Laparoscopic treatment of adrenal diseases: 10 years on

Robotic and Laparoscopic Approaches for Adrenal Surgery in Obese Patients

OBJECTIVE

Minimally invasive adrenalectomy is a challenging procedure in obese patients. Few recent studies have advocated against robot-assisted adrenalectomy, particularly in obese patients. This study aims to compare operative outcomes between the robotic and laparoscopic adrenalectomy, particularly in obese patients.

MATERIALS AND METHODS

A retrospective analysis was performed on all consecutive patients undergoing adrenalectomy for benign disease by a single surgeon using either a laparoscopic or robotic approach. Adrenal surgeries for adrenal cancer were excluded. Demographics, operative time, length of hospital stays, estimated blood loss (EBL), and intraoperative and postoperative complications were evaluated. Patients were divided into 2 groups; obese and nonobese. A sub-analysis was performed comparing robotic and laparoscopic approaches in obese and nonobese patients.

RESULTS

Out of 120, 55 (45.83%) were obese (body mass index ≥ 30 kg/m²). 14 (25.45%) of the obese patients underwent a laparoscopic approach, and 41 (74.55%) underwent a robotic approach. Operative times were longer in the obese vs. nonobese groups (173.30 ± 72.90 minutes and 148.20 ± 61.68 minutes, P = .04) and were associated with less EBL (53.77 ± 82.48 vs. 101.30 ± 122, P = .01). The robotic approach required a longer operative time when compared to the laparoscopic approach (187 ± 72.42 minutes vs. 126.60 ± 54.55 minutes, P = .0102) in the obese but was associated with less blood loss (29.02 ± 51.05 mL vs. 138.30 ± 112.20 mL, P < .01) and shorter hospital stay (1.73 ± 1.23 days vs. 3.17 ± 1.27 days, P < .001).

CONCLUSION

Robot-assisted adrenal surgery is safe in obese patients and appears to be longer; however, it provides improvements in postoperative outcomes, including EBL and shorter hospital stay.

Robotic assisted versus pure laparoscopic surgery of the adrenal glands: a case-control study comparing surgical techniques

PURPOSE

The role of the da Vinci Robotic System ^® in adrenal gland surgery is not yet well defined. The goal of this study was to compare robotic-assisted surgery with pure laparoscopic surgery in a single center.

METHODS

One hundred and 16 patients underwent minimally invasive adrenalectomies in our department between June 1994 and December 2014, 41 of whom were treated with a robotic-assisted approach (robotic adrenalectomy, RA). Patients who underwent RA were matched according to BMI, age, gender, and nodule dimensions, and compared with 41 patients who had undergone laparoscopic adrenalectomies (LA). Statistical analysis was performed using the Student's t test for independent samples, and the relationship between the operative time and other covariates were evaluated with a multivariable linear regression model. P < 0.05 was considered significant.

RESULTS

Mean operative time was significantly shorter in the RA group compared to the LA group. The subgroup analysis showed a shorter mean operative time in the RA group in patients with nodules ≥6 cm, BMI ≥ 30 kg/m² and in those who had previous abdominal surgery (p < 0.05). Results from the multiple regression model confirmed a shorter mean operative time with RA with nodules ≥6 cm (p = 0.010). Conversion rate and postoperative complications were 2.4 and 4.8 % in the LA group and 0 and 4.8 % in the RA group.

CONCLUSIONS

In our experience, RA shows potential benefits compared to classic LA, in particular on patients with nodules ≥6 cm, BMI ≥ 30 kg/m2, and with previous abdominal surgery.

Laparoscopic Expertise Increases Hospital Volume of Adrenal Surgery

The laparoscopic approach is preferred for most adrenal tumors but technical challenges limit its use. We evaluated the effects of the availability of laparoscopic expertise on the volume of the adrenal surgery at a tertiary care hospital. Patients undergoing adrenalectomy 5 years before and 5 years after an advanced laparoscopic program was established were retrospectively reviewed. The average annual volume increased from 2 cases during the first period to 15 cases during the 5 years (1999-2003) after laparoscopic expertise became available. The average distance of travel to the hospital was significantly greater for the latter patients and significantly more patients were referred from outside of a 30-mile radius. Although the average statewide annual number of adrenalectomies has not significantly changed, the proportion of adrenalectomies performed at our institution rose. Offering a laparoscopic approach has altered physicians’ referral patterns and has significantly increased the volume of adrenal surgery at the institution.

