Sub-mesocolic access in laparoscopic left adrenalectomy

Laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA): an alternative approach for severe Cushing's syndrome

Severe uncontrolled Cushing's syndrome (CS) is an acute life-threatening condition. As it is often not responsive to medical therapy, emergency bilateral adrenalectomy (BA) may present the only therapeutic option. Moreover, multiple bone fractures, representing one of the clinical consequences of hypercortisolism, may not permit both prone and lateral patient's positioning during surgery, thus making minimally invasive approaches nonfeasible. We report our preliminary experience with an alternative approach in this selected patients' category. Among 613 patients who underwent endoscopic adrenalectomy at our centre (34-5.6% BA) between January 1997 and October 2021, 3 patients were scheduled for laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA). Surgery was performed with patient in supine position, with fastened arms and legs to allow Trendelenburg and anti-Trendelenburg movements and lateral rotations. The procedure consisted in a synchronous bilateral adrenalectomy. A modern multi-articulated operative table provided rotations on the right and left side to perform left and right adrenalectomy, respectively. One male and two female patients with a mean age of 34 ± 3.1 years underwent La-TABA. Mean operative time was 200 ± 138.3 min. No perioperative complications were registered. Mean postoperative hospital stay was 8 ± 4.4 days. In very severe ACTH-dependent CS, BA should be performed as soon as possible. La-TABA may represent the most appropriate therapeutic option, as this patients' category is not able to tolerate prone and lateral positioning required during the conventional surgery. Despite the higher technical complexity of the procedure compared with the other endoscopic approaches to adrenalectomy, it retains the benefits of minimally invasive surgery in terms of postoperative complications and recovery.

Laparoscopic transperitoneal adrenalectomy: a comparative study of different techniques for vessel sealing

BACKGROUND

Laparoscopic adrenalectomy is the standard surgical approach to adrenal lesions. Adrenal vessel sealing is the critical surgical phase of laparoscopic adrenalectomy. This study aimed at comparing perioperative outcomes of laparoscopic transperitoneal adrenalectomy by means of radiofrequency energy-based device (LARFD) to those performed with traditional clipping device (LACD), while focusing on the different adrenal vessel control techniques.

METHODS

Patients who underwent adrenalectomy for adrenal disease between January 1994 and April 2019 at the Surgical Clinic, Polytechnic University of Marche were included in the study. Overall, 414 patients met inclusion criteria for study eligibility: 211 and 203 patients underwent LARFD and LACD, respectively. Multiple models of quantile regression, logistic regression and Poisson finite mixture regression were used to assess the relationship between operative time, conversion to open procedure, length of stay (LoS), surgical procedure and patient characteristics, respectively.

RESULTS

LARFD reduced operative time of about 12 min compared to LACD. Additional operative time-related factors were surgery side, surgery approach, conversion to open procedure and trocar number. The probability of conversion to open procedure decreased by about 76% for each added trocar, whereas it increased by about 49% for each added centimeter of adrenal lesion and by about 25% for each added year of surgery. Two patient clusters were identified based on the LoS: long-stay and short-stay. In the long-stay cluster, LoS decreased of about 30% in LARFD group and it was significantly associated with conversion to open procedure and postoperative complications, whereas in short-stay cluster only postoperative complications had a significant effect on LoS.

CONCLUSION

Laparoscopic transperitoneal adrenalectomy performed by means of radiofrequency energy-based device for the sealing of adrenal vessels is an effective procedure reducing operative time with potentially improved postoperative outcomes.

The Modified Semi-lateral Transmesocolic Approach for Laparoscopic Left Adrenalectomy

BACKGROUND

As the most appropriate laparoscopic approach for adrenalectomy is still a matter of debate, we present a modified technique of laparoscopic transmesocolic approach for left adrenalectomy.

METHODS

All demographics, intraoperative and postoperative data of patients who underwent laparoscopic transmesocolic left adrenalectomy from 2009 to 2015 in Avicenne Hospital were recorded.

