Transumbilical approach for laparo-endoscopic single-site adrenalectomy: Initial experience and short-term outcome

Laparoendoscopic single-site simple nephrectomy and reduced port procedure for inflammatory nonfunctioning kidney

INTRODUCTION

To describe laparoendoscopic single-site simple nephrectomy and reduced port simple nephrectomy for inflammatory nonfunctioning kidney.

CASE PRESENTATION

Case 1: a 58-year-old female with fever was referred to our hospital. Computed tomography demonstrated a markedly atrophic right kidney and mild hydronephrosis. Case 2: a 64-year-old male with a history of several intra-abdominal surgeries visited our hospital with a complaint of left back pain and fever. Computed tomography demonstrated left marked hydronephrosis, thinning of renal parenchyma, and duplicated inferior vena cava. After antibiotic treatment, transperitoneal reduced port simple nephrectomy and retroperitoneal laparoendoscopic single-site simple nephrectomy were performed in Case 1 and 2, respectively, because the function of the affected kidney was almost lost on renography. Although adhesion was slightly noted around the renal hilum in Case 1, neither conversion to laparotomy nor placement of additional ports was needed.

CONCLUSION

Laparoendoscopic single-site simple nephrectomy and reduced port simple nephrectomy for inflammatory nonfunctioning kidney may be options for experienced laparoscopic surgeons.

Reduced port laparoscopic radical nephrectomy using an umbilical zigzag skin incision for renal cell carcinoma

Reduced port laparoscopic radical nephrectomy (RPLRN) is an equivalent approach to conventional laparoscopic radical nephrectomy (LRN). In LRN, one wound generally needs to be extended for specimen extraction; therefore, some ingenuity is needed to achieve a good cosmetic outcome. We herein describe our initial experience of RPLRN using an umbilical zigzag skin incision for renal cell carcinoma (RCC). A 64-year-old female [body mass index (BMI): 20.0 kg/m²] was diagnosed with right RCC, which was 35 mm in diameter (clinical T1aN0M0). Case 2: a 68-year-old male (BMI: 23.2 kg/m²) was diagnosed with right RCC, which was 58 mm in diameter (clinical T1bN0M1), and perinephric fat was relatively thick. The procedure was safely completed in both cases. Total operative times, pneumoperitoneal times, and estimated blood loss in Case 1 and 2 were 90 and 145 min, 49 and 90 min, and 5 and 80 ml, respectively, and the times required to construct umbilical ports and close umbilical wounds were 8 and 9 min and 33 and 46 min, respectively. In Case 1, the specimen was easily extracted without the extension of the umbilical skin incision, whereas it was extended by an additional 2 cm in Case 2. The umbilical wound was inconspicuous in both cases. RPLRN using an umbilical zigzag skin incision for RCC was safely performed without complications, and clashing between instruments was minimized. The high level of cosmesis is advantageous and an umbilical zigzag skin incision may contribute to more widespread use of RPLRN for RCC; however, further studies on long-term oncological outcomes are needed.

Umbilical closure using 2-octyl cyanoacrylate in transumbilical laparoscopic adrenalectomy: A randomized controlled trial

OBJECTIVES

To evaluate postoperative pain and esthetic outcomes in patients undergoing transumbilical laparoscopic adrenalectomy with wound closure using 2-octyl cyanoacrylate.

METHODS

A total of 26 patients who underwent laparoscopic adrenalectomy with the transumbilical approach and agreed to participate in this study were included. Patients were randomly divided into two groups: the 2-octyl cyanoacrylate group (Glue group) or the non-use group (non-Glue group). A single surgeon (AM) carried out all procedures between 2014 and 2017.

RESULTS

There were no significant differences in the clinical background of the Glue and non-Glue groups. The number of patients with moderate or high levels of pain in the resting/moving period on postoperative days 1, 2 and 3 was 6/10 (46%/77%), 6/9 (46%/69%) and 3/5 (23%/38%) in the non-Glue group, and 5/7 (38%/54%), 2/7 (15%/54%) and 1/3 (8%/23%) in the Glue group. These differences were not significant. In the subgroup analysis of patients aged <50 years, the numbers were 4/6 (57%/86%), 5/7 (71%/100%) and 3/5 (43%/71%) in the non-Glue group, and 3/4 (33%/44%), 1/4 (11%/44%) and 0/1 (0%/11%) in the Glue group in the resting/moving period. On postoperative days 2 and 3, these differences were significant (P = 0.035 and 0.037 in the resting period, and P = 0.017 and 0.013 in the moving period).

