Anterior, lateral, and posterior retroperitoneal approaches in endoscopic adrenalectomy

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform

BACKGROUND

Posterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis.

METHODS

Patients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota's fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test.

RESULTS

A total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant.

CONCLUSION

Perioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

The Role of Intraoperative Indocyanine Green (ICG) and Preoperative 3-Dimensional (3D) Reconstruction in Laparoscopic Adrenalectomy: A Propensity Score-matched Analysis

BACKGROUND

Laparoscopic adrenalectomy (LA) is considered the "gold standard" treatment of adrenal lesions that are often coincidentally diagnosed during the radiologic workup of other diseases. This study aims to evaluate the intraoperative role of indocyanine green (ICG) fluorescence associated with preoperative 3-dimensional reconstruction (3DR) in laparoscopic adrenalectomy in terms of perioperative outcomes. To our knowledge, this is the first prospective case-controlled report comparing these techniques.

MATERIALS AND METHODS

All consecutive patients aged≥18 and undergoing laparoscopic transperitoneal adrenalectomy for all adrenal masses from January 1, 2019 to January 31, 2022 were prospectively enrolled. Patients undertaking standard LA and those undergoing preoperative 3D reconstruction and intraoperative ICG fluorescence were matched through a one-on-one propensity score matching analysis (PSM) for age, gender, BMI, CCI score, ASA score, lesion histology, tumor side, and lesion diameter. Differences in operative time, blood loss, intraoperative and postoperative complications, conversion rate, and length of stay were analyzed.

RESULTS

After propensity score matching analysis, we obtained a cohort of 36 patients divided into 2 groups of 18 patients each. The operative time and intraoperative blood loss were shorter in patients of the 3DR group ( P =0,004 and P =0,004, respectively). There was no difference in terms of length of stay, conversion rate, and intraoperative and postoperative complications between the 2 groups.

CONCLUSIONS

The use of intraoperative ICG in LA and preoperative planning with 3DR images is a safe and useful addition to surgery. Furthermore, we observed a reduction in terms of operating time and intraoperative blood loss.

Comparison of Posterior Retroperitoneoscopic Adrenalectomy Versus Lateral Transperitoneal Laparoscopic Adrenalectomy for Adrenal Tumors: A Systematic Review and Meta-Analysis

Objective

To discuss the differences in the effectiveness and security for adrenal tumors by posterior retroperitoneoscopic adrenalectomy (PRA) and lateral transperitoneal laparoscopic adrenalectomy (LTA).

Methods

We systematically searched PubMed, Embase, Scopus database and Cochrane Library, and the date was from above database establishment to November 2020. Stata 16 was used for calculation and statistical analyses.

Results

Nine studies involving eight hundred patients were included. The following differences were observed in favor of PRA vs LTA: less operative time (MD: -22.5; 95% CI -32.57 to -12.45; P=0.000), Fewer estimated blood loss (MD: -15.17; 95% CI -26.63 to -3.72; P=0.009), lower intensity of postoperative pain (MD: -0.56; 95% CI, -1.05 to -0.07; P=0.026), shorter length of hospital stay (MD: -1.15; 95% CI -1.94 to -0.36; P=0.04). No differences were shown in conversion rate (OR 2.07; 95%CI 0.71 to 6.03; P=0.181) and complications (OR 0.85;95% CI 0.46 to 1.56; P=0.597).

Conclusions

Posterior retroperitoneoscopic adrenalectomy was clinically superior to lateral transperitoneal laparoscopic adrenalectomy for adrenal tumors in operative time, estimated blood loss, length of hospital stay, and postoperative pain. Only in term of conversion rate and complications, both were similar.

Lateral retroperitoneoscopic adrenalectomy: advantages and drawbacks

Lateral retroperitoneoscopic adrenalectomy (LRA) is performed mostly by urologists. It is gaining popularity among general surgeons because of the direct access to the adrenal gland. However, the management of large tumors remains controversial. We report our experience and discuss the advantages and the drawbacks of this approach. Between December 2011 and April 2015, 89 consecutive patients underwent LRA for adrenal tumors. Conversion to open surgery, operative time, blood loss, hospital stay, intra-operative complications, early and late postoperative complications, and mortality were analyzed. The entire group was divided into patients with large tumors (> 5 cm) and patients with small tumors (≤ 5 cm), which were further compared. The conversion rate was 1.1%. The mean operative time was 107.4 ± 27.95 min, the mean blood loss 33.15 ± 25.45 ml. The mean hospital stay was 4.7 ± 2.05 days. Most of the complications were minor. There was zero mortality. Concerning the size of the tumor, we found statistically significant difference in operative time (p = 0.001), hospital stay (p = 0.020), incidence of early postoperative complications (p = 0.049), and conversion rate to open surgery (p = 0.037). LRA is a feasible, effective and safe procedure that offers additional advantages over the standard transabdominal approach because of its direct access to the adrenal gland. However, malignancy, large tumor size, bilateral pathology, and concomitant intra-abdominal pathology may represent a potential setback for this approach.

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.

