Retroperitoneoscopic adrenalectomy: tips and tricks

Impact of Current Technology in Laparoscopic Adrenalectomy: 20 Years of Experience in the Treatment of 254 Consecutive Clinical Cases

BACKGROUND

Laparoscopic adrenalectomy (LA), which avoids large abdomen incisions, is considered the gold standard technique for the treatment of benign small- and medium-size adrenal masses (<6 cm) and weighing < 100 g. A trascurable mortality and morbidity rate, short hospitalization and patient rapid recovery are the main advantages compared to traditional surgery. During the past decade, a new surgical technology has been developed that expedites a "clipless" adrenalectomy. Here, the authors analyze a clinical series of 254 consecutive patients who were affected by adrenal gland neoplasms and underwent LA by the transabdominal lateral approach over the two last decades. A literature review is also presented.

METHODS

Preoperative, intraoperative and postoperative data from 254 patients who underwent LA between January 2003 and December 2022 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in the case of pheochromocytoma (PCC) while spironolactone and potassium were employed to treat Conn's disease. The same surgeon (CG) performed all the LA and utilized the same laparoscopic transabdominal lateral approach. Different dissection tools-ultrasonic, bipolar or mixed scissors-and hemostatic agents were used during this period. The following results were obtained: 254 patients were included in the study; functioning tumors were diagnosed in 155 patients, 52 patients were affected by PCCs, 55 by Conn's disease, 48 by Cushing's disease. Surgery mean operative time was 137.33 min (range 100-180 min) during the learning curve adrenalectomies and 98.5 min (range 70-180) in subsequent procedures. Mean blood loss was respectively 160.2 mL (range 60-280) and 96.98 mL (range 50-280) in the first 30 procedures and the subsequent ones. Only three conversions (1.18%) to open surgery occurred. No mortality or postoperative major complications were observed, while minor complications occurred in 19 patients (3.54%). In 153 out of 155 functioning neoplasms, LA was effective in the normalization of the endocrine profile. According to our experience, a learning curve consisting of 30 cases was identified. In fact, a lower operative time and a lower complication rate was reported following 30 LA.

CONCLUSIONS

LA is a safe procedure, even for masses larger than 6 cm and PCCs. Undoubtedly, the development of surgical technology has made it possible reducing operative times, performing a "clipless" adrenalectomy and extending the indications in the treatment of more complex patients. A multidisciplinary team, in referral high-volume centers, is recommended in the management of adrenal pathology. A 30-procedure learning curve is necessary to improve surgical outcomes.

Outcome of Partial Adrenalectomy in MEN2 Syndrome: Personal Experience and Systematic Review of Literature

Background: Partial adrenalectomy (PA) is an alternative option to total adrenalectomy for the treatment of hereditary pheochromocytoma (PHEO) to preserve cortical function and avoid life-long steroid replacement. The aim of this review is to summarize current evidence in terms of clinical outcome, recurrence, and corticosteroid therapy implementation after PA for MEN2-PHEOs. Material and Methods: From a total of 931 adrenalectomies (1997-2022), 16 of the 194 patients who underwent surgical treatment of PHEO had MEN2 syndrome. There were six patients scheduled for PA. MEDLINE^®, EMBASE^®, Web of Science, and Cochrane Library were searched for English studies from 1981 to 2022. Results: Among six patients who underwent PA for MEN2-related PHEO in our center, we reported two with bilateral synchronous disease and three with metachronous PHEOs. One recurrence was registered. Less than 20 mg/day Hydrocortison therapy was necessary in 50% of patients after bilateral procedures. Systematic review identified 83 PA for MEN2-PHEO. Bilateral synchronous PHEO, metachronous PHEO and disease recurrence were reported in 42%, 26%, and 4% of patients, respectively. Postoperative steroid implementation was necessary in 65% of patients who underwent bilateral procedures. Conclusions: PA seems to be a safe and valuable option for the treatment of MEN2-related PHEOs, balancing the risk of disease recurrence with the need for corticosteroid therapy.

Comparative evaluation of surgical methods for low invasive surgical treatment of diseases of the kidneys and urinary tract

Background. The rapid development of laparoscopic surgery can significantly reduce trauma during operations in the retroperitoneal space. These goals are also achieved by retroperitoneoscopy (RPS), which has become widespread in the last twenty years. The main difficulties for surgeons were associated with a small workspace and a lack of clear anatomical landmarks. Different access methods have different features, advantages and disadvantages, the analysis of which helps to optimize surgical treatment and accelerate patient rehabilitation.

Aim: to study the advantages and disadvantages of retroperitoneoscopic and transperitoneal laparoscopic surgical methods of treatment.

Materials and methods: We analyzed 305  case histories of patients operated on for various kidney diseases. The patients were divided into 2 groups: Group 1 – patients who underwent surgery using an extraperitoneal retroperitoneoscopic approach, Group 2 – patients who used the transperitoneal laparoscopic approach. A comparison of two methods of surgical treatment of kidney diseases, retroperitoneoscopic and laparoscopic access, was carried out. The following indicators were compared: duration of surgery, length of hospital stay, need for analgesics, frequency of postoperative complications.

Results. The duration of the operation with retroperitoneoscopic surgery was reduced by more than 15 % compared with the laparoscopic approach. Shorter periods of pain relief were required, and the number of complications also decreased. The duration of inpatient treatment did not differ significantly.

Conclusion. Retroperitoneoscopic approach can be used as the method of choice for operations on the retroperitoneal space. 