RESULTS

Thirty-three consecutive patients underwent laparoscopic transmesocolic left adrenalectomy. We observed no conversion, negligible blood loss, no red cell transfusion or intraoperative complication. Mean operative time reached 96 min (range: 40-200 min). Postoperatively, the median length of hospital stay was 5 days (range: 3-8 days), mortality was nil, and six (19%) patients suffered from complication, including one major complication (Clavien-Dindo III-IV, an abdominal collection treated with radiologic drainage). R0 resection was achieved in all patients.

CONCLUSION

Laparoscopic left adrenalectomy using semi-lateral transperitoneal transmesocolic approach is feasible and safe with acceptable intraoperative and perioperative outcomes. This technique could be considered as a routine approach and should be compared in further studies.

Primary adrenal hypercortisolism: minimally invasive surgical treatment or medical therapy? A retrospective study with long-term follow-up evaluation

BACKGROUND

Because the most suitable management of subclinical Cushing syndrome (SCS, which involves hypersecretion of cortisol without clinically evident disease) still is undefined, the current study aimed to compare retrospectively the outcome for a cohort of patients treated by medical therapy or laparoscopic adrenalectomy (LA).

METHODS

Over a 12-year period, 47 patients with SCS have been treated by means of LA (19 patients, group A) or medical therapy (28 patients, group B). Group A consisted of 15 women and 4 men with a mean age of 54.8 years. Eight patients had a left adrenal mass, whereas nine had a right adrenal mass, and one patient had bilateral lesion. Group B was composed of 18 women and 10 men with a mean age of 57.8 years. Of these patients, 14 had a left adrenal lesion, 12 had a right adrenal lesion, and 1 had bilateral lesion. The patients were followed up for a mean 4 years (range, 1-11 years) by both an endocrinologist and a surgeon.

RESULTS

In group A, hypertension improved for 66.3% of the patients; body mass index (BMI) decreased for 47.4%; and hyperlipidemia based on high-density lypoproteins (HDL) cholesterol, total cholesterol ratio, and triglyceridemic concentration improved for 63.2% of the patients. No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. Some patients in group B, during their long-term medical therapy, experienced worsening hypertension (14.2%), hyperlipidemia (17.8%), and diabetes mellitus (8%).

CONCLUSIONS

This retrospective study focused on a cohort of patients with SCS. Their medium long-term follow-up evaluation showed that LA is better than medical therapy for treating this condition, especially by reducing the cardiovascular risk (hypertension-hyperlipidemia).

Long-term results of laparoscopic adrenalectomy for primary aldosteronism

BACKGROUND

The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism.

METHODS

From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5).

RESULTS

Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results.

CONCLUSIONS

LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

The learning curve in laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most adrenal tumors. LA learning curve (LC) varies among surgeons and may be influenced by factors depending on surgeon, patient, and lesion peculiarities. The aim of this study was to evaluate the LC by multi-dimensional analysis.

METHODS

Between August 1994 and August 2005, 241 LA were performed in our department. Data were prospectively collected. The pre-operative variables evaluated were patient-related (age, gender, body mass index, co-morbidities) and disease-related (histology, size, and side of lesion). Level of experience of surgical team and surgical approach (anterior, flank, submesocolic routes) were evaluated as well. Flank approached and bilateral procedures were excluded, while submesocolic LA, were collected separately. Operating time (OpT), conversion rate (CR), intra-operative and post-operative complications were evaluated. Patient, surgeon, and procedure-related factors involved in LC were investigated by a multi-factorial logistic regression analysis.

RESULTS

Body mass index, side, size, histology, technology improvement, and experience of surgical team, evaluated through the progressive series of surgical procedures, were independent predictors of CR and OpT. The CR for right adrenalectomy was 3% (3 cases) compared to 4.2% for left side (6 cases). The submesocolic approach significantly influenced OpT, but not CR. Mean OpT for right and left LA was 83 and 109 min, respectively. Based on surgical experience increase, the OpT and CR flattened their curves, roughly at 30 and 40 procedures for right and left LA, respectively. Post-operative complications did not change considerably throughout the series. Readmission rate within 30 days was negligible.