Hemodynamic stability during adrenalectomy for pheochromocytoma: A case control study of posterior retroperitoneal vs lateral transperitoneal approaches

Hemodynamic stability is one of the most critical aspects of adrenal surgery for pheochromocytoma. Few articles have evaluated the hemodynamic status of patients undergoing posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. The aim of this study is to compare the intraoperative hemodynamic parameters between lateral transperitoneal adrenalectomy (TPA) and PRA in this groups of patients.This report describes a retrospective study of 53 pheochromocytoma patients who underwent endoscopic adrenalectomy via transperitoneal (22 patients) or posterior retroperitoneal (31 patients) approaches from January 2008 to March 2015. Data from these patients were compared to investigate the differences in hemodynamic parameters between the 2 approaches.Clinical parameters at presentation were similar between the 2 groups, except for tumor size, which was larger in the TPA group. The PRA group is associated with reduced operative time, blood loss, and length of hospital stay compared to TPA even after adjusting for the tumor size. There was greater BP fluctuations and higher maximum systolic and diastolic blood pressure (BP) within the TPA group compared to PRA during univariate analysis. This was however not significant after adjusting for tumor size. There was no difference in the intraoperative inotropic support requirement between the 2 groups.PRA is associated with stable intraoperative hemodynamic status, as well as favorable perioperative outcomes compared to TPA in patients with small pheochromocytomas.

Comparison of the retroperitoneal versus Transperitoneal laparoscopic Adrenalectomy perioperative outcomes and safety for Pheochromocytoma: a meta-analysis

Background

To compare the perioperative outcomes and safety of transperitoneal laparoscopic adrenalectomy with those of retroperitoneal laparoscopic adrenalectomy for patients with pheochromocytoma.

Methods

We searched PubMed, EMBASE and the Cochrane Central Register for studies from 1999 to 2019 to assess the perioperative outcomes and safety of transperitoneal laparoscopic adrenalectomy and the retroperitoneal approach for laparoscopic adrenalectomy in patients with pheochromocytoma. After data extraction and quality assessments, we used RevMan 5.2 to pool the data.

Results

Four retrospective studies were obtained in our meta-analysis. Patients who underwent retroperitoneal laparoscopic adrenalectomy were associated with shorter operative time (WMD: 34.91, 95% CI: 27.02 to 42.80, I2 = 15%; p < 0.01), less intraoperative blood loss (WMD: 139.32, 95% CI: 125.38 to 153.26, I2 = 0, p < 0.01), and a shorter hospital stay (WMD: 2, 95% CI: 1.18 to 2.82, I2 = 82%, p < 0.01) than patients who underwent transperitoneal laparoscopic adrenalectomy. No significant differences were found in the complication rate (OR: 1.58, 95% CI: 0.58 to 4.33, I² = 0; p = 0.38) or in the incidence of hemodynamic crisis (OR: 0.74, 95% CI: 0.19 to 2.94, p = 0.67) between the two groups.

Conclusion

Retroperitoneal laparoscopic adrenalectomy could achieve better perioperative outcomes than the transperitoneal approach for patients with pheochromocytoma.

Laparoscopic and robot-assisted transperitoneal lateral adrenalectomy: a large clinical series from a single center

Since Gagner performed the first laparoscopic adrenalectomy (LTLA) in 1992, laparoscopy has become the gold-standard procedure in the treatment of adrenal surgical diseases. Among all laparoscopic approaches, the transperitoneal lateral adrenalectomy (LTLA) is currently the most widespread procedure. The aim of this article is to analyze our experience in laparoscopy and robot-assisted laparoscopy for the management of surgical adrenal diseases and to value the safety and feasibility of those surgical approaches. From May 2011 until December 2018 were performed 112 adrenalectomies for adrenal tumors by the second division of General Surgery of tertiary care "A. Cardarelli" Hospital of Naples. Out of these, eight operations were carried out with an open surgery approach. Laparoscopic surgery was performed in 104 patients: 64 patients underwent to laparoscopic surgery (LTLA) and 40 patients were treated with a robot-assisted laparoscopy approach. Operative time, intraoperative blood loss, conversion rate, complications, and length of hospital stay were analyzed. Most patients were female and the mean age was 57.2 years in LTLA group, while in the r-LTLA group, the mean age was 55.7 years. Among the adrenal tumors, 55 were left-sided and 49 were right-sided. Median operative time was shorter in r-LTLA (102.2 ± 44.5 min) than in LTLA (128.5 ± 46.5 min). Conversion from LTLA to open surgery occurred in four cases. There were no statistical differences about tumor size and post-operative complications in the analyzed groups. A shorter hospitalization and intermediate care were recorded in the r-LTLA group. LTLA and r-LTLA are safe and effective approaches which ensure successful outcomes for the treatment of adrenal gland tumors.

Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults

BACKGROUND

Laparoscopic adrenalectomy is an accepted treatment worldwide for adrenal gland disease in adults. The transperitoneal approach is more common. The retroperitoneal approach may be preferred, to avoid entering the peritoneum, but no clear advantage has been demonstrated so far.

OBJECTIVES

To assess the effects of laparoscopic transperitoneal adrenalectomy (LTPA) versus laparoscopic retroperitoneal adrenalectomy (LRPA) for adrenal tumours in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ICTRP Search Portal, and ClinicalTrials.gov to 3 April 2018. We applied no language restrictions.

