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Lee SYH, Wong C. Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy. J Surg Res 2024; 296:189-195. [PMID: 38277956 DOI: 10.1016/j.jss.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/29/2023] [Accepted: 12/27/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve. MATERIAL AND METHODS One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA). RESULTS Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA. CONCLUSIONS RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.
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Affiliation(s)
- Stellina Y H Lee
- Department of General Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.
| | - Clement Wong
- Department of General Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Abstract
While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.
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Affiliation(s)
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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3
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Shirali AS, Clemente-Gutierrez U, Huang BL, Lui MS, Chiang YJ, Jimenez C, Fisher SB, Graham PH, Lee JE, Grubbs EG, Perrier ND. Pheochromocytoma recurrence in hereditary disease: does a cortical-sparing technique increase recurrence rate? Surgery 2023; 173:26-34. [PMID: 36229248 DOI: 10.1016/j.surg.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/25/2022] [Accepted: 05/03/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy is an appealing approach for patients with hereditary pheochromocytoma and lends well to cortex preservation. We sought to examine pheochromocytoma recurrence in patients with hereditary pheochromocytoma in the era of posterior retroperitoneoscopic adrenalectomy and evaluate the predictors of recurrence. METHODS Patients with hereditary pheochromocytoma who underwent adrenalectomy for pheochromocytoma between 1995 and 2020 with biochemical cure and follow-up >1 year were identified. Recurrence was defined as plasma metanephrines above the upper limit of normal with radiographic evidence of disease in the ipsilateral adrenal bed. RESULTS Seventy-eight hereditary pheochromocytoma patients (median age = 32.4 years; 60.3% women) underwent 114 adrenalectomies for pheochromocytoma. Of these patients, 40 had multiple endocrine neoplasia type 2A (51.3%), 10 had multiple endocrine neoplasia type B (12.8%), 17 had von Hippel-Lindau disease (21.8%), and 11 had neurofibromatosis type 1 (14.1%). Thirty-eight adrenalectomies (33.3%) were performed before the introduction of posterior retroperitoneoscopic adrenalectomy and 76 (66.7%) after. Cortical-sparing technique was performed in 62 (54.4%) adrenalectomies, with no difference in its use before and after posterior retroperitoneoscopic adrenalectomy introduction (P > .05). During a median follow-up of 80.7 months (interquartile range 43.4-151.2), 12 ipsilateral recurrences (10.5%) were identified. There was no difference in recurrence before and after the introduction of posterior retroperitoneoscopic adrenalectomy or by surgical technique or approach of the entire cohort (P > .05). Recurrence was more common in those with RET M918T mutation (23.5% vs 8.2%; P = .05). Patients with RET M918T mutations had a shorter recurrence-free survival (P = .013). On multivariate analysis, only RET M918T mutation was independently associated with an increased recurrence risk (hazard ratio = 4.30; 95% confidence interval, 1.26-14.66; P = .019). CONCLUSION The introduction of posterior retroperitoneoscopic adrenalectomy did not influence the recurrence rate after adrenalectomy for hereditary pheochromocytoma patients. Patients with a RET M918T germline mutation are at increased risk for pheochromocytoma recurrence and may benefit from initial total adrenalectomy.
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Affiliation(s)
- Aditya S Shirali
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. https://twitter.com/AdityaShiraliMD
| | | | - Bernice L Huang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael S Lui
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah B Fisher
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. https://twitter.com/EGrubbsMD
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Inoue S, Goto K, Ikeda K, Hieda K, Hayashi T, Teishima J. Longitudinal analysis of retroperitoneoscopic adrenalectomy regarding cosmesis outcomes: comparison of lateral transperitoneal and reduced port laparoscopic adrenalectomy. Updates Surg 2021; 74:757-764. [PMID: 34480272 DOI: 10.1007/s13304-021-01163-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/28/2021] [Indexed: 11/24/2022]
Abstract
The aim of this study is to compare patient-reported cosmesis and satisfaction outcomes between lateral retroperitoneoscopic adrenalectomy (LRA), laparoendoscopic single site and reduced port adrenalectomy (LESS/RP-A) and lateral transperitoneal laparoscopic adrenalectomy (LTA). A total of 26, 86 and 50 patients who underwent LRA, LESS/RP-A and LTA were included in the study. All LESS/RP-A cases were performed taking the transumbilical approach. We mailed a questionnaire to all patients 1, 3, 6, 9 and 12 months after operation. Questionnaires inquiring about cosmesis (0: very ugly, 10: very beautiful) on the basis of a visual analogue scale were administered. The mean scores of cosmesis at postoperative months 1, 3, 6, 9 and 12 were 7.11, 7.00, 6.57, 5.25 and 5.46 for the LRA group, 8.43, 8.86, 8.95, 8.46 and 9.09 for the LESS/RP-A group and 7.18, 7.74, 7.58, 7.44 and 8.09 for the LTA group. The difference in cosmesis score between the LRA and LESS/RP-A groups gradually increased after surgery, and the cosmesis score for the LRA group was significantly lower at every postoperative point. The difference in cosmesis score between the LRA and LTA groups gradually increased after surgery, and the cosmesis score for the LRA group was significantly lower at postoperative months 9 (p = 0.015) and 12 (p = 0.002). This study is the first comprehensive longitudinal analysis of patient-reported cosmesis outcomes between LRA, LESS/RP-A and LTA. LRA was the surgical procedure that resulted in lower cosmesis scores when compared with those following the LESS/RP-A and LTA procedures.
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Affiliation(s)
- Shogo Inoue
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Keisuke Goto
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kenichiro Ikeda
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Keisuke Hieda
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tetsutaro Hayashi
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Jun Teishima
- Department of Urology, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Chiu A, Vargas-Pinto S, Abou-Azar S, Maduka R, Man J, Peters N, Carling T, Gibson C. Contemporary Experience of Posterior Retroperitoneoscopic Adrenalectomy in the US. J Am Coll Surg 2021; 232:815-821. [PMID: 33766728 DOI: 10.1016/j.jamcollsurg.2021.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND As the incidence of adrenalectomy increases steadily, so does the use of minimally invasive approaches like posterior retroperitoneoscopic adrenalectomy (PRA). To date, the largest studies of PRA have been from abroad, and we sought to provide a contemporary US update on the outcomes after PRA. METHODS A retrospective chart review was conducted on all PRAs performed at a single tertiary care institution between 2013 and 2020. Patient demographic characteristics, indication for operation, operative details, and postoperative course were abstracted. Outcomes of interest included 30-day mortality, conversion to open or transabdominal approach, postoperative complication, and 30-day readmission. RESULTS A total of 249 PRAs were performed between 2013 and 2020. The population was 54.2% women and mean (SD) age was 54.1 (14.1) years. Most lesions (60.6%) were left-sided, and the most common diagnosis was nonfunctioning adenoma (39.4%), followed by pheochromocytoma (21.3%) and aldosteronoma (16.6%). Mean (SD) tumor size was 3.2 cm (range 0.5 to 9.4 cm). Median operative length was 110 minutes (range 30 to 319 minutes). Overall, the complication rate was 6.4%. Nine patients (3.6%) had a minor postoperative complication (Clavien-Dindo I to III) and 5 patients (2.0%) had a major postoperative complication (Clavien-Dindo IV to V), including 1 mortality (0.4%). There were 2 conversions of approach (0.8%). The majority of patients (58.2%) were discharged on postoperative day 1, and 92.0% were discharged by postoperative day 3. The 30-day readmission rate was 1.6%. CONCLUSIONS Current practice demonstrates that PRA is an extremely safe approach, with a complication rate < 7% and mortality rate < 1%. In addition, the vast majority of patients are able to return home in an expedient manner.