Robot-assisted versus laparoscopic adrenalectomy: a systematic review and meta-analysis

BACKGROUND

More recently, robot-assisted adrenalectomy (RA) has emerged as an attractive alternative to laparoscopic adrenalectomy (LA), and many studies have shown the feasibility and safety of RA. However, the short- and long-term outcomes of RA versus LA have not been adequately assessed, and the advantage over the laparoscopic approach has not been demonstrated. The aim of this study was to compare the outcomes of RA versus LA by means of a systematic review and meta-analysis of the available literature in the early experience.

MATERIALS AND METHODS

A systematic search of PubMed, SCI/SSCI, CNKI, and the Cochrane Library was performed to identify prospective randomized controlled trials and retrospective observational studies that compared RA and LA and were published between January 2006 to the end of December 2012. Outcomes of interest included demographic and clinical characteristics, perioperative variables, and complications. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement.

RESULTS

Eight trials (232 cases and 297 controls) assessing RA versus LA were considered suitable for meta-analysis, including six prospective and two retrospective studies. There was a significant trend to choose patients for the performance of RA who were associated with a lower body mass index (weighted mean difference [WMD]=-2.78 kg/m(2); 95% confidence interval [CI], -3.00 to -2.55; P<.001) and higher incidence of previous surgery (odds ratio=1.59; 95% CI, 0.99-2.54; P=.05). There were no significant differences between the two groups in any other of the demographic parameters. With regard to perioperative variables, although there was a significant difference in the operating time in favor of LA (WMD=17.52 minutes; 95% CI, 3.48-31.56; P=.01), patients having RA might benefit from significantly less blood loss (WMD=-19.00 mL; 95% CI, -34.58 to -3.41; P=.02) and shorter length of hospital stay (WMD=-0.35 day; 95% CI, -0.51 to -0.19; P<.001). There were no significant differences between RA and LA with regard to conversion rates and overall complications. Sensitivity analysis performed by two methods both showed a positive reversal in the operating time with the statistical significance removed compared with the original analysis.

CONCLUSIONS

In the early experience, our data suggest that RA, compared with LA, may be a safe and feasible option associated with less blood loss and shorter hospital stay when performed by experienced surgeons in selected patients.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

OBJECTIVE

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series.

MATERIAL AND METHODS

322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications.

RESULTS

Twenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V).

CONCLUSIONS

Standardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Laparoscopic adrenalectomy in a patient with situs inversus

This study emphasizes the importance of careful preoperative imaging and select port positions appropriate for the targeted organ in patients with situs inversus undergoing laparoscopic surgery.

Background:

Situs inversus is a relatively rare congenital disease. A patient with a right adrenal tumor complicated by total situs inversus was treated by laparoscopy.

Case Discussion:

The patient was a 45-y-old male with lower limb weakness. He had been diagnosed with situs inversus during a general health check-up as an infant. His blood pressure was 230/160 mm Hg, and the serum potassium level was 2.0 mEq/L. Abdominal ultrasonography and magnetic resonance imaging showed a mass of about 2cm in diameter in contact with the right adrenal gland. Total situs inversus was simultaneously confirmed. The plasma aldosterone concentration was elevated to 442pg/mL, and renin activity was suppressed, at 0.3ng/mL/hr.

Discussion:

These findings indicated a diagnosis of primary aldosteronism due to an adrenal tumor, and the right adrenal tumor was resected laparoscopically. The right adrenal gland was approached and resected from the lateral side of the spleen, which was located on the right side because of situs inversus. The resected specimen was 4.5cm×1.6cm, and no intraoperative complications occurred. The histopathological examination showed the tumor to be an aldosterone-producing adrenocortical adenoma.

[Laparoscopic adrenalectomy for isolated metastasis of adrenal glands]

OBJECTIVES

The treatment of adrenal metastases using laparoscopic surgery still remains a matter of considerable controversy. The aim of this study is to present our experience of laparoscopic adrenalectomy for isolated adrenal metastasis.