SELECTION CRITERIA

Two review authors independently scanned the abstract, title, or both sections of every record retrieved to identify randomised controlled trials (RCTs) on laparoscopic adrenalectomy for preoperatively assessed adrenal tumours. Participants were affected by corticoid and medullary, benign and malignant, functional and silent tumours or masses of the adrenal gland, which were assessed by both laboratory and imaging studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed trials for risk of bias, and evaluated overall study quality using GRADE criteria. We calculated the risk ratio (RR) for dichotomous outcomes, or the mean difference (MD) for continuous variables, and corresponding 95% confidence interval (CI). We primarily used a random-effects model for pooling data.

MAIN RESULTS

We examined 1069 publications, scrutinized 42 full-text publications or records, and included five RCTs. Altogether, 244 participants entered the five trials; 127 participants were randomised to retroperitoneal adrenalectomy and 117 participants to transperitoneal adrenalectomy. Two trials had a follow-up of nine months, and three trials a follow-up of 31 to 70 months. Most participants were women, and the average age was around 40 years. Three trials reported all-cause mortality; in two trials, there were no deaths, and in one trial with six years of follow-up, four participants died in the LRPA group and one participant in the LTPA group (164 participants; low-certainty evidence). The trials did not report all-cause morbidity. Therefore, we analysed early and late morbidity, and included specific adverse events under these outcome measures. The results were inconclusive between LRPA and LTPA for early morbidity (usually reported within 30 to 60 days after surgery; RR 0.56, 95% CI 0.27 to 1.16; P = 0.12; 5 trials, 244 participants; very low-certainty evidence). Nine out of 127 participants (7.1%) in the LRPA group, compared with 16 out of 117 participants (13.7%) in the LTPA group experienced an adverse event. Participants in the LRPA group may have a lower risk of developing late morbidity (reported as latest available follow-up; RR 0.12, 95% CI 0.01 to 0.92; P = 0.04; 3 trials, 146 participants; very low-quality evidence). None of the 78 participants in the LRPA group, compared with 7 of the 68 participants (10.3%) in the LTPA group experienced an adverse event.None of the trials reported health-related quality of life. The results were inconclusive for socioeconomic effects, assessed as time to return to normal activities and length of hospital stay, between the intervention and comparator groups (very low-certainty evidence). Participants who had LRPA may have had an earlier start on oral fluid or food intake (MD -8.6 hr, 95% CI -13.5 to -3.7; P = 0.0006; 2 trials, 89 participants), and ambulation (MD -5.4 hr, 95% CI -6.8 to -4.0 hr; P < 0.0001; 2 trials, 89 participants) than those in the LTPA groups. Postoperative and operative parameters (duration of surgery, operative blood loss, conversion to open surgery) showed inconclusive results between the intervention and comparator groups.

AUTHORS' CONCLUSIONS

The body of evidence on laparoscopic retroperitoneal adrenalectomy compared with laparoscopic transperitoneal adrenalectomy is limited. Late morbidity might be reduced following laparoscopic retroperitoneal adrenalectomy, but we are uncertain about this effect because of very low-quality evidence. The effects on other key outcomes, such as all-cause mortality, early morbidity, socioeconomic effects, and operative and postoperative parameters are uncertain. LRPA might show a shorter time to oral fluid or food intake and time to ambulation, but we are uncertain whether this finding can be replicated. New long-term RCTs investigating additional data, such as health-related quality of life, surgeons' level of experience, treatment volume of surgical centres, and details on techniques used are needed.

Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis

BACKGROUND

Adrenalectomy can be performed via open and various minimally invasive approaches. The aim of this systematic review was to summarize the current evidence on surgical techniques of adrenalectomy.

METHODS

Systematic literature searches (MEDLINE, EMBASE, Web of Science, Cochrane Library) were conducted to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing at least two surgical procedures for adrenalectomy. Statistical analyses were performed, and meta-analyses were conducted. Furthermore, an indirect comparison of RCTs and a network meta-analysis of CCTs were carried out for each outcome.

RESULTS

Twenty-six trials (1710 patients) were included. Postoperative complication rates did not show differences for open and minimally invasive techniques. Operation time was significantly shorter for open adrenalectomy than for the robotic approach (p < 0.001). No differences were found between laparoscopic and robotic approaches. Network meta-analysis showed open adrenalectomy to be the fastest technique. Blood loss was significantly reduced in the robotic arm compared with open and laparoscopic adrenalectomy (p = 0.01). Length of hospital stay (LOS) was significantly lower after conventional laparoscopy than open adrenalectomy in CCTs (p < 0.001). Furthermore, both retroperitoneoscopic (p < 0.001) and robotic access (p < 0.001) led to another significant reduction of LOS compared with conventional laparoscopy. This difference was not consistent in RCTs. Network meta-analysis revealed the lowest LOS after retroperitoneoscopic adrenalectomy.

CONCLUSION

Minimally invasive adrenalectomy is safe and should be preferred over open adrenalectomy due to shorter LOS, lower blood loss, and equivalent complication rates. The retroperitoneoscopic access features the shortest LOS and operating time. Further high-quality RCTs are warranted, especially to compare the posterior retroperitoneoscopic and the transperitoneal robotic approach.

Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation

BACKGROUND The aim of this study was to evaluate the efficiency and clinical outcomes of mini-open anterior approach focal cleaning combined with posterior internal fixation compared to conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in the treatment of lumbar tuberculosis (TB). MATERIAL AND METHODS Medical records from 124 patients were collected from February 2010 to April 2015; patients were divided into two groups: group A (mini-open anterior approach focal cleaning combined with posterior internal fixation) and group B (conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in period I). The data on postoperative mechanical ventilation time, preoperative, postoperative, and last follow-up Cobb angle, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and Frankel classification were collected and analyzed. Operative complications, internal stability, and bone graft fusion were also observed. RESULTS All patients were followed-up for 12 to 36 months (average 22.5 months). Seven cases (five in group A and two in group B) had side psoas abscess and were cured after secondary drainage surgery. The rest of the cases were all cured after primary surgery, with no formation of sinus, incisional hernia, cerebrospinal fluid leakage, or recurrence of spinal TB, with no TB symptoms. Bone graft fusion ranged from 3 to 8 months (average 4.7 months). Compared to group B, group A, which had less time on postoperative mechanical ventilation, had a higher VAS score. Both groups had distinct improvements in Cobb angle, ESR, and Frankel classification after surgery. CONCLUSIONS Treating lumbar TB by mini-open anterior approach focal cleaning combined with posterior internal fixation was safe and effective.

Laparoscopic left and right adrenalectomy from an anterior approach - is there any difference? Outcomes in 176 consecutive patients

Introduction

Traditionally, in open surgery, right adrenalectomy is considered technically more demanding than its left-sided counterpart. This belief is supposed to be attributable mainly to different anatomic characteristics of the adrenal veins. Whether this opinion is also correct for laparoscopic adrenalectomy remains elusive.

Aim

To compare the outcomes of left versus right laparoscopic adrenalectomy from an anterior approach.

Material and methods

Retrospective statistical analysis of a prospectively compiled database of consecutive patients undergoing laparoscopic adrenalectomy in a single center with focus on potential differences in the left- versus right-sided procedure in terms of demographic parameters, tumor size, operating time, occurrence of serious intraoperative complications, conversion, length of hospital stay and re-operation rate.

Results

One hundred seventy-six patients underwent elective laparoscopic adrenalectomy – 80 left-sided (45.45%) and 96 right-sided (54.55%). No significant difference was found between the groups in terms of age (54.09 ±11.2 vs. 56.27 ±11.6; p = 0.2), tumor size (3.39 ±1.86 vs. 3.26 ±1.66; p = 0.64), operating time (71.84 ±22.33 vs. 72.06 ±30.99; p = 0.95), occurrence of serious intraoperative complications (7.5% vs. 10.4%; p = 0.5), conversion (1.25% vs. 1.04%; p = 0.9), length of hospital stay (4.52 ±1.30 vs. 4.37 ±1.91; p = 0.55) or reoperation rate (5% vs. 1%; p = 0.11). There was no mortality.

Conclusions

No significant difference was found between the left and right laparoscopic adrenalectomy in terms of operating time, occurrence of serious intraoperative complications, conversion rate or postoperative outcome. Therefore, the opinion that the right-sided procedure is more difficult does not seem to be justified for laparoscopic adrenalectomy from the anterior approach.

Robotic assisted adrenalectomy: Is it ready for prime time?

Adrenal surgery is undergoing continuous evolution and minimally invasive surgery is increasingly being used for the surgical management of adrenal masses. With robotic-assisted surgery being a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma, the use of the robot has been expanded to include robotic-assisted adrenalectomy, offering an alternative minimally invasive platform for adrenal surgery. We performed a literature review on robotic-assisted adrenalectomy, reviewing the current surgical techniques and perioperative outcomes.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

Laparoscopic and robotic adrenal surgery: transperitoneal approach

Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.

Comparison of Retroperitoneoscopic and Transperitoneal Laparoscopic Adrenalectomy for Right-Sided Benign Tumors: A Single-Institute Experience

<b><i>Introduction:</i></b> There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for right-sided laparoscopic adrenalectomy. The aim of this study was to determine whether there is any difference between right-sided transperitoneal laparoscopic adrenalectomy (TLA) and retroperitoneal laparoscopic adrenalectomy (RLA). <b><i>Material and Methods:</i></b> Our surgery database was reviewed to identify patients who underwent right-sided laparoscopic adrenalectomy with a retroperitoneal or transperitoneal approach since 2000. Fifty-five patients were enrolled (31 RLA and 24 TLA). Patient characteristics, as well as operative and perioperative details, were compared between the two groups. <b><i>Results:</i></b> There was no difference in patient characteristics between the groups. There was a statistically significant difference (p = 0.02) in blood loss (31.7 ± 16.4 vs. 56.9 ± 65.5 ml) between RLA and TLA when the patient's BMI was >26. There was no significant difference in operative time, conversion to open surgery, length of hospitalization, or time to oral intake between the groups. <b><i>Conclusions:</i></b> Right-sided laparoscopic adrenalectomy can be performed safely and effectively via either RLA or TLA. Surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach.

Posterior retroperitoneoscopic versus laparoscopic adrenalectomy in sporadic and MENIIA pheochromocytomas

INTRODUCTION

Retroperitoneal adrenalectomy (PRA) comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. We assess the impact of PRA the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting.

PATIENTS AND METHODS

From May 2008 to January 2013, 17 patients [5 males and 12 females, mean age: 51 yrs (range 26-73)] with pheochromocytomas underwent PRA. Demographics, tumor characteristics, operative time, complications, hospital stay, and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls [7 males and 10 females, mean age 49 yrs (range 25-64)].