CONCLUSIONS

2-octyl cyanoacrylate can be used safely for laparoscopic adrenalectomy with the transumbilical approach, and might be useful for reducing postoperative pain in patients aged <50 years.

Comparison of Cosmetic Effect and Pain Reduction Outcomes of Modified Mini-Laparoscopy Versus Laparoendoscopic Single-Site Surgery for Adrenalectomy

Objective: This study was to introduce the modified mini-laparoscopic adrenalectomy and investigate the advantage of operative time, cosmetic effect, and pain reduction by comparing the modified mini-laparoscopic adrenalectomy and laparoendoscopic single-site surgery (LESS). Methods and Patients: Between May 2015 and Jun 2018, 76 consecutive patients with adrenal tumor underwent laparoscopic adrenalectomy. Of which, 36 cases were in the mini-laparoscopic surgery group (the M group) and 40 cases in the LESS group. Medical records of the consecutive patients were analyzed. The operative time, blood loss, the Visual Analog Scale (VAS) scores and the Scar Cosmesis Assessment and Rating (SCAR) Scale scores were recorded. Results: The mean operative time in the M group was significantly less than that of in the LESS group (54.75 ± 9.37 min vs. 106.48 ± 19.71 min, P < .01). Mean estimated blood loss did not differ between the 2 groups (12.22 ± 5.29 mL vs. 10.80 ± 6.66 mL, P > .05). The mean VAS scores in the M group were significantly lower than those of the LESS group on postoperative days (POD) 1 and 3. The SCAR scale scores at POD 60 were similar in the M group and the LESS group (0.86 ± 0.64 vs. 0.95 ± 0.71, P > .05). Conclusions: Modified mini-laparoscopic adrenalectomy is safe and convenient. It offered less operative time, significant cosmetic benefit, and reduced incisional pain.

Patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical laparoendoscopic single-site adrenalectomy

INTRODUCTION

Laparoendoscopic single-site surgery is a recently innovated urologic surgical procedure. Transumbilical laparoendoscopic single-site adrenalectomy (LESS-A) is technically safe and feasible in patients with benign adrenal tumors. To improve patient counseling and informed consent, we evaluated patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical LESS-A.

METHODS

We reviewed 24 patients who underwent transumbilical LESS-A and assessed their operative and esthetic outcomes and incisional pain. Incisional pain was evaluated using a 10-point visual analog scale, and the body image and cosmetic satisfaction were measured using a questionnaire that included a body image scale (range, 5-20 points) and a cosmetic scale (range, 3-24 points).

RESULTS

Pure LESS-A was performed on 10 patients using a multichannel port; an additional 5-mm trocar was used in two obese patients. Supplementary to the single-incision approach, one or two 3-mm ports were used in 12 patients. The mean operative time was 203 min; the mean blood loss was 41 mL. The mean pain visual analog scale scores on postoperative days 1, 3, and 7 were 3.5, 2.2 (P = 0.012), and 1.5 points (P = 0.018), respectively. The mean body image scale and cosmetic scale scores indicating wound satisfaction 1 month after the surgery were 20 and 22 points, respectively. Although one patient had liver injury during surgery, the postoperative course during the 3-month follow-up was uneventful.

CONCLUSION

Transumbilical LESS-A confers less postoperative pain and better cosmetic satisfaction than conventional laparoscopic adrenalectomy. Therefore, this procedure could potentially become a standard treatment option for benign adrenal tumors.

The learning curve of laparoendoscopic single-site adrenalectomy: an analysis of over 100 cases

BACKGROUND

Recently, laparoendoscopic single-site adrenalectomy (LESS-A) has been developed as an alternative treatment for adrenal tumors. Although LESS-A is more technically complex than conventional laparoscopic adrenalectomy, its learning curve and the factors associated with poor surgical outcomes are poorly understood. We analyzed the learning curve of LESS-A and attempted to identify risk factors associated with worse surgical outcomes.