METHODS

From June 2004 to June 2011, 5 adults (4 males/1 female) with isolated metastases to the adrenal glands underwent laparoscopic adrenalectomy. These patients included 3 cases of lung carcinoma, a case of hepatocellular carcinoma, and a case of renal cell carcinoma. The median patient age was 69 (range 61 to 72), and the median tumor size was 3.5 cm (range 2.5 to 7.0).

RESULTS

Laparoscopic adrenalectomies were performed without any complications using transperitoneal and retroperitoneal approaches. The median operative time was 142 minutes (range 126 to 174), and the estimated blood loss was 38 ml (range 25 to 158). The resection margins were free in all cases. A patient with lung cancer has been treated with adjuvant chemotherapy, otherwise, 4 patients have not. Regarding the oncological outcome, 3 of 5 patients were alive without any recurrence at a median follow-up of 14 months. About the rest two cases, one was alive with lung metastasis occurred at 15 months later, the other was died of the cancer at 14 months later.

CONCLUSIONS

Laparoscopic adrenalectomy for isolated adrenal metastasis is thought to be feasible. However, the indication of the surgery must be determined depending on tumor size, cancer characteristics, risk factors and so on. Additionally, the operative procedures such as approaches must be discussed sufficiently.

Contemporary management of adrenocortical carcinoma

CONTEXT

Adrenocortical carcinoma (ACC) is a rare and typically aggressive malignancy. Available recommendations are based primarily on retrospective series or expert opinions, and only few prospective clinical studies have yet been published.

OBJECTIVE

To combine the available evidence for diagnostic work-up and treatment of ACC to a contemporary recommendation on the management of this disease.

EVIDENCE ACQUISITION

We conducted a systematic literature search for studies conducted on humans and published in English using the Medline/PubMed database up to 31 January 2011. In addition, we screened published abstracts at meetings and several Web sites for recommendations on ACC management.

EVIDENCE SYNTHESIS

In patients with suspected localised ACC, a thorough endocrine and imaging work-up is followed by complete (R0) resection of the tumour by an expert surgeon. In experienced hands, laparoscopic adrenalectomy is probably as effective and safe for localised and noninvasive ACC as open surgery. Most clinicians agree that mitotane should be used as adjuvant therapy in the majority of patients, as they have a high risk for recurrence. An international panel has suggested using tumour stage, resection status, and the proliferation marker Ki67 as guidance for or against adjuvant therapy. In patients with advanced disease at presentation or recurrence not amenable to complete resection, a surgical approach is frequently inadequate. In these cases, mitotane alone or in combination with cytotoxic drugs is the treatment of choice. The most promising regimens (etoposide, doxorubicin, cisplatin plus mitotane, and streptozotocin plus mitotane) are currently compared in an international phase 3 trial, and results should be available by the end of 2011. Several targeted therapies are under investigation and may lead to new treatment options. Management of endocrine manifestations with steroidogenesis inhibitors is required in patients suffering uncontrolled hormone excess.

CONCLUSIONS

Detailed recommendations are provided to guide the management of patients with ACC.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group

OBJECTIVE

To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain.

PATIENTS AND METHODS

The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed.

RESULTS

The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively.

CONCLUSION

LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Laparoscopic resection of retrocaval paraganglioma

OBJECTIVES

Definitive treatment of paraganglioma is by surgical resection. Laparoscopic resection of the paraganglioma presents a unique surgical challenge due to inherent risks associated with excessive catecholamine release during surgical manipulation and variable anatomic presentation. In this report, we present our experience with the laparoscopic resection of the retrocaval paraganglioma.

METHODS

Between October 2001 and November 2007, 2 patients underwent the laparoscopic resection of a retrocaval paraganglioma. In both cases, the tumors were located just behind the inferior vena cava (IVC) without evidence of vessel-wall invasion. The maximum diameter of the tumor was 47 and 44 mm, respectively. There was extrinsic compression of the IVC in an anterior direction by the tumor. To expose the tumor surface completely, the IVC was mobilized medially. Thereafter, we proceeded with dissection of the posterior attachment of the tumor by using a Harmonic Scalpel (Ethicon, Cincinnati, OH). Finally, the tumor and the right adrenal gland were extracted in an endobag.

