Transumbilical single port laparoscopic adrenalectomy: a technical report on right and left adrenalectomy using the glove port

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

[Minimally invasive techniques in adrenal gland surgery]

Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.

Robotic transduodenal ampullectomy: A novel minimally invasive approach for ampullary neoplasms

BACKGROUND

The adoption of minimally invasive surgery for transduodenal ampullectomy has been slow because of special characteristics and complexity of this procedure.

METHODS

Six patients underwent robotic transduodenal ampullectomy. We employed novel methods to facilitate exposure of the ampulla.

RESULTS

All patients completed robotic transduodenal ampullectomy, but one patient was immediately converted to robotic pancreaticoduodenectomy because of presence of invasive carcinoma on frozen biopsy. The final pathologic report revealed high-grade dysplasia in four patients, low-grade dyplasia in one, and T2N0 in one patient who converted to pancreaticoduodenectomy. There was no immediate postoperative complication or mortality. One patient was readmitted after 3 months because of stricture of the bile duct outlet. There was no recurrence over a median follow-up period of 20 months.

CONCLUSION

An appropriate combination of patient positioning and retraction method helps the robot surgical system to provide competent performance for sophisticated and precise manipulation of ampullary lesions.

Single-incision laparoscopic cholecystectomy using instrumental alignment in robotic single-site cholecystectomy

Purpose

There is no standardized single-incision laparoscopic cholecystectomy (SILC) technique in contrast to robot single-site cholecystectomy (RSSC). We tried to implement the array of instruments used in RSSC to SILC.

Methods

A series of 108 consecutive patients underwent SILC between September 2014 and July 2017 by 2 surgeons. The indication was benign disease of the gallbladder. The perioperative outcomes were reviewed. We used the 4-channel Glove port and conventional laparoscopic instruments.

Results

The study subjects consisted of 29 males and 79 females, and the mean age was 44.4 years (range, 16–70 years). Mean body mass index was 24.1 kg/m². The mean working time was 25.0 ± 10.7 minutes and total operation time was 44.4 ± 12.4 minutes. There were 7 cases of conversion (additional 1 port in 4 patients, additional 2 ports in 2, and conventional 4 port technique in 1). Bile spillage from the gallbladder during the procedure occurred in 17 (15.7%). There were no postoperative complications. Postoperative hospital stay was 2.0 ± 0.6 days.

Conclusion

The alignment of the instruments in a RSSC was successfully implemented into a SILC, so that an equally effective operation was possible.

Advantages of the glove port docking technique in robotic single-site cholecystectomy: comparison with the conventional silicone port

Although the da Vinci Single-Site^® silicone port allows exact alignment and effective triangulation of instruments, it also has drawbacks. We introduce an alternative docking technique using the Glove port^®. From April 2014 to December 2016, respective 50 patients of the conventional silicone port and the glove port group were compared. The mean docking time was 16.6 ± 6.6 min in the silicone port group and 10.6 ± 3.6 min in the glove port group. Re-docking during the operation was needed in three patients in the silicone port group and readjustment of cannulae without re-docking could be simply performed in five patients in the glove port group. Skin injury was observed in 17 patients in the silicone port group and 0 patients in the glove port group without significant complications. Some limitations of the conventional silicone port were improved by the glove port.

Two-port laparoscopic anterior resection through a self-made glove device versus conventional laparoscopic anterior resection for rectal cancer: a comparison of short-term surgical results

Background

The laparoscopic approach has become increasingly incorporated into the development of new surgical procedures. An ever-increasing number of surgeons desire methods that minimize surgical trauma and provide improved cosmetic outcomes. Since 2014, we have performed two-port laparoscopic surgery using a transumbilical multichannel glove port and a 12-mm port. The aim of this study was to compare the short-term surgical results of two-port laparoscopic anterior resection (TPLAR) with those of conventional laparoscopic anterior resection (CLAR) for rectal cancer.

Methods

Between January 2014 and May 2014, a total of 27 patients underwent TPLAR and 30 patients underwent CLAR for the treatment of rectal cancer. The short-term surgical results of these two groups of patients were analyzed retrospectively.