RESULTS

17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 19 pheochromocytomas with a mean size 3.7 cm (range 1.7-7.0) at a mean operative time: 105.6 min (range 60-180) were accordingly excised. In the laparoscopic group, 13 patients had sporadic pheochromocytomas, whereas 4 patients had MENIIA syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7-8.5) at a mean operative time of 137 min (range 75-195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analog scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.94 (0-3) vs 4.15 (3-6), p < 0.001 and 0.06 (0-1) vs 3.5 (2-6) p < 0.001] respectively. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group [(2.1 ± 0.24 days vs 40 ± 0.70 days) p < 0.001].

CONCLUSIONS

Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.

Systematic review and meta-analysis of retroperitoneoscopic versus laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has replaced open adrenalectomy as the standard operation for non-malignant adrenal tumours. Retroperitoneoscopic adrenalectomy (RA) is an increasingly popular alternative minimally invasive approach. Advocates of each technique claim its superiority, but the issue has yet to be resolved and conclusions are complicated by the existence of a lateral (LRA) and true posterior (PRA) RA.

METHODS

A literature search was performed for all comparative studies of RA versus LA. Meta-analysis was performed according to PRISMA guidelines. Odds ratios and standardized mean differences (SMD) were used to compare dichotomous and continuous outcomes respectively.

RESULTS

Twenty-two studies were included, reporting on 1257 LAs, 471 LRAs and 238 PRAs. Both PRA and LRA were associated with a reduced length of hospital stay: SMD - 1·45 (95 per cent confidence interval - 2·76 to - 0·14) and - 0·54 (-1·04 to - 0·03) days respectively compared with LA. Interstudy heterogeneity was present throughout the comparisons of hospital stay. When considering only the two randomized clinical trials (RCTs) there was no statistically significant difference in this outcome. One RCT, however, found a reduction in the median time to convalescence of 2·4 weeks in the LRA group. There were no differences in duration of operation, blood loss, time to ambulation and oral intake, or complication rates between techniques.

CONCLUSION

RA overall has equivalent outcomes to LA but may be associated with a shorter hospital stay.

Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy

BACKGROUND

Laparoscopic adrenalectomies are being performed increasingly, either with transperitoneal or retroperitoneal approaches. Studies comparing the 2 approaches have not shown the superiority of either technique, but these studies are limited by small sample sizes and single-institution designs. To overcome these limitations, we performed a meta-analysis of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy.

METHODS

A systematic review of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy was conducted. Study endpoints included perioperative outcomes and measures of postoperative recovery. Meta-analysis was performed using a random effects model, pooling variables evaluated by more than 3 studies.

RESULTS

Twenty-one studies comparing a total of 1,205 lateral transperitoneal adrenalectomies and 688 retroperitoneal adrenalectomies were suitable for meta-analysis. Patients in the 2 groups were similar in term of age, sex, body mass index, lesion size and location, and rates of malignancy. There were no statistically significant differences between lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy in terms of operative time, blood loss, hospital stay, time to oral intake, overall and major morbidity, and mortality.

CONCLUSION

Both lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy are associated with very low rates of perioperative complications. According to our meta-analysis, clinical outcomes after either technique are similar. For most adrenal lesions requiring operation, minimally invasive adrenalectomy can be performed safely and effectively with either transperitoneal or the retroperitoneal approach. Additional studies may be needed to analyze if any difference in long-term results exist.

No outcome differences between a laparoscopic and retroperitoneoscopic approach in synchronous bilateral adrenal surgery

BACKGROUND

Two main approaches have been described for endoscopic adrenalectomy: the transperitoneal approach with the patient in the lateral decubitus position (LA) and the retroperitoneal approach with the patient in the prone position (ERA). The goal of the present study was to compare the results of LA and ERA for endoscopic bilateral synchronous adrenalectomy.

PATIENTS AND METHODS

Between 1994 and 2008, 34 patients underwent bilateral synchronous adrenalectomy in two referral centers: 20 patients underwent LA in Pisa (group A), and 14 patients underwent ERA in Halle (group B). Sex, age, preoperative diagnosis, body mass index, preoperative medical treatments, diameter of glands, blood loss, operative time, complications, conversion, intensive care unit stay, day of first oral intake, length of postoperative recovery, histology report, and outcome were analyzed.

RESULTS

There were 7 men and 13 women in group A and 6 men and 8 women in group B. Mean age was 48.1 years in group A and 38.9 years in group B. Body mass index was similar in the two groups. Diameters of the glands were larger in group A than in group B, at 61.1 versus 42.8 mm for the right side and 64.1 versus 37.4 mm for the left side. Mean hospital stay was longer in group B (8.2 versus 5.25 days; P = 0.002), whereas the intensive care unit stay was longer in group A (1.44 versus 1 day).

CONCLUSIONS

It is not possible to determine which of the two approaches is better; both are feasible, safe, and effective and patient outcomes are almost the same.

Retroperitoneoscopic adrenalectomy in pheochromocytoma

Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.

Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.

Retroperitoneal endoscopic adrenalectomy is safe and effective

Background

The aim of this study was to review an experience with retroperitoneal endoscopic adrenalectomy (REA). This is the procedure of choice for adrenal tumours at this institution.

Methods

Between 1997 and 2008, 112 REAs were performed in a single university centre. Data were retrieved retrospectively from a prospectively collected database, including information on patient demographics, surgical procedure, complications and hospital stay.