CONCLUSIONS

Manifold factors may affect LC and outcome in LA. Their knowledge may support teaching activities as well as reducing conversion and complication rates.

Flank approach versus anterior sub-mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study

BACKGROUND

Laparoscopy is commonly recognized as the gold standard in adrenal surgery. The most used surgical access is at present the so-called flank approach. The aim of this study was to compare the flank approach and the anterior sub-mesocolic access carrying out left laparoscopic adrenalectomy (LA).

METHODS

From January 2003 to January 2006 50 eligible left LAs were randomized to the flank (n = 25, group A) or sub-mesocolic transperitoneal approach (n = 25, group B). The two groups were similar concerning patient and lesion features. Comparing the two approaches, the main parameters analyzed, adjusted for tumor size and histology, were operating time (OpT), complication rate, and hospital stay.

RESULTS

There were no converted procedures. Mean overall OpT was 76.4 min (54-96 min) versus 65.6 min (45-95 min) in group A and B, respectively (p = 0.001), while the OpT required to tie the adrenal vein was 42.8 min (26-55 min) and 24.5 min (16-41 min) (p = 0.000). Oral feeding resumed within 12-24 h in both groups. Mean hospital stay was 3 and 2.4 days in groups A and B, respectively (p = 0.04). Mean tumor size was similar in group A and B: 3.6 cm (1.5-6.5 cm) and 3.8 cm (2-6 cm), respectively. Definitive histology in groups A and B were: Cushing adenoma (6 and 4), Conn adenoma (5 and 6), pheochromocytoma (4 and 9), and incidentaloma (8 and 5, respectively). A myelolipoma and an adrenogenital adenoma were observed in group A and one carcinoma was observed in group B.

CONCLUSIONS

Sub-mesocolic approach provides a statistically significant shorter OpT and hospital stay. Identification and early closure of the adrenal vein by means of a really minimal dissection and no-touch gland technique resulted in the main benefits of this approach.

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BACKGROUND

The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.

METHODS

204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19-75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).

RESULTS

Mean operative time was 80 minutes for right (40-150), 109 minutes for left (64-300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5-12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1-8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing's adenoma 58, Conn's adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.

CONCLUSIONS

LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

BACKGROUND

Since laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA.

METHODS

From January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology.

RESULTS

There was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40-90 mins) and 68.6 mins (range 50-130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55-100 mins) and 94 mins (range 65-140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant).

CONCLUSIONS

EBVS in LA may provide a significantly short operating time and blood loss.

Adrenal incidentaloma: surgical update

Nowadays, the role of surgery in the treatment of adrenal incidentalomas (AI), considering their biologic behavior, is still debated. Surgery is mandatory in cases of hyperfunctioning adrenal masses, in the presence of suspect radiological malignancy, in cases of discordant computed tomography (CT) and scintigraphy findings and when the maximum diameter is 4 cm or more. On the other hand, studies have suggested relative inaccuracy of conventional CT in evaluating the size. The aim of this paper was to evaluate the safety and effectiveness of laparoscopic adrenalectomy (LA) in the treatment of AI by reviewing our experience. Over the period from 1995 to 2005 we laparoscopically managed 78 AI by anterior transperitoneal approach. Two LA (2.6%) were converted to open surgery. Neither intra- nor post-operative major complications were observed. The mean size of lesions was 5.5 cm (range 3-9). Twenty-one large adrenal lesions (exceeding 6 cm) were removed (27%). Definitive histology resulted as follows: adrenocortical adenoma (63), pheochromocytoma (5), nodular hyperplasia (4), myelolipoma (3), cysts (2), and adrenocortical carcinoma (1, with a size of 3 cm). The patients were followed-up by hormonal and radiological evaluation every 12 months (6 for malignancy); their follow-up (median 60.4 months, range 6-123) was uneventful. Also larger AI were treated safely. Laparoscopy has been safe and effective in the treatment of AI in our experience, according to specific literature.