RESULTS

In both cases, the tumors were successfully removed laparoscopically without the need for conversion or blood transfusion. The operative time was 440 and 195 minutes, respectively. There were no significant postoperative complications.

CONCLUSIONS

To our knowledge, this is the first report of the laparoscopic resection of a retrocaval paraganglioma. For the resection of a paraganglioma, in this location, laparoscopy has the advantage of precise visualization, which helps to resect the tumor completely. Laparoscopic resection of a paraganglioma, despite the high level of compression of the IVC, is a feasible, reproducible technique with appropriate preoperative planning.

Should we use laparoscopic adrenalectomy for metastases? Scandinavian multicenter study

INTRODUCTION

Laparoscopic adrenalectomy for metastases is considered controversial. Multicenter retrospective study was performed to gain new knowledge in this issue.

MATERIALS AND METHODS

From January 1997 till November 2008, 41 adrenalectomies were performed during follow-up of the patients operated for malignant tumors. The median age was 64 (52-77) years. Metastases were confirmed in 31/41 cases. Metastatic lesions were further studied and to define factors influencing on survival, patients were divided to sub-groups of metachronous/synchronous, tumor origin and tumor size.

RESULTS

The median operative time was 104 (50-230) min, the median blood loss was 100 (0-500) ml. One procedure (3.2%) was converted. There were 3 (10.7%) intraoperative and 2 (7.4%) postoperative complications. The median tumor size was 6 (1.5-16) cm. Pathohistological analysis revealed 12 colorectal, 9 renal cell carcinoma, 5 lung carcinoma, 4 melanoma, and 1 hepatocellular metastases. The resection margin was not free in one case (3.7%). The median hospital stay was 2 (1-21) days. The median length of survival was 29 +/- 2.1 months for all patients.

CONCLUSION

Laparoscopic adrenalectomy for metastases is feasible regardless of their sizes. However these procedures should be performed by highly skilled laparoscopic surgeon in a fully equipped operating room and with a coordinated operation team.

Robot-assisted laparoscopic adrenalectomy for adrenocortical carcinoma: initial report and review of the literature

We report the first robot-assisted laparoscopic adrenalectomy for adrenocortical carcinoma. This patient was referred to our center for extirpation of an incidentally discovered 8-cm adrenal mass. The patient underwent robot-assisted laparoscopic adrenalectomy. Surgical margins were negative for malignancy, and the patient was discharged home on the first postoperative day. We review the literature regarding robot-assisted laparoscopic adrenalectomy and discuss the potential benefits of this technique as compared with standard laparoscopy in the management of adrenocortical carcinoma.

Bilateral laparoscopic adrenalectomy for corticotrophin-dependent Cushing's syndrome: a review of the Mayo Clinic experience

BACKGROUND

There has been a rapid shift from open to laparoscopic approaches in adrenal surgery, but the safety and efficacy of bilateral laparoscopic adrenalectomy (BLA) in patients with corticotrophin (ACTH)-dependent Cushing's syndrome continues to be defined.

OBJECTIVE

Review outcomes in the largest series of patients reported to date undergoing BLA for ACTH-dependent Cushing's syndrome.

DESIGN

Retrospective review study.

PATIENTS

Between January of 1995 and October of 2006, BLA was attempted in 68 patients with ACTH-dependent Cushing's syndrome (26 ectopic ACTH syndrome; 42 persistent pituitary-dependent Cushing's syndrome following pituitary surgery).

MEASUREMENTS

Review of peri-operative morbidity and mortality, biochemical parameters and patient-reported symptom response from chart review and mailed questionnaire.

RESULTS

BLA was successfully completed in 59 of 68 patients (87%); nine (13%) required conversion to open adrenalectomy (OA). Intra-operative complications occurred in three patients (4.4%) (two BLA, one OA), and non-operative complications occurred in 11 (16%) patients (eight BLA, three OA). There were no peri-operative deaths. Median hospitalization was 5.5 days (range, 3-28) and 11.9 days (range, 4-29) for the BLA and OA groups, respectively. In patients with follow-up data available, all achieved biochemical resolution and at least partial clinical resolution of signs and symptoms associated with hypercortisolism. Resolution of hypertension, diabetes and obesity was achieved in 64%, 29% and 35% of patients carrying those diagnoses prior to surgery, respectively.