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Dickson PV, Alex GC, Grubbs EG, Jimenez C, Lee JE, Perrier ND. Robotic-Assisted Retroperitoneoscopic Adrenalectomy: Making a Good Procedure Even Better. Am Surg 2020. [DOI: 10.1177/000313481307900135] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive procedure offering several advantages over a transabdominal laparoscopic operation. The three-dimensional optics and articulating instrumentation offered by current robotic surgical technology potentially improve this procedure. Robotic-assisted PRA (RA-PRA) was performed in patients meeting standard criteria for minimally invasive adrenalectomy. We prospectively collected demographic, clinical, perioperative, and pathologic data on patients undergoing RA-PRA. Thirty consecutive RA-PRAs were performed in 28 patients (26 unilateral and 2 bilateral). Indications for adrenalectomy included pheochromocytoma (8), hyperaldosteronism (3), hypercortisolism (8), oligometastases (5), and nonfunctional tumors (6). Mean tumor size was 3.8 ± 1.6 cm. Mean body mass index was 30.7 ± 6.5 kg/m2. Mean operative time was 154 ± 43 minutes for unilateral total adrenalectomy. Four patients with multiple endocrine neoplasia Type 2A-associated pheochromocytomas underwent cortical-preserving procedures. Three patients experienced perioperative complications (one pneumothorax, one urinary retention, one required postoperative blood transfusion). No patient required conversion to an open procedure. Robotic surgical technology is an excellent complement to retroperitoneoscopic adrenalectomy. The three-dimensional view and ergonomic advantages of a robotic procedure promote better visualization and a more flexible approach to dissection. We believe these features may optimize the ability to maintain a vascularized remnant during minimally invasive cortical-sparing adrenalectomy.
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Affiliation(s)
- Paxton V. Dickson
- Departments of Surgical Oncology and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Gillian C. Alex
- Departments of Surgical Oncology and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Elizabeth G. Grubbs
- Departments of Surgical Oncology and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Camilo Jimenez
- Endocrine Neoplasia and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Lee
- Departments of Surgical Oncology and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Nancy D. Perrier
- Departments of Surgical Oncology and Hormonal Disorders, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges. Indian J Surg Oncol 2020; 11:518-526. [PMID: 33013138 DOI: 10.1007/s13193-020-01114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/30/2020] [Indexed: 10/24/2022] Open
Abstract
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.
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Kim LT, Solórzano CC. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1338-1347. [PMID: 32112213 DOI: 10.1245/s10434-020-08221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/10/2023]
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that secrete excess catecholamines leading to secondary hypertension and cardiovascular morbidity. Once biochemical testing with either 24-hour urinary fractioned metanephrines or plasma free metanephrines confirms the diagnosis, patients are optimized with adequate hydration to maintain their intravascular volume and the appropriate antihypertensive medications are initiated for optimal blood pressure control. Genetic testing and imaging is performed to determine the extent of adrenalectomy and the optimal surgical approach. Surgical approaches include transabdominal or retroperitoneal minimally invasive approaches, and transabdominal open approaches. Factors that influence the surgical approach include germline genetic test results, the size of the tumor, body mass index, surgeon experience, and the likelihood of malignancy. The extent of adrenalectomy is based on germline genetic findings. Patients with syndromes such as von Hippel Lindau (VHL) or multiple endocrine neoplasia 2 (MEN 2) benefit from cortical-sparing adrenalectomy to avoid chronic steroid replacement and the risk of Addisonian crisis. Postoperative management includes hemodynamic monitoring and assessment for signs of hypoglycemia. Outcomes after surgery show improved blood pressure control in most patients and normalization of blood pressure in about a third of patients. Long-term follow-up is required for all patients to assess for recurrence.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Lateral Transperitoneal Adrenalectomy Versus Posterior Retroperitoneoscopic Adrenalectomy for Benign Adrenal Gland Disease: Randomized Controlled Trial at a Single Tertiary Medical Center. Ann Surg 2020; 269:842-848. [PMID: 29189215 DOI: 10.1097/sla.0000000000002603] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to compare the surgical outcomes of lateral transperitoneal adrenalectomy (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA) for benign adrenal tumor. BACKGROUND Although LTA is the standard treatment for benign adrenal gland tumor, PRA has recently gained popularity. Studies comparing the surgical outcomes of the 2 approaches have reported conflicting findings and thus it remains unclear which approach is superior. METHODS This trial was conducted between September 2012 and February 2016. Patients were randomized to either LTA or PRA groups in a 1:1 ratio using web-based randomization. The primary outcome was operative time, and the secondary outcomes were blood loss, intraoperative hemodynamic stability, postoperative pain, recovery of bowel movement, and complication rates. This trial was registered with ClincalTrials.gov, number NCT01676025. RESULTS A total of 83 patients were randomly assigned to the LTA group (n = 42) or the PRA group (n = 41). Median follow-up was 31.3 months. The mean operative times of LTA and PRA were comparable (59.7 ± 18.6 vs 67.6 ± 28.7 minutes, P = 0.139). Logistic regression analysis showed that male sex [odds ratio (OR) = 4.20] and pheochromocytoma (OR = 5.06) were associated with an operative time ≥60 minutes. There were no differences in the secondary outcomes between the groups. One patient in the PRA group required open conversion. CONCLUSION Both LTA and PRA were performed safely with similar operative outcomes, and thus are comparable options for the treatment of benign adrenal gland tumor.
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Seeliger B, Walz MK, Alesina PF, Agnus V, Pop R, Barberio M, Saadi A, Worreth M, Marescaux J, Diana M. Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model. Surg Endosc 2019; 34:1401-1411. [PMID: 31338664 DOI: 10.1007/s00464-019-06997-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/15/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. METHODS Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. RESULTS In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). CONCLUSIONS Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.
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Affiliation(s)
- Barbara Seeliger
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France. .,Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany. .,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.
| | - Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Pier F Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Interventional Radiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Alend Saadi
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Marc Worreth
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.,Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
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12
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Alesina PF. Retroperitoneal adrenalectomy-learning curve, practical tips and tricks, what limits its wider uptake. Gland Surg 2019; 8:S36-S40. [PMID: 31404183 DOI: 10.21037/gs.2019.03.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The minimally invasive retroperitoneal approach to the adrenal surgery has been described in the early 90s following the first description of laparoscopic adrenalectomy. Although the advantages of the technique compared to laparoscopic surgery have been demonstrated in many studies, it remained for a long period confined to few centers. The operation has been standardized over the years into a safe and reproducible procedure that finally gained worldwide acceptance in the last 10 years. The present paper summarizes the surgical steps of the procedure focusing on the recent technical developments. Retroperitoneoscopic adrenalectomy should be part of the surgical armamentarium of any center dedicated to endocrine surgery.
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Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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13
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White J, Simmonds AV, Darrabie MD. Complicated Retroperitoneal Abscess after Laparoscopic Cholecystectomy. Am Surg 2019. [DOI: 10.1177/000313481908500322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jonah White
- Center for Specialized Surgery Florida Hospital Orlando Orlando, Florida
| | - Alric V. Simmonds
- Center for Specialized Surgery Florida Hospital Orlando Orlando, Florida
| | - Marcus D. Darrabie
- Center for Specialized Surgery Florida Hospital Orlando Orlando, Florida
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14
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Kiernan CM, Lee JE. Minimally Invasive Surgery for Primary and Metastatic Adrenal Malignancy. Surg Oncol Clin N Am 2019; 28:309-326. [PMID: 30851831 DOI: 10.1016/j.soc.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Since the first description of laparoscopic adrenalectomy (LA) for pheochromocytoma and Cushing syndrome in 1992, the utilization of and indications for a minimally invasive approach to the adrenal gland have vastly expanded. Although minimally invasive adrenalectomy has been established as the preferred approach for patients with benign tumors of the adrenal gland, minimally invasive adrenalectomy for cancer remains controversial. In this article, the authors review the indications for minimally invasive adrenalectomy for adrenal nodules suspicious for, or established to represent, a primary malignancy or a site of metastatic cancer.