Results

One hundred and twelve REAs were carried out successfully in 105 patients, including seven bilateral adrenalectomies. Thirty-nine patients with unilateral adrenal disease had a phaeochromocytoma, of whom 16 had multiple endocrine neoplasia syndrome type 2, 21 patients had Cushing's disease and 20 had Conn's disease. Median body mass index was 27 (interquartile range 23–29) kg/m2. The median duration of unilateral operations was 100 (90–130) min with a median blood loss of 5 ml. Median tumour size was 3·1 (2·0–4·4) cm. Conversion from REA to open surgery was needed in two patients. Seven patients experienced postoperative complications (2 major, 5 minor). One patient needed a reoperation. The median postoperative hospital stay was 3 days. A learning curve with a significant decrease in operating time was observed over the years.

Conclusion

REA appears to be a safe and effective surgical technique for adrenal gland tumours up to 6 cm in diameter, with a minimal complication rate.

Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy

BACKGROUND

For the past 14 years, we have been performing laparoscopic adrenalectomy via the lateral transabdominal as well as the posterior retroperitoneal approach. The aim of this study is to describe patient selection criteria for each approach with comparison of perioperative outcomes.

METHODS

In patients with smaller tumors, low body mass index (BMI), history of previous abdominal operations, appropriate body habitus, and bilateral pathology, we have performed preferentially the posterior approach. Data regarding clinical pathology, tumor size, BMI, estimated blood loss (EBL), operating time (OT), morbidity, mortality, and duration of stay were analyzed retrospectively. Data are expressed as mean +/- standard error of the mean (SEM).

RESULTS

One hundred seventy-two laparoscopic adrenalectomy procedures were performed in 159 patients between 1994 and 2008. The lateral approach was used in 69 patients (right side: 39%, left side: 55%, bilateral: 6%) and the posterior approach in 90 patients (right side: 42%, left side: 48%, bilateral: 10%). The incidence of prior abdominal surgery was greater in the posterior group (26% vs 19%, NS). The lateral approach was used in 9% (3/34) of aldosteronoma, 38% (9/24) of Cushing's disease/syndrome, 47% (18/38) of nonsecreting cortical adenoma, 66% (23/35) of pheochromocytoma, 41% (7/17) of malignant lesions, and 73% (8/11) of others. Thirty percent of the bilateral adrenalectomies were performed via lateral and 70% via posterior approach. Two patients in the posterior approach were converted to the laparoscopic lateral approach, and 2 patients in the lateral approach were converted to open. Overall, patient age and sex were similar between groups. BMI was higher in patients undergoing adrenalectomy via lateral vs posterior approach (32.4 vs 28.4; P = .005). Tumor size was larger than 6 cm in 11 (16%) and 1 (1%) of the patients in the lateral and posterior groups, respectively. On univariate analysis, mean OT for lateral and posterior approaches was similar for unilateral cases (157 +/- 7 vs 138 +/- 6 min, respectively; P = NS). This was also true on multivariate analysis when corrected for patient selection factors. EBL was 35 +/- 7 mL for lateral versus 25 +/- 6 mL for posterior approach (P = .05). The duration of stay in lateral and posterior approaches was 1 day in 56% vs 82%, 2 days in 29% vs 13%, and more than 2 days in 15% vs 5% of the patients, respectively. Two patients in the lateral group died postoperatively because of cardiac and pulmonary causes, and 2 patients in the posterior group developed temporary neuralgia.

CONCLUSION

This series compares 2 different approaches for laparoscopic adrenalectomy. Our study shows that the lateral and posterior techniques have a similar peri-operative outcome when patients are selected for each option based on certain criteria.

Endoscopic adrenalectomy: Is there an optimal operative approach? Results of a single-center case-control study

BACKGROUND

The choice in between the laparoscopic lateral transabdominal (LTA) or the posterior retroperitoneoscopic (PRA) approach for adrenalectomy is usually based on surgeon's preference, rather than on objective arguments. We compared the intraoperative and postoperative outcomes of LTA and PRA to determine whether there is a preferable approach.

METHODS

Thirty-eight consecutive patients successfully underwent PRA for benign adrenal tumors </=6 cm. A case-control study including 38 patients who successfully underwent LTA was performed. Operative time, intraoperative ventilatory parameters (CO(2) production [Vco(2)], whole body oxygen consumption, arterial partial pressure of carbon dioxide [Paco(2)], and arterial partial pressure of oxygen [Pao(2)]), final histology, complications, postoperative stay, analgesic requirement, time to regain normal bowel function, and time to return to work were recorded and compared between the 2 groups.

RESULTS

The 2 groups did not differ in terms of operative time, analgesic requirement, time to first flatus, complication rate, duration of postoperative stay, or final histology. Patients in the LTA group showed significantly lower Paco(2), Pao(2), and Vco(2) at the end of the operation. Patients in the PRA group experienced a significantly faster return to work.

CONCLUSION

No procedure can be considered preferable overall. In cases of bilateral adrenalectomy and previous abdominal surgery, PRA may offer some advantages. Surgeon's preference and experience will continue to guide this choice.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy has become an accepted method for removing benign lesions of the adrenal gland. There are few contraindications to the laparoscopic approach, and the transperitoneal and retroperitoneal techniques yield excellent results. Virtually all benign lesions and select malignant lesions can be removed laparoscopically. Laparoscopic adrenalectomy has been shown to be a safe and effective approach to many forms of adrenal pathologic conditions. It should be considered the standard of care in the management of benign lesions of the adrenal gland that require surgical removal.