METHODS

We identified 103 patients who underwent LESS-A [performed by the same surgeon (A.M.)] from 2009 to 2015. The learning curve was analyzed using the moving average method (the 10-case moving average), and we assessed potential risk factors for a prolonged pneumoperitoneum time.

RESULTS

The learning curve stabilized at 30 cases. The cases were divided into two groups, the learning stage (LS) (cases 1-29) and master stage (MS) (cases 30-103) groups. The percentage of females and the frequency of previous abdominal surgery were higher in the LS group (p = 0.022 and 0.001, respectively). In the LS group, the mean pneumoperitoneum time was 92 ± 35 min, which was significantly longer than the equivalent value for the MS group (55 ± 18 min, p < 0.001). In the LS group, univariate analysis revealed that tumor size (≥50 mm) and the visceral fat area (VFA)/total fat area (TFA) ratio (≥0.49) were significantly associated with a prolonged pneumoperitoneum time (p = 0.046 and 0.046, respectively). In the multivariate analysis, tumor size and the VFA/TFA ratio were confirmed to be associated with a prolonged pneumoperitoneum time (p = 0.029 and 0.029, odds ratio 20.83 and 20.83, respectively). On the other hand, none of the examined factors were found to be associated with a prolonged pneumoperitoneum time in the MS group.

CONCLUSIONS

LESS-A was performed safely in most cases. However, surgeons who are learning the LESS-A procedure need to pay attention to tumor size and visceral obesity.

Expanding the indications for single-incision laparoscopic cholecystectomy to all patients with biliary disease: is it safe?

PURPOSE

The safety of single-incision laparoscopic cholecystectomy (SILC) has been proven in well-selected patients. The objective of this study was to determine whether SILC can be offered to all patients with any indication for cholecystectomy.

METHODS

A total of 173 consecutive SILCs were performed between January 2010 and November 2012 with no exclusion criteria. Demographic data, operative, and postoperative outcomes were prospectively collected and analyzed.

RESULTS

Patients with acute cholecystitis and gallstone pancreatitis had longer operative times and a higher conversion to 4-port cholecystectomy than patients with biliary colic. Similar relationships were seen when comparing patients with obesity to nonobese patients. There were no differences in complication rates between the groups.

CONCLUSIONS

SILC can be safely offered to patients with a wide spectrum of biliary disease with the understanding that this may result in increased operative times and a higher likelihood of conversion to multiport laparoscopy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Needlescopic-assisted laparoendoscopic single-site adrenalectomy

OBJECTIVE

Our objective was to compare the perioperative parameters of needle-assisted and conventional laparoendoscopic single-site adrenalectomy (LESS-A).

METHODS

We compared 23 patients undergoing needle-assisted LESS-A with 29 patients undergoing conventional LESS-A at Hiroshima University Hospital between November 2009 and February 2014. Needle-assisted LESS-A was performed using a MiniLap instrument (Stryker, San Jose, CA, USA). We used this instrument to protectively retract the liver at the right side of the tumor and the spleen at the left side by grasping with a Securea endoscopic surgical spacer (Hogy Medical Co., Ltd., Tokyo, Japan). Various parameters including insufflation time, estimated blood loss, pain scale, resumption of oral intake, transfusion rate, and complications were analyzed using the Mann-Whitney U test.

RESULTS

In all cases, LESS-A was completed successfully with no major intraoperative complications. Patients in both treatment groups had similar age, body mass index, sex, and laterality. Significantly, needle-assisted LESS-A was performed using the transumbilical approach rather than the subcostal approach. The insufflation time of the needle-assisted LESS-A was shorter than that of the conventional LESS-A (p = 0.0335). No patients required intraoperative or postoperative blood transfusions. Retrospective design and the small sample size are main limitations of this study.

CONCLUSION

Needle-assisted LESS-A was performed safely and in a manner that mitigated many of the difficulties of LESS surgery.

Past and present in abdominal surgery management for Cushing's syndrome

INTRODUCTION

Data on specific abdominal surgery and Cushing's syndrome are infrequent and are usually included in the adrenalectomy reports. Current literature suggests the feasibility and reproducibility of the surgical adrenalectomies for patients diagnosed with non-functioning tumours and functioning adrenal tumours including pheochromocytoma, Conn's syndrome and Cushing's syndrome.