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Affiliation(s)
- Colleen M Kiernan
- Department of Surgical Oncology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Jeffrey E Lee
- Department of Surgical Oncology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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15
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Christakis I, Ng CS, Chen C, Yiin YH, Grubbs EG, Perrier ND, Lee JE, Graham PH. Operation duration and adrenal gland size, but not BMI, are correlated with complication rate for posterior retroperitoneoscopic adrenalectomy for benign diseases. Surgery 2018; 165:637-643. [PMID: 30482519 DOI: 10.1016/j.surg.2018.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/10/2018] [Accepted: 09/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND We sought to determine whether obesity is correlated with complications after posterior retroperitoneoscopic adrenalectomy for benign diseases and to develop surrogate markers of abdominal fat in preoperative computed tomography. METHODS We conducted a retrospective chart review of all patients who had undergone posterior retroperitoneoscopic adrenalectomy and preoperative computed tomography between January 1, 2008 and December 31, 2015. The cross-sectional components of fat assessed by computed tomography included total fat area, subcutaneous fat area, retroperitoneal fat area, and peritoneal fat area. The patients were grouped into 2 categories according to the absence or presence of a postoperative complication (the no-complications group and the complications group, respectively). RESULTS Of 116 study patients, 20 patients (17%) had a postoperative complication. Operations of greater duration and smaller adrenal gland size were significantly correlated with complications both in univariate and multivariate analyses. Body mass index, total fat area, subcutaneous fat area, retroperitoneal fat area, peritoneal fat area, and distance of skin to muscle (in axial and sagittal images) correlated with complications in univariate analysis but not in multivariate analysis. In the no-complications group, the removed adrenal gland was larger than that removed in the complications group (6 vs 4 cm, respectively, P = .001), whereas the complications group had a greater operative duration (139 vs 104 min, respectively, P = .001) and a greater duration of hospital stay (3 days vs 1 day, respectively, P = .001). CONCLUSION In this study, operations of greater duration and smaller adrenal gland size were better predictors of complications after posterior retroperitoneoscopic adrenalectomy for benign disease than measures of obesity, including body mass index.
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Affiliation(s)
- Ioannis Christakis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chaan S Ng
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chao Chen
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yeh Hung Yiin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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16
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Ko J, Jeong J, Lee S, Son H, Kweon OK, Kim WH. Feasibility of single-port retroperitoneoscopic adrenalectomy in dogs. Vet Surg 2018; 47:O75-O83. [PMID: 29697143 PMCID: PMC6032942 DOI: 10.1111/vsu.12789] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 01/22/2018] [Accepted: 03/02/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the feasibility of single-port retroperitoneoscopic adrenalectomy (SPRA) in dogs. STUDY DESIGN A pilot experimental study. ANIMALS Eight healthy beagle dogs. METHODS SPRA was performed on the left and right sides (4 dogs each). Resection of the adrenal gland was performed through a SILS port using a retroperitoneal approach. Operative time was defined from skin incision to the completion of skin suture. Postoperative pain was evaluated by using 3 pain scores. Integrity of the adrenal gland capsule was evaluated by histologic assessment. RESULTS Mean time taken to complete the SPRA was 44.1 minutes (range, 37-51) and was significantly longer on the right side than on the left side (P < .05). There were no complications intraoperatively or during 14 days of postoperative monitoring. The adrenal gland capsule was found to be injured in 3 of the 8 dogs by histologic assessment. CONCLUSION This is the first report of SPRA in the veterinary literature. With this technique it is possible to perform adrenalectomy with some risk of capsule penetration and with excellent visibility. CLINICAL SIGNIFICANCE This study suggests that SPRA is feasible and can be used to resect small adrenal tumors with minimal complications.
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Affiliation(s)
- Jonghyeok Ko
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Junemoe Jeong
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | | | - Hyunglak Son
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Oh-Kyeong Kweon
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Wan Hee Kim
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
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17
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Vrielink OM, Engelsman AF, Hemmer PHJ, de Vries J, Vorselaars WMCM, Vriens MR, Karakatsanis A, Hellman P, Sywak MS, van Leeuwen BL, El Moumni M, Kruijff S. Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy. Br J Surg 2018; 105:544-551. [PMID: 29493779 DOI: 10.1002/bjs.10740] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/20/2017] [Accepted: 09/30/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy has gained international popularity in the past decade. Despite major advantages, including shorter duration of operation, minimal blood loss and decreased postoperative pain, many surgeons still prefer laparoscopic transperitoneal adrenalectomy. It is likely that the unfamiliar anatomical environment, smaller working space and long learning curve impede implementation. The present study assessed the number of procedures required to fulfil the surgical learning curve for posterior retroperitoneoscopic adrenalectomy. METHODS The first consecutive posterior retroperitoneoscopic adrenalectomies performed by four surgical teams from university centres in three different countries were analysed. The primary outcome measure was duration of operation. Secondary outcomes were conversion to an open or laparoscopic transperitoneal approach, complications and recovery time. The learning curve cumulative sum (LC-CUSUM) was used to assess the learning curves for each surgical team. RESULTS A total of 181 surgical procedures performed by four surgical teams were analysed. The median age of the patients was 57 (range 15-84) years and 61·3 per cent were female. Median tumour size was 25 (range 4-85) mm. There were no significant differences in patient characteristics and tumour size between the teams. The median duration of operation was 89 (range 29-265) min. There were 35 perioperative and postoperative complications among the 181 patients (18·8 per cent); 17 of 27 postoperative complications were grade 1. A total of nine conversions to open procedures (5·0 per cent) were observed. The LC-CUSUM analysis showed that competency was achieved after a range of 24-42 procedures. CONCLUSION In specialized endocrine surgical centres between 24 and 42 procedures are required to fulfil the entire surgical learning curve for the posterior retroperitoneoscopic adrenalectomy.
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Affiliation(s)
- O M Vrielink
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A F Engelsman
- Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - P H J Hemmer
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J de Vries
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - W M C M Vorselaars
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M R Vriens
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Karakatsanis
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - P Hellman
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - M S Sywak
- Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - B L van Leeuwen
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - M El Moumni
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - S Kruijff
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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18
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Fraser S, Norlén O, Bender K, Davidson J, Bajenov S, Fahey D, Li S, Sidhu S, Sywak M. Randomized trial of low versus high carbon dioxide insufflation pressures in posterior retroperitoneoscopic adrenalectomy. Surgery 2018; 163:1128-1133. [PMID: 29395236 DOI: 10.1016/j.surg.2017.10.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/10/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy has gained widespread acceptance for the removal of benign adrenal tumors. Higher insufflation pressures using carbon dioxide (CO2) are required, although the ideal starting pressure is unclear. This prospective, randomized, single-blinded, study aims to compare physiologic differences with 2 different CO2 insufflation pressures during posterior retroperitoneoscopic adrenalectomy. METHODS Participants were randomly assigned to a starting insufflation pressure of 20 mm Hg (low pressure) or 25 mm Hg (high pressure). The primary outcome measure was partial pressure of arterial CO2 at 60 minutes. Secondary outcomes included end-tidal CO2, arterial pH, blood pressure, and peak airway pressure. Breaches of protocol to change insufflation pressure were permitted if required and were recorded. RESULTS A prospective randomized trial including 31 patients (low pressure: n = 16; high pressure: n = 15) was undertaken. At 60 minutes, the high pressure group had greater mean partial pressure of arterial CO2 (64 vs 50 mm Hg, P = .003) and end-tidal CO2 (54 vs 45 mm Hg, P = .008) and a lesser pH (7.21 vs 7.29, P = .0005). There were no significant differences in base excess, peak airway pressure, operative time, or duration of hospital stay. Clinically indicated protocol breaches were more common in the low pressure than the high pressure group (8 vs 3, P = .03). CONCLUSION In posterior retroperitoneoscopic adrenalectomy, greater insufflation pressures are associated with greater partial pressure of arterial CO2 and end-tidal CO2 and lesser pH at 60 minutes, be significant. Commencing with lesser CO2 insufflation pressures decreases intraoperative acidosis.