CONCLUSIONS

This study further supports the role of BLA as an effective treatment option for patients with ACTH-dependent Cushing's syndrome.

Laparoscopic adrenalectomy: lessons learned from an initial series of 100 patients

BACKGROUND

Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of adrenal disorders in most centers. This study analyzes the authors' experience using the lateral intraperitoneal approach with the first 100 patients. In addition to analyzing the authors' experience, this article aims to contrast it with some published series as an internal quality control.

METHODS

In a 10-year period, 138 laparoscopic adrenalectomies were performed for 100 patients. Demographics, surgical results, complications, and long-term outcomes were analyzed.

RESULTS

The participants comprised 69 women and 31 men with a mean age of 37 years. The procedures included 24 right, 38 left, and 38 bilateral adrenalectomies. The indications for surgery were Cushing's disease for 33 patients, pheochromocytoma (4 bilateral) for 23 patients, Cushing's syndrome for 18 patients, Conn's syndrome for 16 patients, and incidentaloma for 10 patients. Five procedures were converted to open surgery. Two patients with pheochromocytoma required intraoperative blood transfusion. The mean operative time was 174 min for unilateral adrenalectomies and 302 min for the bilateral procedures. The mean hospital stay was 5 days. Surgical morbidity included an abdominal wall hematoma, a small pneumothorax, and intraabominal bleeding in one patient that required reexploration. There were three operative mortalities not related to the technique. The long-term results showed control of hypercortisolism in all the patients with Cushing's disease and 82% of the patients with pheochromocytoma. Most of the patients with Conn's syndrome (91.4%) became normotensive after surgery.

CONCLUSIONS

Laparoscopic adrenalectomy is safe and effective. The complications are mild, and mortality is related more to the patient's condition than to the surgical technique.

Laparoscopic surgery and corticoadrenalomas

BACKGROUND

Nowadays, laparoscopic adrenalectomy is the "gold standard" procedure for the treatment of benign lesions. However, the situation is not so clearcut when the issue is laparoscopic excision of malignant adrenal tumors. We present our results of laparoscopic adrenalectomy for treating malignant tumors over the past decade.

METHODS

Between October 1995 and June 2004, 131 consecutive laparoscopic adrenalectomies were performed on 120 patients (11 synchronous bilateral procedures). All patients underwent a standardized investigation protocol during their workup for surgery.

RESULTS

There were only two conversions to laparotomy (1.6%). Complications that occurred during the procedure were limited to six patients (5%). Postoperative 30-days mortality was nil. Postoperative complications occurred in five patients (4.7%) during the first 30 days of recovery. The median hospital stay for all patients was 2.5 days (range = 2-10 days). Twelve patients (9%) had a malignant tumor: nine corticoadrenalomas, one pleomorphic sarcoma, one metastatic deposit from a previously excised colonic cancer, and one malignant pheochromocytoma. At mean followup of 34 months, mean survival time was 42.3 months for corticoadrenalomas that had undergone laparoscopy versus 29.7 months for those who had had a laparotomy. Five of the nine patients are alive and well at a mean of 37 months following surgery. One patient developed pulmonary metastases one year postsurgery; they were responsive to mitotane. Five years later, the same patient had a reoperation for an intra-abdominal retrogastric recurrence of her tumor and continues to do well. Another patient developed pulmonary metastases 22 months following adrenalectomy. Two patients died of metastatic intra-abdominal disease 20 and 7 months postsurgery.

CONCLUSION

When laparoscopic surgery is to used for cancer treatment, caution is the rule to maintain the primary objective of securing a survival rate at least as high as that for open surgery, without increased risk of recurrence. Considering the results presented within this study, it seems that the laparoscopic removal of a corticoadrenaloma should not worsen the prognosis, provided the surgeon respects the primary rules of oncologic resectional surgery. Any surgical conditions that would preclude the strict application of these criteria are contraindications to a laparoscopic procedure.

Clinical outcomes and learning curve of a laparoscopic adrenalectomy in 103 consecutive cases at a single institute

OBJECTIVE

We examined the clinical outcomes and the learning curve for a laparoscopic adrenalectomy (LA) in 103 consecutive cases performed by three surgeons at our institute, according to the type of adrenal disorder.

