Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: experience with initial 30 cases

Catecholamine release induces elevation in plasma lactate levels in patients undergoing adrenalectomy for pheochromocytoma

STUDY OBJECTIVE

To determine the relationship between preoperative catecholamine levels and intraoperative peak plasma lactate levels in patients who underwent adrenalectomy for pheochromocytoma.

DESIGN

Retrospective observational study.

SETTING

Operating room in one university hospital.

MEASUREMENTS

The records of 27 ASA physical status 1 and 2 patients who underwent adrenalectomy for pheochromocytoma were studied. Preoperative catecholamine levels and intraoperative plasma lactate levels were recorded.

MAIN RESULTS

Twenty cases had high lactate levels (>2 mmol/L). Preoperative urine epinephrine levels and urine metanephrine levels showed a moderate correlation with intraoperative peak plasma lactate levels (rs = 0.475 and rs = 0.499, respectively; Spearman's rank correlation test). Receiver operating characteristic (ROC) curve analysis for preoperative urine epinephrine levels showed good performance for prediction of high lactate levels [>2 mmol/L, area under the curve (AUC) =0.800], whereas ROC for preoperative urine norepinephrine levels showed no predictive performance for high lactate levels.

CONCLUSIONS

Catecholamine release caused by surgical manipulation may be a possible cause of intraoperative transient lactic acidosis, and it should be considered as a differential diagnosis of intraoperative lactic acidosis. Intraoperative peak plasma lactate level was correlated with preoperative epinephrine-releasing activity.

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

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

Surgical treatment options for aldosteronomas

Introduction

Single access retroperitoneoscopic adrenalectomy (SARA) is the most feasible approach for removing aldosteronomas.

Aim

To analyse the advantages and disadvantages of surgical approaches to treating small adrenal tumours.

Material and methods

In the period 2002-2011, 31 patients were operated on at Vilnius University Hospital Santariskiu Clinics for aldosteronomas. Adrenalectomies were performed in the lateral laparoscopic (group A, n = 6), the endoscopic retroperitoneal (group B, n = 20), and the single incision laparoscopic surgery (SILS) and SARA (group C, n = 5) approaches. Seventy five percent of patients were operated on by the same surgeon. The duration of adrenalectomies, and intraoperative and postoperative complications were compared. The possibility of minimally invasive adrenalectomies was evaluated.

Results

According to the patients’ age, body mass index and tumour size, the groups were equal. The average duration of surgery in group A was shorter than in groups B and C (91 ±23 min vs. 118 ±57 min vs. 144 ±88 min). Right laparoscopic adrenalectomy was longer than the left (105 ±26 min vs. 77 ±6 min), whereas right endoscopic retroperitoneal adrenalectomy was shorter than the left (109 ±50 min vs. 126 ±57 min). The best cosmetic view was in group C. The SARA method was converted into the endoscopic retroperitoneal approach and then into the laparoscopic for one patient. There were no intraoperative or postoperative complications.

Conclusions

Evaluating the minimal invasion of the method, its abilities and simplicity of conversion into another type of endoscopic surgical way, the SARA approach should be the first option for removing aldosteronomas.

Antimicrobial prophylaxis is not necessary in clean category minimally invasive surgery for renal and adrenal tumors: a prospective study of 373 consecutive patients

OBJECTIVE

To assess the feasibility of the nonuse of antimicrobial prophylaxis (AMP) on the incidence of infectious complications after clean category minimally invasive surgery for renal and adrenal tumors.

METHODS

We evaluated 415 consecutive patients who underwent gasless laparoendoscopic single-port surgery (GasLESS) for renal or adrenal tumors between 2006 and 2010. Forty-two patients with poorly controlled diabetes mellitus, coexisting infection, or opening of the urinary tract during partial nephrectomy were excluded from this study. The remaining 373 patients underwent radical nephrectomy (n = 187), partial nephrectomy (n = 103), or adrenalectomy (n = 83) without AMP. Perioperative infections were categorized into superficial surgical site infection (SSI), deep SSI, and remote infection (RI) and graded using an established 5-grade modification of the original Clavien-Dindo classification system. We investigated the association between the incidence of infectious complications and clinical or perioperative factors.