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Affiliation(s)
- Sheila Fraser
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Olov Norlén
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kyle Bender
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Joanne Davidson
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Sonya Bajenov
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - David Fahey
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Shawn Li
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Stan Sidhu
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Mark Sywak
- University of Sydney, Endocrine Surgery Unit, Sydney, Australia.
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19
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Puccini M, Panicucci E, Candalise V, Ceccarelli C, Neri CM, Buccianti P, Miccoli P. The role of laparoscopic resection of metastases to adrenal glands. Gland Surg 2017; 6:350-354. [PMID: 28861375 DOI: 10.21037/gs.2017.03.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The potential role of the laparoscopic approach for metastases to the adrenal gland is debated. We review here a series of patients consecutively submitted to laparoscopic adrenalectomy (LA) for suspected adrenal metastasis (AM). METHODS Retrospective study (consecutive series) of LA for AM. We measured parameters associated to primary tumor and metastasis. Statistical analysis: stepwise regression model. RESULTS Thirty-seven LA were performed on 36 patients. The mean age was 62.1 yrs. The side was right in 13 cases. Primary tumor was in the lung (n=22), breast (n=4), colon-rectum (n=4), kidney (n=3), thyroid, melanoma and ovary (n=1 each). Thirty-three out of 37 were confirmed to be AM (mean diameter 50 mm). Twenty-five were single metastasis. One LA was converted due to cava vein infiltration. Mean operative time was 142 min', median p.o. hospital stay was 3 days. After a mean follow-up of 33 months, 9 patients (25%) were alive free of disease, 6 (17%) were alive with disease. Mean post-adrenalectomy DFI was 19 months (range, 0-97 months), and it was the most predictive variable for survival (P<0.001). CONCLUSIONS The dimensions and absence of invasion on imaging, the evolutive status of the disease and the performance status of the patient are key factors for LA, which is associated with adequate oncologic results, a quicker postoperative recovery, and potential survival benefits.
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Affiliation(s)
- Marco Puccini
- Department of Surgery, University of Pisa, Pisa, Italy
| | - Erica Panicucci
- Department of Experimental Pathology, University of Pisa, Pisa, Italy
| | | | | | | | | | - Paolo Miccoli
- Department of Surgery, University of Pisa, Pisa, Italy
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20
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De Crea C, Raffaelli M, D'Amato G, Princi P, Gallucci P, Bellantone R, Lombardi CP. Retroperitoneoscopic adrenalectomy: tips and tricks. Updates Surg 2017; 69:267-270. [PMID: 28612211 DOI: 10.1007/s13304-017-0469-1] [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: 05/11/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023]
Abstract
Posterior retroperitoneoscopic adrenalectomy has recently increased in popularity and currently adopted in about 20% of referral centers. It may provide more direct access to the adrenals, thus avoiding post-operative adhesions and the need for patient repositioning in bilateral adrenalectomy. Although it has been suggested to be feasible for large tumors, large tumor size is indicated as the main limitation of PRA, mainly because of the small space available for dissection.
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Affiliation(s)
- Carmela De Crea
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Marco Raffaelli
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy.
| | - Gerardo D'Amato
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Pietro Princi
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Pierpaolo Gallucci
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Rocco Bellantone
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Celestino Pio Lombardi
- Istituto di Semeiotica Chirurgica, U.O. Chirurgia Endocrina e Metabolica, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168, Rome, Italy
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21
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Bakkar S, Materazzi G, Fregoli L, Papini P, Miccoli P. Posterior retroperitonoscopic adrenalectomy; a back door access with an unusually rapid learning curve. Updates Surg 2017; 69:235-239. [PMID: 28405951 DOI: 10.1007/s13304-017-0437-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/01/2017] [Indexed: 11/24/2022]
Abstract
Posterior retroperitonoscopic adrenalectomy (PRA) has become a standard approach to the adrenal gland. The aim of this study was to report an initial experience with the procedure following a proper preparatory phase highlighting the rapidity, safety and effectiveness by which it could be introduced into a surgeon's practice. Between May 2015 and July 2016, 14 PRAs were performed in 14 patients (9 females and 5 males). The average age was 46 years, BMI: 25.5 kg/m2, and ASA score: 2. Indications included: incidenatloma (n = 5), Conn's adenoma (n = 5), and Cushing's adenoma (n = 4). Lesions were on average 3.3 cm in size. Outcomes of interest included: operative time (OT), conversion rate, postoperative morbidity and mortality rates, and the length of hospital stay. Mean OT was 87.5 min (range 35-150 min). A significant reduction in OT occurred after the sixth procedure and was progressive thereafter. After the tenth case, the OT became less than 1 h. No conversion was required. No intra- or post-operative complications occurred, and mortality was zero. All patients commenced oral intake and ambulated following full recovery from anesthesia. The mean length of hospital stay was 3 days (range 2-6 days). PRA offers a direct access to the adrenal gland allowing for target-oriented dissection. Cognitive reorientation to the anatomy of this back door access and an adequate learning curve could be rapidly achieved by experienced and properly prepared laparoscopic surgeons.
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Affiliation(s)
- Sohail Bakkar
- Division of Endocrine Surgery, Department of Surgical Pathology, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy. .,Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan.
| | - Gabriele Materazzi
- Division of Endocrine Surgery, Department of Surgical Pathology, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Lorenzo Fregoli
- Division of Endocrine Surgery, Department of Surgical Pathology, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Piermarco Papini
- Division of Endocrine Surgery, Department of Surgical Pathology, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Paolo Miccoli
- Division of Endocrine Surgery, Department of Surgical Pathology, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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22
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Chen W, Lin W, Han DJ, Liang Y. Lateral retroperitoneoscopic adrenalectomy for complicated adrenal tumor larger than 5 centimeters. Afr Health Sci 2017; 17:293-300. [PMID: 29026405 PMCID: PMC5636251 DOI: 10.4314/ahs.v17i1.36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Wei Chen
- Department of Urology, Zigong Fourth People's Hospital, Sichuan, China, 643000
| | - Wei Lin
- Department of Urology, Zigong Fourth People's Hospital, Sichuan, China, 643000
| | - Deng-Jun Han
- Department of Urology, Zigong Fourth People's Hospital, Sichuan, China, 643000
| | - Yong Liang
- Department of Urology, Zigong Fourth People's Hospital, Sichuan, China, 643000
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23
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Comparative outcomes of lateral transperitoneal adrenalectomy versus posterior retroperitoneoscopic adrenalectomy in consecutive patients: A single surgeon's experience. Asian J Surg 2017; 39:74-80. [PMID: 26117204 DOI: 10.1016/j.asjsur.2015.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 03/30/2015] [Accepted: 04/15/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Among several minimally invasive adrenalectomy techniques, lateral transperitoneal adrenalectomy (LTA) is the procedure of choice for benign adrenal tumors; however, posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative that is increasing in popularity. This study compared the outcomes of these two approaches. METHODS Since a single surgeon started adrenalectomy, LTA had been performed exclusively until PRA was adopted and became the standard treatment. Therefore, the consecutive patients were allocated into two groups according to the date of surgery: the first group received LTA and the second group received PRA. RESULTS LTA was performed in 29 patients and PRA in 19 patients. There was no difference in sex, age, body mass index, clinical diagnosis, and tumor size between the LTA and the PRA group. The PRA group showed less blood loss (117.0 mL vs. 58.5 mL, p = 0.035) and tended to have a shorter operating time (92.2 minutes vs. 78.1 minutes, p = 0.054) and less pain score on postoperative Day 1 (3.8 vs. 3.0, p = 0.095) and Day 2 (3.2 vs. 2.5, p = 0.051). The mean operation time was significantly shorter for patients in the PRA group undergoing right adrenalectomy (109.2 minutes vs. 80.5 minutes, p = 0.009), but those undergoing left adrenalectomy had a similar operating time to the LTA group (83.2 minutes vs. 74.8 minutes, p = 0.380). CONCLUSION PRA is a good alternative operative technique for an endocrine surgeon who is experienced in the transperitoneal approach.