Application of retroperitoneal laparoscopy and robotic surgery in complex adrenal tumors

As a surgical method for the treatment of adrenal surgical diseases, laparoscopy has the advantages of small trauma, short operation time, less bleeding, and fast postoperative recovery. It is considered as the gold standard for the treatment of adrenal surgical diseases. Retroperitoneal laparoscopy is widely used because it does not pass through the abdominal cavity, does not interfere with internal organs, and has little effect on gastrointestinal function. However, complex adrenal tumors have the characteristics of large volume, compression of adjacent tissues, and invasion of surrounding tissues, so they are rarely treated by retroperitoneal laparoscopy. In recent years, with the development of laparoscopic technology and the progress of surgical technology, robotic surgery has been gradually applied to the surgical treatment of complex adrenal tumors. This paper reviews the clinical application of retroperitoneal laparoscopic surgery and robotic surgery in the treatment of complex adrenal tumors.

Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis

BACKGROUND

Insufflation pressures of or in excess of 25 mm Hg CO2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy.

OBJECTIVE

To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications.

METHODS

A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time.

RESULTS

The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups.

CONCLUSION

Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy.

Surgery for adrenocortical carcinoma: When and how?

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.

Surgical Approach to Endocrine Hypertension in Patients with Adrenal Disorders

Increased hormonal secretion of aldosterone, cortisol, or catecholamines from an adrenal gland can produce a variety of undesirable symptoms, including hypertension, which may be the initial presenting symptom. Consequences of secondary hypertension can result in potential cardiovascular and cerebrovascular complications at higher rates than in those with essential hypertension. Once a biochemical diagnosis is confirmed, targeted pharmacotherapy can be initiated to improve hypertension and may be corrected with surgical intervention. Adrenalectomy can be curative and can reverse the risk of cardiovascular sequelae once blood pressure control is achieved. This article discusses perioperative and operative considerations of adrenal causes of hypertension.

Challenges of training in adrenal surgery

While adrenal tumors are common, adrenalectomy is rather uncommon. This is one reason for the many challenges regarding the training of adrenal surgery. Here we focus on issues that are most pertinent regarding training of the young surgeons performing adrenalectomy. Due to the very limited literature, what is presented is mainly based on personal experience and/or from the literature published for other surgical operations and subspecialties. The discussed challenges include indications for surgery, surgical approaches and extent, and intraoperative complications. With advances in adrenal surgery, we expect some old challenges to be resolved, and some new challenges to arise. These challenges will be faced in order to continue to help our younger trainee acquire the knowledge and skills to best care for our patients with adrenal diseases.

The diagnostic utility of retroperitoneoscopic tissue biopsy for unresectable retroperitoneal lesions excluding urogenital cancers

Background

Retroperitoneal tumors are an uncommon disease known to consist of a diverse group of benign and malignant neoplasms. Treatment of unresectable retroperitoneal lesions requires pathological diagnosis. Here, we report the utility and safety of retroperitoneoscopic biopsy for unresectable retroperitoneal lesions excluding urogenital cancers.

Methods

We analyzed 47 patients consisting of 23 (49%) and 24 (51%) cases that underwent retroperitoneoscopic tissue biopsy and open biopsy, respectively. The clinicopathological features, including postoperative complications, were compared between the two groups.

Results

Tumor pathology was diagnosed successfully with a single operation in all patients. Malignant pathology (68%) was more common than benign pathology (32%). The most common pathology was malignant lymphoma, which accounted for about 50% of all cases. There was no significant difference with respect to the age, sex, tumor size, presence of tumor-related symptom, histopathology, operative time, and complications. Three (13%) of 23 patients in the retroperitoneoscopic biopsy group received percutaneous needle biopsy before laparoscopic excisional biopsy because the evaluation of needle cores failed to confirm subclasses of diagnosed pathologies. One patient was converted to open surgery just after the initiation of operation due to severe adhesion of adjacent structures. We had two cases with iatrogenic urinoma due to ureteral injury after retroperitoneoscopic biopsy.

Conclusions

We conclude that retroperitoneoscopic biopsy is a safe and useful tool for benign and malignant retroperitoneal lesions, in comparison to open biopsy. It is critical to carefully examine the preoperative imaging for the location of tumors, especially those close to the renal pelvis and ureter.

Carbon dioxide absorption during retroperitoneoscopic adrenalectomy: comparison between monolateral and synchronous bilateral approaches

Synchronous posterior retroperitoneoscopic bilateral adrenalectomy (PR-BilA) is a novel technique proposed for the definitive cure of hypercortisolism when a surgical approach is indicated. The aim of the present prospective cohort study was to compare the carbon dioxide (CO₂) absorption in patients undergoing PR-BilA with those undergoing single posterior retroperitoneoscopic adrenalectomy (PRA). Twenty-nine patients undergoing PR-BilA or PRA were consecutively enrolled. Anaesthesia was standardised. In both groups, CO₂ elimination (VCO₂), CO₂ dissolved in arterial blood (PaCO₂), end-tidal CO₂ (EtCO₂), and volume per minute (VM) were measured at the following time points: after anaesthesia induction and before CO₂ insufflation (T1), 5 min after CO₂ insufflation (T2), at the time of maximum VCO₂ (T3), and at desufflation (T4). VCO₂ was continuously measured using a metabolic monitor. ANOVA for repeated measures was used for statistical analysis. With respect to VCO₂, a significant group × time interaction was found (p = 0.03). Post hoc analysis revealed that VCO₂ was significantly increased at T4 compared with T1 in both groups (p = 0.02 and p = 0.0001 in the PRA and PR-BilA groups, respectively). Regarding PaCO₂, ANOVA analysis showed a significant group effect (p = 0.01), with higher values in the PR-BilA group. EtCO₂ and VM did not differ between the two groups. We found that the CO₂ absorption was increased in both groups at the end of surgery, in the presence of a higher trend in PaCO₂ values during PR-BilA. Therefore, PR-BilA may be considered a safe surgical approach with respect to CO₂ absorption, when a mild degree of hypercapnia may be accepted.