DISCUSSION

Medical treatment for Cushing's syndrome is feasible but follow-up or clinical situations force the patient to undergo a surgical procedure. Laparoscopic surgery has become a gold standard nowadays in a broad spectrum of pathologies. Laparoscopic adrenalectomies are also standard procedures nowadays. However, despite the different characteristics and clinical disorders related to the laparoscopically removed adrenal tumours, the intraoperative and postoperative outcomes do not significantly differ in most cases between the different groups of patients, techniques and types of tumours. Tumour size, hormonal type and surgeon's experience could be different factors that predict intraoperative and postoperative complications. Transabdominal and retroperitoneal approaches can be considered. Outcomes for Cushing's syndrome do not differ depending on the surgical approach. Novel technologies and approaches such as single-port surgery or robotic surgery have proven to be safe and feasible.

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery. Single-port access and robotic surgery can be performed but more data are required to identify their correct role between the different surgical approaches. Factors such as surgeon's experience, tumour size and optimal technique can affect the outcomes of this surgery.

Visceral fat is correlated with prolonged operative time in laparoendoscopic single-site adrenalectomy and laparoscopic adrenalectomy

OBJECTIVE

To investigate the effect of visceral fat on operative time and discuss whether the measurement of adipose accumulation could be used as a sensitive predictor of technical difficulty in performing laparoendoscopic single-site adrenalectomy (LESS-A) and laparoscopic adrenalectomy (LA).

METHODS

We reviewed the medical records of 106 patients undergoing LA or LESS-A at our institution. Total fat area (TFA) and visceral fat area (VFA) were measured at the level of the L4 vertebra by computed tomography. To categorize the type of obesity, the VFA/TFA ratio was calculated. Multiple logistic regression analyses were performed to identify independent predictors of prolonged operative time.

RESULTS

The VFA/TFA ratio does not always coincide with body mass index (BMI, r = 0.415), and a higher correlation coefficient was observed between operative time and the VFA/TFA ratio (r = 0.359) than with that of BMI (r = 0.189). Multivariate analysis revealed that pheochromocytoma, tumor size ≥ 5 cm, and the VFA/TFA ratio ≥ 0.35, defined as the visceral type of adipose accumulation, were independent predictive factors for prolonged operative time in LA and LESS-A. We were able to stratify patients into short, intermediate, and long operative times using these preoperative variables.

CONCLUSION

This study revealed that the visceral type of adipose accumulation increases operative complexity in LA and LESS-A as measured by operative time. The VFA/TFA ratio might be a more sensitive indicator of technical difficulty than that of BMI.

Molecular and therapeutic advances in the diagnosis and management of malignant pheochromocytomas and paragangliomas

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.

Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital

INTRODUCTION

Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy.

METHODS

Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port.

RESULTS

The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days).

CONCLUSION

Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.

Improving the advantages of single port in right hemicolectomy: analysis of the results of pure transumbilical approach with intracorporeal anastomosis

Background. Single-port laparoscopic surgery has recently emerged as a method to improve patient recovery and cosmetic benefits of laparoscopic surgery. The evolution of our technique has led us to move from a periumbilical incision to a transumbilical one, avoiding the use of drain and maintaining a pure single-port approach with intracorporeal anastomosis in order to maintain the incision as smaller as possible. Method. We report a prospective clinical analysis of our first 38 patients. Oncological surgical steps were followed as during the standard laparoscopic approach, performing the anastomosis intracorporeally in all cases. Results. Mean age of 68,39 years old and an average BMI of 27,88%. (range 19,81–41,5). Most lesions were adenocarcinoma (65,8%), while the remaining were polyps (31,5%) and one a mucocele of the appendix. We moved from a periumbilical incision, initial 14 cases, into a transumbilical one, (medium size of the incision 3,25 cm). Average surgical time was 117,42 minutes. Drains was only used in our first 3 cases. Mean hospital stay was 5,2 days, (86,5% stayed less than 5 days). Total morbidity was 13%. Histological exams of the specimens showed that the oncological criteria were preserved. Conclusions. Single-port right hemicolectomy with intracorporeal anastomosis is feasible and safe. The advantages of a total intracorporeal anastomosis include that there is no need to enlarge the umbilical incision and avoid traction of the pedicle of the mesenterium of the transverse colon during the extracorporeal anastomosis. A transumbilical incision offers better cosmetic results, and the use of drains can be avoided, which increase, patient's satisfaction.