RESULTS

Infectious complications occurred in 16 cases (4.3%), including 4 superficial SSIs (1.1%), 2 deep SSIs (0.5%), and 10 RIs (2.7%). Neither superficial SSI nor deep SSI was significantly associated with any clinical or perioperative factors. The incidence of RI, however, was associated with longer operative time and higher National Nosocomial Infection Surveillance (NNIS) risk index. All perioperative infections were successfully treated with antibiotics without surgical interventions. No infectious complications equal to or greater than grade IIIa occurred.

CONCLUSION

The nonuse of AMP and the on-demand use of antibiotics seem to be sufficient for perioperative infectious management in clean category minimally invasive surgery for renal and adrenal tumors.

Single access retroperitoneoscopic adrenalectomy: initial experience

Today, endoscopic adrenalectomy has become a gold standard in endocrine surgery. To minimize the morbidity and improve cosmesis, single access retroperitoneoscopic adrenalectomy (SARA) has been developed as an alternative to traditional multiport laparoscopy and single port access (SPA) surgery, potentially exploiting even more the already proven benefits of minimally invasive surgery. We applied the SARA technique to adrenalectomy using the posterior retroperitoneal approach. The aim is to highlight the current situation regarding the feasibility and safety of single access retroperitoneoscopic adrenalectomy and to present our initial experience. Between October 2010 and February 2011, a 74-year-old woman (body mass index (BMI) - 31 kg/m(2)) with pheochromocytoma (1.2 cm in size) and 3 women, aged 45, 46 and 66 years (BMI - 27, 32, 33 kg/m(2)), respectively, and all diagnosed with Conn's adenoma (from 1.2 cm to 2.0 cm in size), underwent single access retroperitoneoscopic adrenalectomies. Operations were performed using conventional laparoscopic (STORZ) equipment. No conversions to the open or conventional retroperitoneal approach were necessary. There were no perioperative or postoperative complications. Operating time ranged from 60 min to 80 min. All patients left the hospital 2 days after surgery. The single access retroperitoneoscopic technique has been successfully applied to adrenalectomy as an available alternative to multiport laparoendoscopic adrenalectomy and single port access surgery. Exposure, visualization and dissection are the same as in retroperitoneal endoscopic adrenalectomy. The SARA surgery offers patient benefits such as faster convalescence, decreased postoperative scarring, better cosmetic effect and financial benefit.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

Background

Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure.

Methods

Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence.

Results

The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03).

Conclusions

The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.

Single minimum incision endoscopic radical nephrectomy for renal tumors with preoperative virtual navigation using 3D-CT volume-rendering

Background

Single minimum incision endoscopic surgery (MIES) involves the use of a flexible high-definition laparoscope to facilitate open surgery. We reviewed our method of radical nephrectomy for renal tumors, which is single MIES combined with preoperative virtual surgery employing three-dimensional CT images reconstructed by the volume rendering method (3D-CT images) in order to safely and appropriately approach the renal hilar vessels. We also assessed the usefulness of 3D-CT images.

Methods

Radical nephrectomy was done by single MIES via the translumbar approach in 80 consecutive patients. We performed the initial 20 MIES nephrectomies without preoperative 3D-CT images and the subsequent 60 MIES nephrectomies with preoperative 3D-CT images for evaluation of the renal hilar vessels and the relation of each tumor to the surrounding structures. On the basis of the 3D information, preoperative virtual surgery was performed with a computer.

Results

Single MIES nephrectomy was successful in all patients. In the 60 patients who underwent 3D-CT, the number of renal arteries and veins corresponded exactly with the preoperative 3D-CT data (100% sensitivity and 100% specificity). These 60 nephrectomies were completed with a shorter operating time and smaller blood loss than the initial 20 nephrectomies.

Conclusions

Single MIES radical nephrectomy combined with 3D-CT and virtual surgery achieved a shorter operating time and less blood loss, possibly due to safer and easier handling of the renal hilar vessels.

Gasless single-port access endoscopic surgery in urology: minimum incision endoscopic surgery, MIES

Abstract Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO(2) gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection.