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24
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Vrielink OM, Wevers KP, Kist JW, Borel Rinkes IHM, Hemmer PHJ, Vriens MR, de Vries J, Kruijff S. Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy: a shift to a new golden standard? Langenbecks Arch Surg 2016; 402:767-773. [PMID: 27888343 PMCID: PMC5506107 DOI: 10.1007/s00423-016-1533-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
Purpose There has been an increased utilization of the posterior retroperitoneal approach (PRA) for adrenalectomy alongside the “classic” laparoscopic transabdominal technique (LTA). The aim of this study was to compare both procedures based on outcome variables at various ranges of tumor size. Methods A retrospective analysis was performed on 204 laparoscopic transabdominal (UMC Groningen) and 57 retroperitoneal (UMC Utrecht) adrenalectomies between 1998 and 2013. We applied a univariate and multivariate regression analysis. Mann-Whitney and chi-squared tests were used to compare outcome variables between both approaches. Results Both mean operation time and median blood loss were significantly lower in the PRA group with 102.1 (SD 33.5) vs. 173.3 (SD 59.1) minutes (p < 0.001) and 0 (0–200) vs. 50 (0–1000) milliliters (p < 0.001), respectively. The shorter operation time in PRA was independent of tumor size. Complication rates were higher in the LTA (19.1%) compared to PRA (8.8%). There was no significant difference in recovery time between both approaches. Conclusions Application of the PRA decreases operation time, blood loss, and complication rates compared to LTA. This might encourage institutions that use the LTA to start using PRA in patients with adrenal tumors, independent of tumor size.
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Affiliation(s)
- O M Vrielink
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - K P Wevers
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - J W Kist
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - I H M Borel Rinkes
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P H J Hemmer
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - M R Vriens
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J de Vries
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - S Kruijff
- Department of Surgical Oncology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
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25
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Bakkar S, Materazzi G. Posterior Retroperitonoscopic Adrenalectomy; How to Do it – Pearls and Secrets. ACTA ACUST UNITED AC 2016. [DOI: 10.17795/minsurgery-42362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Jeong J, Ko J, Lim H, Kweon OK, Kim WH. Retroperitoneal Laparoscopy in Dogs: Access Technique, Working Space, and Surgical Anatomy. Vet Surg 2016; 45:O102-O110. [PMID: 27731512 PMCID: PMC5129584 DOI: 10.1111/vsu.12571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/09/2016] [Indexed: 11/27/2022]
Abstract
Objective To develop and describe a laparoscopic retroperitoneal access technique, investigate working space establishment, and describe the surgical anatomy in the retroperitoneal space as an initial step for clinical application of retroperitoneal laparoscopy in dogs. Study Design Cadaveric and experimental study. Animals Cadaveric (n=8) and healthy (n=6) adult dogs. Methods The retroperitoneal access technique was developed in 3 cadavers based on the human technique and transperitoneal observation. Its application and working space establishment with carbon dioxide (CO2) insufflation alone was evaluated in 5 cadavers by observing with a transperitoneal telescope and in 6 live dogs by repeated computed tomography (CT) scans at pressure of 0, 5, 10, and 15 mmHg. Recordings of retroperitoneoscopy as well as working space volume and linear dimensions measured on CT images were analyzed. Results Retroperitoneal access and working space establishment with CO2 insufflation alone were successfully performed in all 6 live dogs. The only complication observed was in 1 dog that developed subclinical pneumomediastinum. As pressure increased, working space was established from the ipsilateral to the contralateral side, and peritoneal tearing eventually developed. Working space volume increased significantly from 5 mmHg and linear dimensions increased significantly from 0 to 10 mmHg. With pneumo‐retroperitoneum above 5 mmHg, retroperitoneal organs, including kidneys and adrenal glands, were easily visualized. Conclusion The retroperitoneal access technique and working space establishment with CO2 insufflation starting with 5 mmHg and increasing to 10 mmHg provided adequate working space and visualization of retroperitoneal organs, which may allow direct access for retroperitoneal laparoscopy in dogs.
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Affiliation(s)
- Junemoe Jeong
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Jonghyeok Ko
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Hyunjoo Lim
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Oh-Kyeong Kweon
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Wan Hee Kim
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
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Abstract
Minimally invasive adrenalectomy has become the gold standard for removal of benign adrenal tumors. The imaging characteristics, biochemical evaluation, and patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic approaches are discussed with details of surgical technique for both procedures.
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Affiliation(s)
- Azadeh A Carr
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Oltmann SC, Chen H. The transabdominal minimally invasive approach to the isolated adrenal mass. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tumor size, previous abdominal operation, medical comorbidities and surgeon skill set are factors to determine if a minimally invasive approach is feasible for patients with benign adrenal pathology, as patient outcomes are far superior with this approach. Laparoscopic techniques have largely replaced the open operations, and are often viewed as the standard of care for many general surgery operations. For this reason, general surgeons are very familiar with the anatomy within the peritoneal cavity. Often, the skill set from one advanced laparoscopic procedure may translate to another, potentially allowing a low volume adrenal surgeon but high volume laparoscopic surgeon to safely perform transabdominal laparoscopic adrenalectomy.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, TX 75390-9092, USA
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, 600 Highland Ave., Madison, WI 53792, USA
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Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow-up. Ann Surg 2015; 260:740-7; discussion 747-8. [PMID: 25243546 DOI: 10.1097/sla.0000000000000982] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To test if posterior retroperitoneoscopic adrenalectomy (PRA) is superior to lateral transperitoneal laparoscopic adrenalectomy (LTLA). BACKGROUND Most popular LTLA has been recently challenged by an increasing popularity of PRA, which is believed by many surgeons (not evidence-based) as superior to LTLA in the treatment of small and benign adrenal tumors. METHODS Participants were assigned randomly to PRA or LTLA and followed for 5 years after surgery. The primary endpoint was the duration of surgery. Secondary endpoints were blood loss, conversion rate, postoperative recovery, morbidity, and costs. RESULTS Sixty-five patients were included, of whom 61 (PRA 30, LTLA 31) completed the 5-year follow-up. The following differences were identified in favor of PRA vs LTLA: shorter duration of surgery (50.8 vs 77.3 minutes), lower intraoperative blood loss (52.7 vs 97.8 mL), diminished pain intensity within 48 hours postoperatively, lower prevalence of shoulder-tip pain (3.0% vs 37.5%), shorter time to oral intake (4.4 vs 7.3 hours), shorter time to ambulation (6.1 vs 11.5 hours), shorter length of hospital stay, and lower cost (1728 € vs 2315 €), respectively (P<0.001 for all). No differences were noted in conversion rate or morbidity except for herniation occurring more often after LTLA than PRA (16.1% vs 0%, P=0.022) and need for hernia repair (12.9% vs 0%, P=0.050), respectively. CONCLUSIONS Both approaches were equally safe. However, outcomes of PRA operations were superior to LTLA in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, improved cost-effectiveness, and abolished risk of surgical access site herniation. REGISTRATION NUMBER NCT01959711 (http://www.clinicaltrials.gov).