Laparoscopic adrenalectomy for large adrenal masses

Open adrenalectomy has been the gold-standard therapy for adrenal neoplasms. Minimally invasive treatments, however, have assumed a more central role in the management of these lesions. The traditional benefits of laparoscopy, including reduced blood loss, shorter hospital duration, and improved convalescence, extend to adrenal disease without compromising the oncologic efficacy of the surgery. Contemporary series suggest that minimally invasive surgery is also a reasonable therapeutic modality for larger adrenal masses. Laparoscopic adrenalectomy for these large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy and adept with vascular techniques in the event of an open conversion. Oncologic outcomes collectively suggest that in the setting of adequate surgical resection, recurrence patterns relate more to disease-process biology than surgical approach. Neither size criteria, suspicion of malignancy, nor locally invasive disease should be considered an absolute contraindication to laparoscopic adrenalectomy.

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.

Predictive factors for open conversion of laparoscopic adrenalectomy: a 13-year review of 456 cases

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy has largely replaced open adrenalectomy for the treatment of adrenal tumor. However, certain cases still require conversion to open procedures. Identifying the risk of conversion remains difficult. This study identified risk factors that may predict conversion from a laparoscopic to an open procedure.

PATIENTS AND METHODS

From January 1993 to September 2006, a total of 456 laparoscopic adrenalectomies were performed at two urologic centers. A retrospective analysis of parameters, including tumor size, patient age, American Society of Anesthesiology classification, body mass index (BMI), sex, laparoscopic approach, previous abdominal surgery, laterality, type of tumor, laparoscopist experience, and surgeon, was performed. Multivariate logistic regression was used to identify those variables predicting conversion.

RESULTS

A total of 25 (5.5%) laparoscopic adrenalectomies required conversion. Significant predictors of conversion according to univariate analysis were tumor size > or =5 cm, BMI > or =24 kg/m(2), and pheochromocytoma. Multivariate analysis showed that the significant independent predictive factors for conversion were tumor size > or =5 cm (8.884 greater odds ratio [OR] of conversion; 95% confidence interval 3.543, 22.277; P < 0.001), BMI > or = 24 kg/m(2) (OR 3.632; 95% confidence interval 1.367, 9.648; P = 0.010), and pheochromocytoma (OR 3.068; 95% confidence interval 1.175, 8.007; P = 0.022).

CONCLUSIONS

Knowledge of tumor size, BMI, and tumor type can help in counseling patients undergoing laparoscopic adrenalectomy with regard to the probability of conversion. The size of the tumor was found to be the most important predictor.

Outcomes of laparoscopic adrenalectomy. Clinical experience with 68 patients

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.

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.

Posterior Retroperitoneoscopic Adrenalectomy: A Comparison between the Initial Experience in the Invention Phase and Introductory Phase of the New Surgical Technique

BACKGROUND

Today, the posterior retroperitoneoscopic technique has become a standard procedure in adrenal surgery. The procedure allows direct access to the adrenal glands, but it seems to be difficult because of the uncommon anatomic view. This study compares the learning period of the new procedure of "posterior retroperitoneoscopic adrenalectomy" in the primary invention phase and the secondary introductory phase in a different hospital 10 years later.

MATERIALS AND METHODS

The analysis included 100 posterior retroperitoneoscopic adrenalectomies (PRA) and involved 50 procedures in each center. Group A consisted of 44 patients (14 males, 30 females; age: 48.7 +/- 14.5 years) undergoing surgery between 07/1994 and 8/1996 (24 right, 26 left; 8 Cushing adenomas, 14 Conn adenomas, 11 pheochromocytomas, 7 nonfunctioning adrenocortical adenomas, 10 ACTH-dependent adrenal hyperplasias). Group B consisted of 50 patients (12 males, 38 females; mean age 59.3 +/- 10.7 years) operated between 01/2004 and 01/2006 (28 right, 22 left tumors; 5 Cushing adenomas, 12 Conn adenomas, 4 pheochromocytomas, 29 nonfunctioning adrenocortical adenomas). All PRAs were performed with the patient in the prone position with 3-4 trocars placed caudally in the region of the 11th and 12th ribs. In group A, the surgical team developed the technique of PRA themselves. Before their first PRA, the surgical team of group B was introduced to the technique by the group A surgeons and afterwards were supervised continuously.

RESULTS

No serious intraoperative or postoperative complication occurred in either group. Group A experienced 7 conversions to open surgery, whereas group B had one conversion and one early reoperation due to bleeding (P = 0.03; chi(2)-test). The mean operative time was 117 +/- 41 minutes versus 83 +/- 35 minutes (group A and B respectively; P < 0.001; t-test). Estimated blood loss was similar in the two groups (47.2 +/- 46.2 ml versus 54 +/- 16.3 ml, group A versus B, respectively; P = 0.36; t-test).

CONCLUSIONS

The study demonstrates the feasibility, safety, and reproducibility of the new surgical method of PRA both when it is employed in the early phase of invention, as well as when performed by surgeon-learners. After comprehensive training, the operative time and conversion rate are dramatically reduced, allowing for a short learning period.