PATIENTS AND METHODS

One hundred and three patients with adrenal tumors, including 38 cases of primary aldosteronism, 33 cases of Cushing syndrome (including preclinical Cushing syndrome), 15 cases of pheochromocytoma, and nine cases of non-functioning adenoma were evaluated, while focusing on the approaches, intraoperative and postoperative data, and the learning curve of LA, according the type of adrenal disorder.

RESULTS

There was no significant difference in the operation time, estimated blood loss, incidence of conversion to open surgery and blood transfusion, or postoperative recovery among the patients treated by LA for aldosteronoma, Cushing adenoma, pheochromocytoma, and non-functioning adenoma. In the cases of aldosteronoma and Cushing adenoma, the learning curve for the operation time and blood loss in each operator tended to decrease as the number of operations increased. On the other hand, in the cases treated by LA for pheochromocytoma, no trends in either the operation time or blood loss were observed. However, there has been neither any conversion to open surgery nor blood transfusion in cases treated by LA since 1998 (our 42nd case), even after the changes in the operators.

CONCLUSIONS

Our results clearly indicate that LA is becoming safer than before, probably due to improvements in the technique, education, and training of surgeons, in addition to the increased number of cases now treated by LA.

Stellenwert der laparoskopischen Nierenchirurgie in der Urologie

Since the first laparoscopic nephrectomy in 1990, most ablative and reconstructive urological kidney surgery has been attempted laparoscopically. The advantages of this method were first demonstrated for benign diseases, with less postoperative pain, shorter hospitalization, faster convalescence and, for the objective evaluation of these findings, with lower serum levels of interleukins and acute phase proteins, and without disadvantages in therapy efficiency. Over the last few years, sufficient data have been published to show the oncological outcome for patients with kidney cancer. For laparoscopic radical nephrectomy, and recently also for partial nephrectomy, oncological equality with open procedures could be demonstrated, with all of the benefits of minimally invasive techniques. The use of laparoscopy was one of the most important steps in the progress of medicine in the 20th century. Our aims include the further improvement of this technique and its distribution to surgical centers.

Cirugía laparoscópica en el tratamiento de enfermedades adrenales: experiencia en 200 casos

OBJECTIVE

We report our experience in laparoscopic adrenalectomy, after adopting the laparoscopic technique for 10 years as a primary option for suprarenal surgery.

METHODS

We included 200 laparoscopic adrenal surgeries performed consecutively in 183 patients with surgical adrenal pathology between November 1994 and November 2005. Sixty-seven (36.6%) patients were male and 116 (63.4%) were female, with an average age of 49.1 years (age range 8 months to 78 years).

RESULTS

The most frequents clinical diagnosis were hyperaldosteronism (17.5%), metastatic cancer (15.8%), pheochromocytoma (15.3%), Cushing syndrome (7.1%), adrenal cyst (4.9%) and myelolipoma (2.7%). A total of 164 total adrenalectomies, 29 partial adrenalectomies and 7 marsupializations of adrenal cysts were performed. Mean surgical time was 82.6 minutes (range 25 to 240 minutes) and mean hospitalization time was 2.5 days (range 1-10 days). The size of the suprarenal gland and/or tumor varied between 1 and 14 cm (average 5.6 cm). The rate of complication was 6%. In 8 of the patients, there was another laparoscopic procedure besides the adrenal surgery: cholecystectomies (2), marsupialization of a renal cyst (2), block nephrectomy (2), partial nephrectomy for a tumor (1) and pancreatic cystectomy (1). One patient underwent a right laparoscopic adrenalectomy and an ipsilateral percutaneous nephrolithotomy.

CONCLUSION

The accumulated experience with 200 laparoscopic adrenal procedures has allowed the management of endocrine pathologies, such as, aldosteroma, pheochromocytoma, Cushing syndrome and rare entities, such as, cysts, myelolipomas in a suitable manner. Additionally, it has permitted us to extend the benefits of a minimally invasive procedure for large adrenal masses and selected oncology cases.

Thirty robotic adrenalectomies

BACKGROUND

Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution's series of 30 robotic adrenalectomies, and evaluates the procedure's safety, efficacy, and cost.

METHODS

Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period.