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Montes-Osorio ZE, Aguilar-Priego JM, Soriano-Ramírez L, García-Salazar JM. Aldosteronoma. Reporte de un caso y revisión bibliográfica. GACETA MEXICANA DE ONCOLOGÍA 2015. [DOI: 10.1016/j.gamo.2015.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Sommerey S, Foroghi Y, Chiapponi C, Baumbach SF, Hallfeldt KKJ, Ladurner R, Gallwas JKS. Laparoscopic adrenalectomy—10-year experience at a teaching hospital. Langenbecks Arch Surg 2015; 400:341-7. [DOI: 10.1007/s00423-015-1287-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/08/2015] [Indexed: 02/07/2023]
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Romero Arenas MA, Sui D, Grubbs EG, Lee JE, Perrier ND. Adrenal metastectomy is safe in selected patients. World J Surg 2014; 38:1336-42. [PMID: 24452292 DOI: 10.1007/s00268-014-2454-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The benefit of adrenalectomy (ADX) for adrenal metastasis is not established. We evaluated outcomes after ADX for patients with adrenal metastasis. METHODS We retrospectively analyzed the records of 90 patients who underwent ADX for metastatic disease. Overall survival (OS) after ADX was calculated using the Kaplan-Meier method. Clinical factors were evaluated for associations with OS using a Cox regression model, and with operative factors using the Wilcoxon two-sample or Fisher's exact test. RESULTS The most common primary tumor types were melanoma (35, 39 %) and lung cancer (32, 35 %). A total of 49 (54 %) patients had isolated adrenal metastasis; 55 (61 %) underwent laparoscopic resection (LADX). Median OS was 2.46 years (range < 1 month-15 years), and 5-year survival rate was 38 % (6 % standard error). Most patients experienced disease progression (56, 62 %) despite achieving disease-free status following ADX (78, 86 %). When compared with the open approach, LADX was associated with smaller tumor size, as well as reduced blood loss, operative time, and length of stay (all p < 0.0001), and no difference in OS (p = 0.4122) or complications (p = 1). Isolated adrenal bed recurrence was similar in LADX (N = 3, 5 %) and open ADX (N = 2, 6 %) (p = 1), and did not affect OS (p = 0.2). Larger tumors were associated with shorter median OS (p = 0.0014). CONCLUSIONS ADX for metastasis can be safely performed in selected patients. Some patients with adrenal metastasis achieve prolonged survival following ADX. Compared with an open approach, LADX has no measurable oncologic disadvantage, minimizes morbidity, and should be considered when tumor characteristics permit.
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Affiliation(s)
- Minerva Angelica Romero Arenas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Dr., Unit 1484, Houston, TX, 77030, USA,
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Hodin R, Lubitz C, Phitayakorn R, Stephen A. Diagnosis and management of pheochromocytoma. Curr Probl Surg 2014; 51:151-87. [DOI: 10.1067/j.cpsurg.2013.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 12/27/2013] [Indexed: 12/21/2022]
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Cabalag MS, Mann GB, Gorelik A, Miller JA. Posterior retroperitoneoscopic adrenalectomy: outcomes and lessons learned from initial 50 cases. ANZ J Surg 2014; 85:478-82. [PMID: 24438017 DOI: 10.1111/ans.12508] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative approach to minimally invasive adrenalectomy, potentially offering less pain and faster recovery compared with laparoscopic transperitoneal adrenalectomy (LA). The authors have recently changed from LA to PRA in suitable patients and audited their first 50 cases. METHODS Data were prospectively collected for 50 consecutive PRAs performed by the same surgeon. Patient demographics, tumour characteristics, analgesia use, operative and preparation time, length of stay, and complications were recorded. RESULTS Fifty adrenalectomies were performed in 49 patients. The median (range) age was 58.5 years (30-83) and the majority of patients were female (n = 33, 66.0%). The median (interquartile range (IQR)) preparation time was 35.5 (28.5-50.0) and median operation time was 70.5 (54-85) min, which decreased during the study period. After a learning curve of 15 cases, median operative time reached 61 min. PRA patients required minimal post-operative analgesia, with a median (IQR) of 0 (0-5) mg of intravenous morphine equivalent used. The median (IQR) length of stay was 1 (1-1) day, with 8 (16.0%) same-day discharges. There were four complications: one blood pressure lability from a phaeochromocytoma, one reintubation, one self-limited bleed and one temporary subcostal neuropraxia. There were no conversions to open surgery or deaths. CONCLUSION Our results support previously published findings that PRA is a safe procedure, with a relatively short learning curve, resulting in minimal post-operative analgesia use and short length of hospital stay.
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Affiliation(s)
- Miguel S Cabalag
- Endocrine Surgery Unit, Royal Melbourne Hospital, Victoria, Australia.,Epworth Freemasons Hospital, Victoria, Australia
| | - G Bruce Mann
- Endocrine Surgery Unit, Royal Melbourne Hospital, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | | | - Julie A Miller
- Endocrine Surgery Unit, Royal Melbourne Hospital, Victoria, Australia.,Epworth Freemasons Hospital, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
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Epelboym I, Digesu CS, Johnston MG, Chabot JA, Inabnet WB, Allendorf JD, Lee JA. Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections. J Surg Res 2013; 187:496-501. [PMID: 24314603 DOI: 10.1016/j.jss.2013.10.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 10/22/2013] [Accepted: 10/31/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients. METHODS All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ(2)-test. Prediction models were constructed using linear or logistic regression as appropriate. RESULTS Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications. CONCLUSIONS Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.
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Affiliation(s)
- Irene Epelboym
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Christopher S Digesu
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Michael G Johnston
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - John A Chabot
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - William B Inabnet
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida, Mount Sinai Hospital, New York, NY
| | - John D Allendorf
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - James A Lee
- Division of Endocrine Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
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Stefanidis D, Goldfarb M, Kercher KW, Hope WW, Richardson W, Fanelli RD. SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc 2013; 27:3960-80. [PMID: 24018761 DOI: 10.1007/s00464-013-3169-z] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 08/02/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, CMC Surgical Specialty Center, Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC, 28204, USA,
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Treter S, Perrier N, Sosa JA, Roman S. Telementoring: A Multi-institutional Experience with the Introduction of a Novel Surgical Approach for Adrenalectomy. Ann Surg Oncol 2013; 20:2754-8. [DOI: 10.1245/s10434-013-2894-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Indexed: 11/18/2022]
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39
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Miller JA, Kwon DS, Dkeidek A, Yew M, Hisham Abdullah A, Walz MK, Perrier ND. Safe introduction of a new surgical technique: remote telementoring for posterior retroperitoneoscopic adrenalectomy. ANZ J Surg 2012; 82:813-6. [PMID: 23013552 DOI: 10.1111/j.1445-2197.2012.06188.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy (PRA) is a safe and effective approach to adrenalectomy, offering less pain and faster recovery than open or laparoscopic surgery. Although the popularity of PRA is increasing, few surgical centres have extensive experience with the procedure. The ideal approach to achieve proficiency with any new technique involves on-site observation of an experienced surgeon-mentor, followed by mentored hands-on experience of the surgeon-learner. However, it is not always feasible for a surgeon-mentor to offer on-site supervision to the surgeon-learner in his or her home institution. Advances in Internet applications have made remote telementoring a viable alternative to on-site mentoring in selected situations. METHODS We describe our experience in safely introducing PRA to Melbourne, Australia, where no highly experienced surgeon-mentors were available. A surgeon with experience of 12 PRA procedures attended from interstate, along with live telementoring via Skype video link by an overseas surgeon who had performed more than 200 PRA procedures, to mentor the surgeon-learner performing her first three cases. RESULTS The operating surgeon's first three PRA procedures proceeded uneventfully, with no complications, relatively short operative times and one-night hospital stays for all three patients. Twenty-two more have been performed since, without complications. CONCLUSION Remote telementoring is a safe and feasible way to assist surgeons in safely introducing new techniques. This strategy is particularly applicable in centres where no surgeon-mentor is locally available. It is important that the surgeon-learner has the skills and experience to complete the procedure using alternative techniques in the case of complications or technical failure.