Laparoscopic adrenalectomy

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

Indications and Results of Surgery for Incidentally Found Adrenal Tumors

INTRODUCTION

The accidental discovery of an adrenal mass called incidentaloma has become an increasingly frequent clinical problem with the question of a correct and appropriate therapeutic approach being the subject of controversial discussions.

MATERIALS AND METHODS

Clinical charts of 52 patients (22 male, 30 female) who underwent adrenalectomy for an incidentaloma at our institution between 1987 and 2001 were reviewed.

RESULTS

Median age was 56.4 years. Reasons for surgery were unclear significance in 22 patients, suspicion of malignancy in 5, increase in size in 8, maximum tumor diameter of more than 5 cm in 7, fear of malignancy in 1, and subclinical secretion of cortisol in 5 patients. No data were available for 4 patients. Surgical resection was performed using a conventional transabdominal approach in 28 patients, a conventional dorsal approach in 17 patients, and an endoscopic retroperitoneal approach in 7 patients. Histopathologic examination ruled out adrenal adenoma in 32 patients, adrenal myelolipoma in 12, unilateral nodular hyperplasia in 4, cystic lesion in 3, and adrenocortical carcinoma in 1 patient. The mean size of all lesions was 5.5 cm. Evaluating the criteria for surgical treatment regarding age of the patients and size of the lesions, 25 patients (48%), including the patient with the adrenocortical carcinoma, were younger than 60 years and had an adrenal lesion exceeding 4 cm in size. During postoperative follow-up that was available for 39 patients, 3 developed contralateral tumors that were treated by resection in 1 and by close follow-up in 2.

CONCLUSIONS

Size should not be the sole criterion; treatment should be tailored to the individual patient. Especially in patients younger than 60 years with an adrenal lesion exceeding 4 cm in size, an adrenalectomy, predominantly via an endoscopic approach, should be carried out, because a repeated and life-long close follow-up of an anxious patient who has been informed of the diagnosis will in some cases exceed the cost of a single endoscopic operation.

Safety and efficacy of endoscopic retroperitoneal adrenalectomy

Background

Minimally invasive adrenalectomy has replaced open surgery in the treatment of benign adrenal tumours. Transperitoneal and retroperitoneal approaches have been advocated. However, long-term outcome data are rare.

Methods

Over a period of 8 years, 123 patients underwent surgery for benign adrenal lesions using the endoscopic retroperitoneal approach. Data were analysed retrospectively by review of medical charts. Long-term results were obtained by sending questionnaires to patients and contacting their primary physicians.

Results

One hundred and twenty-three patients underwent 126 endoscopic retroperitoneal adrenalectomies. Mean operating time for unilateral adrenalectomy was 115 min, whereas that for bilateral adrenalectomy was 208 min. The conversion rate was 4·8 per cent. Complications occurred after 15·9 per cent of adrenalectomies. One patient died during the postoperative period. Long-term results were obtained in 80 patients (74·8 per cent). Nine patients (11 per cent) reported chronic incisional pain and six patients (8 per cent) had chronic abdominal pain. Addisonian crisis after bilateral adrenalectomy occurred in three patients. Most patients (86 per cent) were satisfied with the cosmetic results.

Conclusion

Endoscopic retroperitoneal adrenalectomy is a safe and effective procedure. Long-term outcome is acceptable and the procedure has excellent cosmetic results.

Laparoscopic adrenalectomy in pheochromocytomas

BACKGROUND

The aim of this study was to evaluate 17 patients undergoing laparoscopic adrenalectomy for the treatment of pheochromocytoma by transperitoneal anterior approach.

METHODS

Seventeen patients underwent laparoscopic adrenalectomy for pheochromocytoma between January 1994 and May 2002. Ten females (58.8%) and 7 males (41.2%) were operated on; 14 patients (82.3%) had sporadic pheochromocytoma and 3 (17.7%) were familiar cases. Mean age was 42 yr (range 25-72 yr). All patients were treated pre-operatively with alpha-blockers. Seven patients (41.2%) underwent right adrenalectomy; 9 (52.9%) underwent left adrenalectomy and 1 (5.9%) bilateral adrenalectomy.

RESULTS

No conversion to open surgery occurred and no mortality was observed. The right-side adrenalectomy required a mean operative time of 86 min (range 45-120), the left-side procedure a mean operative time of 116 min (range 80-140) and the bilateral one 219 min. In two patients (11.8%), a laparoscopic cholecystectomy and ovariectomy, respectively, were performed without changing the position of the patient on the operating table. Only 1 patient (5.9%) presented significant intraoperative hypertension, and arrhythmia resolved by medical therapy. No other intraoperative and post-operative complications were reported. Mean hospital stay was 3 days (range 2-8 days). At mean follow-up of 48 months (range 6-96 months), regression of symptoms and control of blood pressure were obtained without additional treatment in all patients. No recurrences were reported.

CONCLUSION

In our experience, adrenal pheochromocytoma can be treated safely and effectively by laparoscopic transperitoneal anterior approach.

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course

BACKGROUND

Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma.

METHODS

Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed.

RESULTS

There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (> 1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05).

CONCLUSION

After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.

Sub-mesocolic access in laparoscopic left adrenalectomy

BACKGROUND

This article reports an alternative laparoscopic access to left adrenal gland.

METHODS

From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection.

RESULTS

No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group.

CONCLUSIONS

Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.