Results

The differences in operative time, blood loss, conversion rate, complication rate, distal resection margin, number of harvested lymph nodes, duration until ambulation, duration until first flatus, length of postoperative hospital stay, and overall hospital costs between the two groups were not significant. The median (range) length of the abdominal incisions of the TPLAR patients was shorter than the length of the CLAR patients (5.1 (4.5–16.3) cm vs 8.2 (7.0–10.0) cm, respectively; p < 0.001). The respective median (range) postoperative pain scores were lower in the TPLAR than in the CLAR patients at 24 h (4 (1–6) h vs 5 (2–8) h; p = 0.045), 48 h (3 (1–4) h vs 4 (range 1–8) h; P = 0.004) and 72 h (1 (0–3) h vs 2 (1–5) h; p = 0.010). The median overall score on the satisfaction-with-abdominal-incision questionnaire of the TPLAR patients was significantly higher (better) than the score of the CLAR patients.

Conclusions

TPLAR for rectal cancer is safe and feasible, with short-term perioperative and oncological outcomes similar to those of CLAR. TPLAR provides less postoperative pain and better cosmetic outcomes.

Advances in endoscopic surgery for small animal reproduction

Although endoscopic surgery entered its "golden era" in the mid-1980s, it is still advancing at a tremendous pace. Novel surgical techniques and devices are continuously developed and applied, and new indications (and/or contraindications) for the use of endoscopic surgery are routinely reported in the literature and subjected to systematic assessments. Although endoscopic surgery (laparoscopy in particular) has already become established as the gold standard in human medicine, it has yet to be proven as a viable alternative to open surgery in the field of veterinary medicine. The advantages of minimally invasive surgery include better intra-operative visualization, reduced postoperative pain, reduced scar formation and increased postoperative mobility. Therefore, it is reasonable to expect that the application of this will continue to expand. Small animal reproduction, a field within the broad discipline of veterinary medicine, has already recognized and begun to reap the benefits of endoscopic surgery. Herein, we retrospectively review the most recent successful novel applications of endoscopic surgery in the small animal reproduction system to provide small animal reproductive surgeons with important knowledge to help improve their own veterinarian medical practice.

A new glove port for single incision procedure

Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, inconvenience remains for inexperienced surgeons during surgery when instruments conflict with each other, and a glove port is used hesitantly for such diagnosis related groups (DRG) because of its high cost. Authors made a new glove port by an odd surgical gloves and one wound protectors. This glove port is ease to make besides being convenient to us, and inexpensive. This new glove port has the benefit of easy utilization and cost effectiveness for surgeons performing single-incision laparoscopic surgery.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Laparo-endoscopic single-site left adrenalectomy using conventional ports and instruments

Laparo-endoscopic single-site adrenalectomy (LESS-A) is commonly performed using specialized access devices and/or instruments. We report a LESS-A in a 47-year-old woman with a left aldosteranoma via a subcostal approach utilizing conventional laparoscopic ports and instruments. The feasibility and cost-effectiveness of this approach are highlighted and the literature on the subject is reviewed.

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.

Changing surgical approaches for laparoscopic adrenalectomy: single-surgeon data of a 6-year experience

AIM

To evaluate outcomes of laparoscopic adrenalectomy (LA) and laparoendoscopic single-site surgery (LESS) for adrenal masses in the light of changing laparoscopic surgical techniques.

MATERIALS AND METHODS

Seventy-three patients were analyzed retrospectively. There were 2 groups; group 1 included patients who had conventional transperitoneal LA and transperitoneal LESS, and group 2 included patients who had lateral retroperitoneal LA, retroperitoneal LA in prone position, and retroperitoneal LESS. Demographic data, urine 3-methoxy-4-hydroxymandelic acid, normetanephrine, epinephrine, serum cortisol, aldosterone, adrenocorticotropic hormone, American Society of Anesthesiologists score, side and size of mass, conversion to open surgery, complications, estimated blood loss, operation time, pathological results were recorded and analyzed.