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Affiliation(s)
- Julie A Miller
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.
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Nigri G, Rosman AS, Petrucciani N, Fancellu A, Pisano M, Zorcolo L, Ramacciato G, Melis M. Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy. Surgery 2012; 153:111-9. [PMID: 22939744 DOI: 10.1016/j.surg.2012.05.042] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 05/18/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomies are being performed increasingly, either with transperitoneal or retroperitoneal approaches. Studies comparing the 2 approaches have not shown the superiority of either technique, but these studies are limited by small sample sizes and single-institution designs. To overcome these limitations, we performed a meta-analysis of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy. METHODS A systematic review of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy was conducted. Study endpoints included perioperative outcomes and measures of postoperative recovery. Meta-analysis was performed using a random effects model, pooling variables evaluated by more than 3 studies. RESULTS Twenty-one studies comparing a total of 1,205 lateral transperitoneal adrenalectomies and 688 retroperitoneal adrenalectomies were suitable for meta-analysis. Patients in the 2 groups were similar in term of age, sex, body mass index, lesion size and location, and rates of malignancy. There were no statistically significant differences between lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy in terms of operative time, blood loss, hospital stay, time to oral intake, overall and major morbidity, and mortality. CONCLUSION Both lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy are associated with very low rates of perioperative complications. According to our meta-analysis, clinical outcomes after either technique are similar. For most adrenal lesions requiring operation, minimally invasive adrenalectomy can be performed safely and effectively with either transperitoneal or the retroperitoneal approach. Additional studies may be needed to analyze if any difference in long-term results exist.
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Affiliation(s)
- Giuseppe Nigri
- Department of Surgery, Sapienza University of Rome, Rome, Italy.
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41
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Heloury Y, Muthucumaru M, Panabokke G, Cheng W, Kimber C, Leclair MD. Minimally invasive adrenalectomy in children. J Pediatr Surg 2012; 47:415-21. [PMID: 22325405 DOI: 10.1016/j.jpedsurg.2011.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 07/14/2011] [Accepted: 08/09/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE Minimally invasive adrenalectomy (MIA) is the criterion standard for removal of small adrenal tumors in adults. The purpose of this review was to determine the place of MIA in children. METHODS The authors conducted a systematic review of the pediatric and adult literature about MIA, focusing on the technique and indications. RESULTS Minimally invasive adrenalectomy appears superior to open adrenalectomy for small tumors. The potential advantages of MIA are appealing for postoperative pain, risk of intestinal obstruction, and quality of scars. The most common approach is the transperitoneal lateral laparoscopy, which allows for a large working space. For small tumors or for bilateral adrenalectomy, the prone retroperitoneoscopy is a promising new technique. In children, the learning curve is an issue because the indications are rare. The most common indication is neuroblastoma without image-defined surgical risk factors. The incidence of local recurrence is low, but the follow-up is short in most cases. CONCLUSIONS Minimally invasive adrenalectomy is promising for removal of small adrenal tumors. Long-term follow-up is required to evaluate the efficacy of MIA in neuroblastomas. Benign diseases are excellent candidates for this minimally invasive technique.
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Affiliation(s)
- Yves Heloury
- Department of Pediatric Surgery, Monash Children's, Monash Medical Center, Clayton, Victoria,3168, Australia.
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42
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Dickson PV, Alex GC, Grubbs EG, Ayala-Ramirez M, Jimenez C, Evans DB, Lee JE, Perrier ND. Posterior retroperitoneoscopic adrenalectomy is a safe and effective alternative to transabdominal laparoscopic adrenalectomy for pheochromocytoma. Surgery 2011; 150:452-8. [PMID: 21878230 DOI: 10.1016/j.surg.2011.07.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 07/06/2011] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Laparoscopic adrenalectomy (LA) is a safe minimally invasive approach for treatment of pheochromocytoma (PHEO). Posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative minimally invasive technique; however, there is a lack of data regarding the appropriateness of this approach in patients with PHEO. METHODS Our endocrine surgery database was queried to identify patients who underwent LA or PRA for PHEO. Patient and tumor characteristics, as well as operative details and postoperative course were compared between the 2 groups. RESULTS LA or PRA was attempted in 46 patients with PHEO (23 LA, 23 PRA). There were no differences in age, BMI, or tumor size between these groups. PRA was associated with significantly reduced operative times (99 min vs 145 min, P < .001), estimated blood loss (8.4 cc vs 123.8 cc, P = .02), and postoperative length of stay (1.9 nights vs 3.1 nights, P < .01). There was no significant difference in rates of conversion to an open procedure or perioperative complications between these groups. CONCLUSION LA and PRA are both safe and effective approaches in patients with PHEO. In our experience, PRA results in decreased operative times, blood loss, and postoperative length of stay compared with LA. PRA has become our preferred approach for patients with PHEO.
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Affiliation(s)
- Paxton V Dickson
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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43
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Abstract
Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).
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Affiliation(s)
- A Germain
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital d'adultes, CHU de Nancy-Brabois, université Henri-Poincaré-Nancy-1, 11, allée du Morvan, 54511 Vandœuvre-lès-Nancy, France
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Gaujoux S, Bonnet S, Leconte M, Zohar S, Bertherat J, Bertagna X, Dousset B. Risk factors for conversion and complications after unilateral laparoscopic adrenalectomy. Br J Surg 2011; 98:1392-9. [PMID: 21618212 DOI: 10.1002/bjs.7558] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most benign adrenal tumours, with a reported overall complication rate around 10 per cent. The aim of this study was to determine predictive factors for postoperative complications and conversion to open surgery after unilateral LA. METHODS From 1994 to 2009, consecutive patients undergoing unilateral LA by the lateral transabdominal approach were analysed from a prospectively maintained database. A mass larger than 12 cm in diameter and suspected primary adrenal carcinoma were considered contraindications to LA. Predictive factors for postoperative complications and conversion to open surgery were analysed. RESULTS Some 462 patients were analysed. There were no postoperative deaths. Postoperative complications occurred in 53 patients (11·5 per cent), medical complications in 28, and surgical complications in 33 patients. Six patients underwent reoperation for complications. Multivariable logistic regression analysis showed that conversion to open surgery (odds ratio (OR) 6·20, 95 per cent confidence interval 2·08 to 18·53; P = 0·001) and left-sided tumour (OR 1·89, 1·02 to 3·52; P = 0·044) were independent predictive factors for overall complications. Conversion to open surgery was the only independent predictive factor for medical complications (OR 12·88, 4·21 to 39·41; P = 0·001), and left-sided LA was the only predictive factor for surgical complications (OR 2·22, 1·01 to 4·89; P = 0·047). No factor was predictive of conversion to open surgery. CONCLUSION In this single-institution study, conversion to open surgery and left-sided tumours were independent predictive factors for overall complications, but none of the variables analysed was predictive of conversion.
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Affiliation(s)
- S Gaujoux
- Department of Digestive and Endocrine Surgery, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
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Ramacciato G, Nigri GR, Petrucciani N, Di Santo V, Piccoli M, Buniva P, Valabrega S, D'Angelo F, Aurello P, Mercantini P, Del Gaudio M, Melotti G. Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches. Am Surg 2011. [DOI: 10.1177/000313481107700414] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.