Which patients are suitable candidates for laparoscopic adrenalectomy with needlescopic instruments?

Laparoscopic adrenalectomy has become the standard surgical procedure for benign adrenal tumors. The benefits of this type of surgery are reduced blood loss and postoperative pain, improved cosmetic outcomes and a reduced hospital stay. All these features could potentially be improved further by use of needlescopic instruments, which have diameters < or =3 mm, in contrast to the 5-12 mm diameters of standard laparoscopic instruments. Liao and colleagues have presented comprehensive and objective results for laparoscopic adrenalectomy with needlescopic instruments (LANI) performed in 112 patients with presumptively benign adrenal tumors <5 cm in diameter. Their results provide evidence to support the use of LANI in this setting and show that the technique is feasible for surgeons who have extensive experience in performing laparoscopic surgery. Prospective comparisons of LANI with traditional laparoscopic adrenalectomy are awaited.

Absence of prophylactic antibiotics in minimum incision endoscopic urological surgery (MEUS) of adrenal and renal tumors

OBJECTIVE

Recently, some studies suggested that antimicrobial prophylactics (AMP) are not needed to prevent surgical site infection (SSI) for clean operations despite worldwide acceptance of AMP. However, appropriate use of AMP in urological surgery has not been fully studied. Herein, we report an attempt of gradual decrease of AMP to non-use of AMP in minimum incision endoscopic urological surgery (MEUS) of adrenal and renal tumors.

MATERIALS AND METHODS

We investigated 95 consecutive patients who underwent 16 MEUS adrenalectomy and 79 MEUS radical and partial nephrectomy in our hospital. Patients were classified into the following three groups by means of prevention of SSI: the first step group received ampicillin sodium/sulbactam sodium 1.5 g i.v. 30 min before the operation; the second step group received a single 300 mg of levofloxacin orally 60 min before the operation; and the third step group received no AMP. Clinical backgrounds and incidences of SSI were compared among these three groups.

RESULTS

The first, second and third step groups consisted of 31, 36 and 28 patients, respectively. There was no statistically significant difference among these groups in terms of clinical backgrounds including age, sex, body mass index, American Society of Anesthesiologists classification, National Nosocomial Infections Surveillance risk index, and type and length of operation. The first step group had one superficial SSI that healed without any non-specific treatment. None of the second and third step groups had superficial SSI. There was no case of deep surgical site or distant infection.

CONCLUSION

AMP could be discarded in clean MEUS of adrenal and renal tumors without increasing the incidence of SSI.

Minimum incision endoscopic nephrectomy for giant hydronephrosis

Five consecutive patients with symptomatic giant hydronephrosis underwent minimum incision endoscopic nephrectomy. The originally huge renal specimen was retroperitoneally mobilized using both of endoscopy and direct vision, without the use of trocar ports or gas insufflation, via a single minimum incision that narrowly permitted extraction of the specimen. The specimen was successfully extracted from the incision in all patients. Technically, proper deflation of the hydronephrotic sac facilitates mobilization and enables extraction of the specimen. Median (range) size of incision, operative time, and estimated blood loss were 4 cm (3-5), 205 min (156-222), and 210 mL (110-350), respectively. No patient required blood transfusion or encountered operative complications. Postoperative convalescence was short and uneventful; all patients resumed oral intake and ambulance on the day following surgery, and were physically dischargeable from hospital after 2-3 postoperative days. Thus, this technique is a feasible, minimally invasive and safe procedure for symptomatic giant hydronephrosis.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Radical retropubic prostatectomy through a minimal incision with portless endoscopy: Our initial experience

Twenty-one patients with clinically localized prostate cancer underwent minilaparotomy radical retropubic prostatectomy through a single 5-cm midline or Pfannenstiel incision. A 30 degrees laparoscope was usually positioned around the edge of the incision to facilitate the procedure. The mean operating time was 255 min. The mean blood loss was 859 mL, and no patient required an allogenic blood transfusion. Postoperative pain was noticeably reduced, especially in the Pfannenstiel incision group. Endoscope-assisted minilaparotomy did not involve a learning curve, and could be useful for most urologic surgeons as minimally invasive surgery.