RESULTS

There was no difference in demographic data and serum parameters between both groups. Tumor size, estimated blood loss, operation time, transfusion rate and hospital stay were less for group 2 (p < 0.05, p = 0.0001). However, the complication rate was similar in both groups; in retroperitoneal prone position, the complication rate was less than for other surgical approaches, but statistically significant results could not be assessed.

CONCLUSIONS

Even if the diameter of adrenal mass is larger than 6 cm, LA may be considered as the gold standard. The retroperitoneal approach especially in prone position may be a promising treatment method in the near future for adrenalectomy in selected patients.

Single-port endo-laparoscopic surgery in combined abdominal procedures

Single-port endo-laparoscopic surgery has gained support in the surgical community because it is perceived to offer a better postoperative outcome as it requires only a single incision. We write this prospective observational study to ascertain the feasibility and safety of this technique in patients otherwise requiring two operations. Five patients who underwent double procedures with a single-port device were reviewed: Case 1, a transabdominal preperitoneal hernia repair and gastric wedge resection; Case 2, cholecystectomy and diaphragmatic hernia repair; Case 3, oophorectomy and incisional hernia repair; Case 4, anterior resection of the rectum and hepatic segmentectomy; and Case 5, left adrenalectomy and cholecystectomy. Patient demographics, type of port used, operative time, complications and incision length were collected. Mean operative time for the cases ranged from 100 to 315 min. Incision length for the single-port device was 2 cm. In Case 2, an additional 5-mm port was used and an intraoperative complication involving a laceration of the liver occurred during the suturing of the gallbladder fundus. An additional 8-cm lower abdominal incision (Pfannenstiel) was required in Case 4 to complete the colonic anastomosis and for specimen retrieval. Single-port endo-laparoscopic surgery is a feasible and safe technique for approaching double procedures. It drastically reduces the number of scars that a double procedure creates, and if difficulty arises, another port can always be added to ease the operation. It can also potentially reduce the number of admissions and anesthesia that a patient undergoes.

Laparo-endoscopic single-site surgery: recent advances in urology

Significant advances have been achieved in the field of urologic laparo-endoscopic single-site surgery (LESS) since the first reported clinical series in 2007. The aim of the present review paper is to summarize and critically analyze the most recent advances in the field of urologic LESS. A literature review was performed using PubMed to retrieve publications related to LESS in urology over the last two years (from January 2011 to May 2012). In the free-text protocol, the following terms were applied: LESS; single port laparoscopy; single incision laparoscopy. Despite unsolved challenges, LESS can be regarded as an emerging trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique in a relatively short time. Outcomes demonstrate that a broad range of procedures can be effectively and safely done, given a solid laparoscopic surgical background and stringent patient-selection criteria. The recent introduction of a purpose-built instrumentation is likely to further foster the application of robotics to LESS. Further improvements are needed before this technique might reach a widespread adoption. Future advances in the field of robotic technology are expected to overcome the current limitations of LESS.

[Minimally invasive adrenal gland surgery]

Nowadays, minimally invasive operating techniques are an essential part of adrenal gland surgery. Meanwhile four different methods are being used: laparoscopically in the supine or lateral position or retroperitoneoscopically as a prone or lateral method. Ideal indications for endoscopic adrenalectomy are adrenal hyperplasias and benign, hormonally active adrenal gland tumors up to 5 cm in diameter. In comparison to the conventional operating procedures, the endoscopic methods have the advantage of less blood loss and minimized postoperative pain as well as shortening of hospital stay. Yet in contrast, the operating time of these procedures is prolonged. To date, it is not evident whether laparoscopy or retroperitoneoscopy should be preferred. Laparoscopy offers a familiar anatomical exposure but requires 5-6 trocars. For the retroperitoneoscopic methods only 3 trocars are needed, but orientation in the operating field is more difficult. All endoscopic procedures on the adrenal gland are technically difficult. They require a extended experience in minimally invasive surgery as well as special knowledge in endocrine surgery.