotic and single-site surgery in urology

CONTEXT

This is a short version of the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology, as created in 2013 by the EAU Guidelines Office Panel on Urological Technologies.

OBJECTIVE

To evaluate current evidence regarding robotic and single-site surgery in urology and to provide clinical recommendations.

EVIDENCE ACQUISITION

A comprehensive online systematic search of the literature according to Cochrane recommendations was performed in July 2012, identifying data from 1990 to 2012 regarding robotic and single-site surgery in urology.

EVIDENCE SYNTHESIS

There is a lack of high-quality data on both robotic and single-site surgery for most upper and lower urinary tract operations. Mature evidence including midterm follow-up data exists only for robot-assisted radical prostatectomy. In the absence of high-quality data, the guidelines panel's recommendations were based mostly on the review of low-level evidence and expert opinions.

CONCLUSIONS

Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations. Further documentation including long-term oncologic and functional outcomes is deemed necessary before definite conclusions can be drawn regarding the superiority or not of robotic assistance compared with the conventional laparoscopic and open approaches. Laparoendoscopic single-site surgery is a novel laparoscopic technique providing a potentially superior cosmetic outcome over conventional laparoscopy. Nevertheless, further advantages offered by this technology are still under discussion and not yet proven. Due to the technically demanding character of the single-site approach, only experienced laparoscopic surgeons should attempt this technique in clinical settings.

PATIENT SUMMARY

This work represents the shortened version of the 2013 European Association of Urology guidelines on robotic and single-site surgery. The authors systematically evaluated published evidence in these fields and concluded that robotic assisted surgery is possible and safe for most urologic operations. Whilst laparoendoscopic single-site surgery is performed using the fewest incisions, the balance between risk and benefit is currently unclear. The evidence to support the conclusions in this guideline was generally poor, but best for robotic assisted radical prostatectomy. As such, these recommendations were based upon expert opinion, and further high-quality research is needed in this field.

Single-incision transperitoneal laparoscopic left adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy.

METHODS

Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period.

RESULTS

There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay.

CONCLUSION

SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.

Scarless single-incision laparoscopic loop ileostomy: a novel technique

BACKGROUND

Laparoscopic surgery has become a favorable alternative to conventional open surgery for the creation of intestinal stomas, and it offers many benefits including reduced postoperative pain, ileus, and hospital stay. Single-incision laparoscopic surgery has been described for many abdominal operations. It may offer better cosmetic outcomes and reduce incisional pain, adhesions, and recovery time.

OBJECTIVE

In this study, we aimed to describe a novel technique of scarless single-incision laparoscopic loop ileostomy for fecal diversion and to report our experience with 8 patients who underwent this procedure within a 1-year period.

DESIGN

This study was designed as a retrospective case series.

SETTINGS

This investigation was conducted at a single-institution, tertiary referral center.

PATIENTS

Eight consecutive patients undergoing scarless single-incision laparoscopic loop ileostomy between August 2009 and August 2010 were included.

INTERVENTION

Scarless single-incision laparoscopic loop ileostomies were performed.

MAIN OUTCOME MEASURES

Among the outcomes measured were operation time, intraoperative blood loss, recovery of intestinal function, length of hospital stay, and surgical complications.

RESULTS

Seven patients underwent surgery for active Crohn's disease refractory to medical therapy. One patient underwent surgery for radiation-induced rectovesical fistula. Median surgery time was 76 minutes, and median intraoperative blood loss was 10 mL. Median length of postoperative hospitalization was 7 days. Of the 8 patients included in our series, 2 patients (25%) required reoperation for stoma ischemia because of vascular congestion that we attribute to a tight fascial opening or extensive bowel manipulation. Other surgical complications included nonoperative readmission for ileus and partial small-bowel obstruction (n = 2), anal dilation to evacuate an obstructed distal colon (n = 1), and peristomal cellulitis (n = 1).

LIMITATIONS

This study was limited by its small sample size and its retrospective nature.

CONCLUSION

Scarless single-incision laparoscopic loop ileostomy is a feasible alternative to standard laparoscopy for fecal diversion. Surgeons attempting this technique should do so with caution, given the high stoma ischemia rate in our small case series.

Minimally invasive adrenal surgery: an update

PURPOSE OF REVIEW

To summarize the recent developments in minimally invasive adrenal surgery.

RECENT FINDINGS

Modern adrenal surgery continues to evolve with new techniques. Both the laparoscopic transabdominal and retroperitoneoscopic approaches are now the standard of care for the removal of nonmalignant adrenal tumors. Other recent developments include robotic retroperitoneal adrenalectomy, single-incision laparoendoscopic surgery, and ambulatory adrenalectomy.

SUMMARY

Here, we review the literature of minimally invasive adrenal surgery over the last year to highlight new developments and technical refinements.

Left transperitoneal adrenalectomy with a laparoendoscopic single-site surgery combined technique: initial case reports

Laparoendoscopic single-site surgery (LESS) is a step toward the development of minimally invasive surgery. It is initially difficult for surgeons with limited experience to perform the surgery. We describe two cases of left adrenalectomy with a LESS combined with the addition of an accessory port. After a 2.5-cm skin incision was made at the level of the paraumbilicus to insert the primary 12-mm trocar for the laparoscope, a 5-mm nonbladed trocar was placed through the skin incision side-by-side with the primary trocar. A second 3-mm nonbladed trocar was then placed along the anterior axillary line; a multichannel trocar was not used as a single port. Both adrenalectomies were completed successfully. In patients with a minor adrenal tumor, a combined technique using LESS and an additional port is easier than LESS alone and may, therefore, be a bridge between the conventional laparoscopic approach and LESS.

Laparoendoscopic single site (LESS) adrenalectomy: technique and outcomes

PURPOSE

To describe the surgical technique, to analyze outcomes and to provide an overview of the current status of laparoendoscopic single site (LESS) adrenalectomy.

METHODS

A comprehensive PubMed search was performed for all relevant urological literature regarding LESS and adrenal surgery. In addition, experience gained at the authors' own institutions was considered. Clinical descriptive and comparative reports on LESS adrenal surgery procedures were analysed.

RESULTS

LESS adrenal surgery has been effectively performed for a number of indications. A wide variety of approaches (transperitoneal versus retroperitoneal, multichannel trocar versus multiple ports, trans- or extraumbilical) have been described. LESS adrenalectomy seems to be safe, taking more time than the standard laparoscopic counterpart but appears to offer the patient less postoperative discomfort. Technical difficulties of the procedure include the requirement of more time for adjustment of articulating instruments, longer 'one-handed' manipulation time, and a high peroperative tissue re-grasping rate.

CONCLUSIONS

The feasibility and safety of LESS adrenalectomy has been demonstrated. Only long-term follow-up outcomes will prove its benefits over conventional laparoscopy and define the role and the oncological safety of LESS adrenal surgery.