RESULTS

Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy (12,977 dollars) were not significantly different than charges for traditional laparoscopic (11,599 dollars) or open adrenalectomy (14,600 dollars).

CONCLUSIONS

Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.

Laparoscopic Adrenal Surgery: New Frontiers

After about 10 years of experience, laparoscopic adrenalectomy has become the gold standard for the treatment of adrenal lesions. Here, we describe the presenting features, imaging methods, and current surgical approaches to diseases of the adrenal gland. There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, but controversy exists about using laparoscopy for suspected adrenal malignancy, metastasis, and partial adrenalectomy. This article reviews the literature on laparoscopic adrenalectomy. In particular, we focus our attention on the new surgical approaches to the gland. We evaluate the indications, operative techniques, and tools for partial adrenalectomy, and we discuss new surgical strategies such as cryosurgery and radiofrequency ablation.

Laparoscopic adrenalectomy and adrenal-preserving surgery

PURPOSE OF REVIEW

The aim of this paper is to define the current role of laparoscopy in the management of surgical adrenal diseases evaluating the surgical aspects, the indications and contraindications of laparoscopic adrenalectomy, focusing also on the most innovative tendencies in the laparoscopic adrenal-preserving surgery.

RECENT FINDINGS

Recent publications have described some interesting new indications that need to be confirmed by long-term follow up. The present review mainly focuses on defining the state of the art of current adrenal laparoscopic surgery.

SUMMARY

Laparoscopic adrenalectomy is becoming the 'platinum standard' for the treatment of the adrenal surgical diseases and it should be considered the treatment of choice for benign adrenal diseases. In cases of malignancy and conservative surgery, adrenalectomy appears to be very promising, although a longer follow up and further studies are still needed to accurately assess the role played by these procedures. Finally, who should do laparoscopic adrenalectomy? Every patient who requires the ablation of the adrenal should receive laparoscopic opportunity. And the surgeons? Only those with advanced laparoscopic skills and a good knowledge of adrenal anatomy and pathophysiology will obtain the same excellent results currently reported in the literature.

¿Qué ha cambiado en la adrenalectomía? De la cirugía abierta a la laparoscópica

INTRODUCTION

After the introduction of the laparoscopic approach in adrenal surgery, this technique has become the gold standard in surgical adrenal diseases. Nevertheless, comparative studies with open surgery are scarce and the impact of laparoscopic techniques on these diseases is unknown.

OBJECTIVE

To evaluate our experience of adrenal surgery over a 14-year period, before and after the introduction of laparoscopic adrenalectomy, and to analyze the influence of this technique on the surgical management of adrenal diseases.

PATIENTS AND METHOD

From January 1990 to June 2004, 78 patients underwent adrenalectomy. Between 1990 and 1998, open adrenalectomy was performed in 24 patients, while between 1999 and 2004, 54 patients underwent the laparoscopic approach and 1 underwent open surgery. Data for the open group were retrospectively reviewed while those for the laparoscopic group were prospectively registered in the advanced laparoscopic surgery database of Hospital Sant Pau (HSP).

RESULTS

The mean age was 47 years (16-75) in the open group and was 49 years (17-77) (p = NS) in the laparoscopic group. Distribution by surgical indication was similar in both periods concerning primary hyperaldosteronism, hypercortisolism, and pheochromocytoma, with a significant increase in surgical cases indicated by malignancy (1 vs 4) or incidentaloma (2 vs 13) (p<.001). Operating time was reduced from 150 min (65-210) in the open group to 90 min (30-300) in the laparoscopic group (p<.01). Morbidity was also reduced (20% vs 6%, p<.01). The size of lesions resected by open or laparoscopic surgery (4 cm [0.4-16] vs 3.5 cm [1.2-14]) was similar. The mean length of hospital stay was reduced from 8 days (3-13) to 3 days (2-12) (p<.01). The number of adrenalectomies performed in HSP was 24 in the first period (1990-1997) vs 40 in the second (1998-2004). This represented an increase from 3/year to 6.6/year mainly due to the increase in the number of incidentalomas.

CONCLUSIONS

The laparoscopic approach has improved immediate surgical results (operating time, morbidity, and length of hospital stay). There was a clear increase in the number of adrenalectomies, and especially of incidentalomas, due to improved diagnostic techniques and the availability of a less aggressive approach.