Clipless and Sutureless Laparoscopic Adrenalectomy Carried Out With the LigaSure Device in 32 Patients

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience

Background

The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery.

The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others.

Methods

A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate.

Results

There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn’t significant statistical difference (p = 0.178).

Conclusions

Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient’s satisfaction.

Transperitoneal laparoscopic adrenalectomy: a review and single-center experience

Background: Laparoscopic adrenalectomy (LA) is the preferred approach to adrenal gland tumors.

Objective: To evaluate the perioperative and functional outcomes of transperitoneal LA.

Methods: We retrospectively reviewed data of all consecutive patients who underwent transperitoneal LA at our institution between April 2000 and December 2011.

Results: Two hundred two patients with mean age of 46 years were included in the study. There were 109 left, 89 right, and 4 bilateral tumors. Preoperative diagnosis included 126 aldosterone-producing adenomas (APA), 33 patients with Cushing syndrome, 19 pheochromocytomas, 20 nonfunctional tumors, and 4 adrenal metastases. Mean tumor size was 3.3 cm (range 0.4-22 cm). Mean operative time was 109 min and estimated blood loss 90 mL for unilateral adrenalectomy; and 195 min and 300 mL for bilateral adrenalectomy. Four patients with pheochromocytoma required transfusion and 2 required conversion to an open approach. Seven intraoperative complications and 18 30-day postoperative complications occurred. These included 5 major complications (Clavien-Dindo grade 3-5). Ninety-seven percent of APA patients had normal serum potassium levels after surgery. Among the patients with functioning endocrine tumors, complete resolution rate from secondary hypertension was significantly higher in the pheochromocytoma group compared with those with APA or Cushing syndrome (82% vs. 48% vs. 68% respectively, p = 0.02). Mean follow up was 35.2 months.

Conclusion: LA is the treatment of choice for most adrenal gland tumors with excellent outcomes and low complication rates. There was a high chance for complete resolution of secondary hypertension after surgery for pheochromocytoma.

Advanced sealing and dissecting devices in laparoscopic adrenal surgery

OBJECTIVES

This study sought to analyze the impact of advanced sealing/dissecting devices on operative and postoperative outcomes in laparoscopic adrenalectomy.

METHOD

Patients were divided into three groups according to the devices used during their procedures [electrothermal bipolar vessel system (EBVS), ultrasound shears (US), and monopolar electrocautery (ME)]. A comparison of the perioperative outcomes was performed.

RESULTS

Conversion rates and intraoperative and postoperative complication rates did not differ among the three groups. Major blood loss that required transfusion was registered in only two cases, all of which were performed with ME. Procedures with EBVS were shorter than those with US or ME. For left adrenalectomies only, operative times were similar for US and EBVS. The use of EBVS was found to be an independent predictor of decreased operative time.

CONCLUSION

The use of advanced sealing devices was associated with reduced operative time, with particular benefits in left adrenalectomy. EBVS and US may provide better hemostasis than ME.

Surgical technique: Retroperitoneoscopic approach for adrenal masses in children

Laparoscopic adrenalectomy is considered to be the standard of care for the surgical excision of adrenal masses. The transperitoneal laparoscopic and retroperitoneoscopic approaches are described. Both are safe and as effective as open adrenalectomy, with the added benefit of the minimally invasive approach. It can be utilized for patients requiring surgery for a phaeochromocytoma, adrenal adenoma, adrenal adenocarcinoma, Cushing's syndrome, neuroblastoma, and an incidentaloma. Relative contraindications include previous surgery of the liver or kidney, large tumours (>8-10 cm in diameter) or coagulation disorders. Although the transperitoneal route is used more widely, the retroperitoneal approach provides direct access to the adrenal gland and easy visualization of the adrenal vein. It avoids also colonic mobilization, minimizes the risk of injury to hollow viscera, and the potential risk of adhesion formation. However, the reversed orientation of the kidney and hilum, combined with a significantly smaller working space, may make this approach difficult to master.

Minimally invasive adrenal surgery: an update

PURPOSE OF REVIEW

To summarize the recent developments in minimally invasive adrenal surgery.

RECENT FINDINGS

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

SUMMARY

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