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Affiliation(s)
- Giovanni Ramacciato
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Giuseppe R. Nigri
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Niccolò Petrucciani
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | | | - Michaela Piccoli
- Department of General Surgery, Ospedale S. Agostino-Estense, Modena, Italy
| | - Paolo Buniva
- Department of General Surgery, Ospedale S. Agostino-Estense, Modena, Italy
| | - Stefano Valabrega
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Francesco D'Angelo
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Paolo Aurello
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Paolo Mercantini
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Massimo Del Gaudio
- Department of Surgery, St. Andrea Hospital, II School of Medicine, Sapienza University, Rome, Italy
| | - Gianluigi Melotti
- Department of General Surgery, Ospedale S. Agostino-Estense, Modena, Italy
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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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Schreinemakers JMJ, Kiela GJ, Valk GD, Vriens MR, Rinkes IHMB. Retroperitoneal endoscopic adrenalectomy is safe and effective. Br J Surg 2010; 97:1667-72. [DOI: 10.1002/bjs.7191] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
The aim of this study was to review an experience with retroperitoneal endoscopic adrenalectomy (REA). This is the procedure of choice for adrenal tumours at this institution.
Methods
Between 1997 and 2008, 112 REAs were performed in a single university centre. Data were retrieved retrospectively from a prospectively collected database, including information on patient demographics, surgical procedure, complications and hospital stay.
Results
One hundred and twelve REAs were carried out successfully in 105 patients, including seven bilateral adrenalectomies. Thirty-nine patients with unilateral adrenal disease had a phaeochromocytoma, of whom 16 had multiple endocrine neoplasia syndrome type 2, 21 patients had Cushing's disease and 20 had Conn's disease. Median body mass index was 27 (interquartile range 23–29) kg/m2. The median duration of unilateral operations was 100 (90–130) min with a median blood loss of 5 ml. Median tumour size was 3·1 (2·0–4·4) cm. Conversion from REA to open surgery was needed in two patients. Seven patients experienced postoperative complications (2 major, 5 minor). One patient needed a reoperation. The median postoperative hospital stay was 3 days. A learning curve with a significant decrease in operating time was observed over the years.
Conclusion
REA appears to be a safe and effective surgical technique for adrenal gland tumours up to 6 cm in diameter, with a minimal complication rate.
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Affiliation(s)
- J M J Schreinemakers
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G J Kiela
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G D Valk
- Department of Endocrinology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M R Vriens
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Landry CS, Waguespack SG, Perrier ND. Surgical management of nonmultiple endocrine neoplasia endocrinopathies: state-of-the-art review. Surg Clin North Am 2009; 89:1069-89. [PMID: 19836485 DOI: 10.1016/j.suc.2009.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The development of genetic testing has given patients with familial endocrine diseases the opportunity to be identified earlier in life. The importance of this technological advancement cannot be underestimated, as some of these heritable diseases have significant potential for malignancy. This article focuses on the identification and surgical management of familial endocrinopathies of the thyroid, parathyroid, adrenal glands, and pancreas. Familial endocrinopathies discussed include hereditary nonmedullary carcinoma of the thyroid, Cowden disease, familial adenomatous polyposis, Carney complex, Werner syndrome, familial medullary thyroid carcinoma, Pendred syndrome, hereditary hyperparathyroidism jaw-tumor syndrome, familial isolated hyperparathyroidism, Beckwith- Wiedemann syndrome, Li-Fraumeni syndrome, neurofibromatosis I, von Hippel-Lindau disease, and tuberous sclerosis.
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Affiliation(s)
- Christine S Landry
- Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Berber E, Tellioglu G, Harvey A, Mitchell J, Milas M, Siperstein A. Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy. Surgery 2009; 146:621-5; discussion 625-6. [PMID: 19789020 DOI: 10.1016/j.surg.2009.06.057] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 06/30/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND For the past 14 years, we have been performing laparoscopic adrenalectomy via the lateral transabdominal as well as the posterior retroperitoneal approach. The aim of this study is to describe patient selection criteria for each approach with comparison of perioperative outcomes. METHODS In patients with smaller tumors, low body mass index (BMI), history of previous abdominal operations, appropriate body habitus, and bilateral pathology, we have performed preferentially the posterior approach. Data regarding clinical pathology, tumor size, BMI, estimated blood loss (EBL), operating time (OT), morbidity, mortality, and duration of stay were analyzed retrospectively. Data are expressed as mean +/- standard error of the mean (SEM). RESULTS One hundred seventy-two laparoscopic adrenalectomy procedures were performed in 159 patients between 1994 and 2008. The lateral approach was used in 69 patients (right side: 39%, left side: 55%, bilateral: 6%) and the posterior approach in 90 patients (right side: 42%, left side: 48%, bilateral: 10%). The incidence of prior abdominal surgery was greater in the posterior group (26% vs 19%, NS). The lateral approach was used in 9% (3/34) of aldosteronoma, 38% (9/24) of Cushing's disease/syndrome, 47% (18/38) of nonsecreting cortical adenoma, 66% (23/35) of pheochromocytoma, 41% (7/17) of malignant lesions, and 73% (8/11) of others. Thirty percent of the bilateral adrenalectomies were performed via lateral and 70% via posterior approach. Two patients in the posterior approach were converted to the laparoscopic lateral approach, and 2 patients in the lateral approach were converted to open. Overall, patient age and sex were similar between groups. BMI was higher in patients undergoing adrenalectomy via lateral vs posterior approach (32.4 vs 28.4; P = .005). Tumor size was larger than 6 cm in 11 (16%) and 1 (1%) of the patients in the lateral and posterior groups, respectively. On univariate analysis, mean OT for lateral and posterior approaches was similar for unilateral cases (157 +/- 7 vs 138 +/- 6 min, respectively; P = NS). This was also true on multivariate analysis when corrected for patient selection factors. EBL was 35 +/- 7 mL for lateral versus 25 +/- 6 mL for posterior approach (P = .05). The duration of stay in lateral and posterior approaches was 1 day in 56% vs 82%, 2 days in 29% vs 13%, and more than 2 days in 15% vs 5% of the patients, respectively. Two patients in the lateral group died postoperatively because of cardiac and pulmonary causes, and 2 patients in the posterior group developed temporary neuralgia. CONCLUSION This series compares 2 different approaches for laparoscopic adrenalectomy. Our study shows that the lateral and posterior techniques have a similar peri-operative outcome when patients are selected for each option based on certain criteria.
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Affiliation(s)
- Eren Berber
- Section of Endocrine Surgery, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Callender GG, Kennamer DL, Grubbs EG, Lee JE, Evans DB, Perrier ND. Posterior retroperitoneoscopic adrenalectomy. Adv Surg 2009; 43:147-57. [PMID: 19845175 DOI: 10.1016/j.yasu.2009.02.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PRA has become our preferred technique for resection of relatively small, benign adrenal masses and isolated metastases to the adrenal glands. PRA offers a direct, minimally invasive approach to the adrenal glands and avoids the need to enter the peritoneal cavity, deal with intraabdominal adhesions, and mobilize adjacent organs-steps necessary during anterior laparoscopic adrenalectomy. In addition, some patients tolerate retroperitoneal CO2 insufflation better than intraperitoneal CO2 insufflation from a hemodynamic and respiratory perspective. Finally, bilateral PRA can be performed without the need for patient repositioning. PRA requires the surgeon to become comfortable with the anatomy of the adrenal gland and surrounding structures from the posterior perspective. In addition, the surgeon must become adept at working in the retroperitoneal space, which is relatively restricted compared with the large cavity created by insufflation of the intraperitoneal space. However, in our experience, the learning curve can be overcome in a relatively short period, and the posterior approach is particularly advantageous in patients who have undergone prior open abdominal surgery or who are moderately obese. Proper patient positioning and trocar placement, high-pressure CO2 insufflation, and mobilization of the inferior aspect of the adrenal gland from the superior pole of the kidney before dividing its other attachments are critical technical details that greatly facilitate the procedure. In experienced hands, PRA is safe and is an ideal option for patients who are candidates for minimally invasive adrenalectomy.
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Affiliation(s)
- Glenda G Callender
- Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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