Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases

Minilaparoscopy in gynecology: applications, benefits and limitations

The word "minilaparoscopy" refers to laparoscopic surgical procedures performed using <5-mm trocars, with the exception of the umbilical access. The aim of this review is to explore the feasibility of minilaparoscopy in gynecologic surgery, focusing on instruments, surgical techniques, application and limits of this approach. In this review the authors discussed the positive features and limitation of 3-mm laparoscopy for gynecologic surgery. Using smaller trocars decreases incisional and postoperative pain, and shortens hospitalization, and provides a better cosmetic outcome. Transvaginal specimen extraction can be used to maximize the aesthetic outcomes. A minilaparoscopic surgical procedure is accomplished with lower carbon dioxide pressures, reducing pneumoperitoneum related complications. Accurate patient selection is critical in order to offer the best laparoscopic approach, considering that obesity and endometriosis may represent a challenge for 3-mm surgical tools, which are more flexible and have lower grasping ability. Minilaparoscopy has been shown as a valid alternative to conventional laparoscopy both for diagnostic purpose, major surgical procedures and oncological surgery. Minilaparoscopy in gynecologic surgery represents an option for selected patients, for both benign and malignant indications. The aesthetic outcome represents the main benefit of this approach. Surgeons must be aware of few limitations of this technique such as severe obesity and endometriosis.

WFUMB position paper on the management incidental findings: adrenal incidentaloma

Focal lesions of the adrenal glands are incidentally detected in approximately 5% of cases by modern imaging techniques. Fewer than 5% of these adrenal incidentalomas are malignant and approximately 10% have endocrine activity. Reliable differentiation of malignant versus benign and hormonally active versus nonfunctional adrenal incidentalomas significantly influences therapeutic management and the outcome of affected individuals. Therefore, each adrenal incidentaloma should undergo a standardized diagnostic work-up to exclude malignancy and endocrine activity. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on the management of adrenal incidentaloma and describes efficient management strategies with particular reference to the role of ultrasound techniques.

Factors associated with patient satisfaction in laparoscopic adrenalectomy

Laparoscopic adrenalectomy a treatment that is recommended for patients with adrenal adenoma and has been shown to lead to a 94% biochemical remission rate of aldosterone as well as improvements to quality of life in five domains of the SF-36. This method is also associated with high rates of patient satisfaction. However, there is little information available on the factors associated with patient satisfaction in cases of laparoscopic adrenalectomy. This study aimed to evaluate these factors in patients with Conn's syndrome who underwent laparoscopic adrenalectomy. This study was based on a survey and was conducted at Srinagarind Hospital at the Khon Kaen University Faculty of Medicine in Thailand. The inclusion criteria were that patients were between 15 and 60 years of age, had been diagnosed with adrenal gland tumors, and had undergone trnasperitoneal laparoscopic adrenalectomy. All eligible patients were asked to fill out a self-report questionnaire in which they rated their satisfaction (out of 10) and factors associated with their level of satisfaction in the areas of clinical treatment and scarring. There were 44 patients who participated in the study. The average (SD) age of all patients was 47.10 (10.90) years. The average overall satisfaction scores for the surgery and with regard to scarring post surgery were 9.47 (1.15) and 8.11 (2.21), respectively. Only the presence of headaches was an independent factor associated with the overall satisfaction, with a coefficient of -0.29 (p value 0.001). Only age was significantly predictive of overall satisfaction with regard to scarring with a coefficient of 0.05 and p value of 0.046. In conclusion, the presence of headaches was related to overall satisfaction and age was associated with satisfaction with regard to scarring in patients Conn's syndrome who underwent laparoscopic adrenalectomy.

Minilaparoscopy in urology: Systematic review

CONTEXT

There has been a boom in recent years in urological procedures using minilaparoscopy (ML).

OBJECTIVE

To conduct a systematic review of the published evidence on ML and its current role in urology.

ACQUISITION OF EVIDENCE

We performed a search on MedLine spanning October 1983 to December 2016 according to PRISMA criteria. A total of 6 comparative articles and 13 series were selected for this manuscript.

SUMMARY OF THE EVIDENCE

Only 1 study was randomised, 4 studies were prospective and comparative, and most were case series in which the operations were performed with 3-mm instruments. The most common procedures were adrenalectomy, followed by nephrectomy, living donor and pyeloplasty. Other minor conditions were also operated on, including cyst decortications, pyelolithotomies, lymphadenectomies, varicocelectomies and orchiectomies.

DISCUSSION

There have been significant technical improvements in recent years in the materials of ML. Most procedures were for reconstructive surgery and by transperitoneal approach, with a gradually increasing number of cases of oncologic surgery. Only 36.8% of the series assessed the cosmetic results with validated questionnaires, and 68.4% of the studies used the visual analogue scale to measure pain during the postoperative period.

CONCLUSIONS

The level of evidence of most published studies is low. ML is a reproducible technique for urological surgery and is safe even for operations on large surgical masses. The procedure's cosmetic and pain results after surgery are superior to those of conventional laparoscopy, although these conclusions should be taken with caution given the limitations of the current studies.

Single-plane retroperitoneoscopic adrenalectomy: a new operative procedure for benign adrenal disease

To evaluate the therapeutic effect of single-plane retroperitoneoscopic adrenalectomy. From February 2014 to March 2017, 251 patients underwent single-plane retroperitoneoscopic adrenalectomy, and their operative outcomes were compared with those of 98 patients who underwent anatomical three-plane retroperitoneoscopic adrenalectomy. Among 35 patients with a body mass index (BMI) of ≥30 kg/m², their operative outcomes were compared between two operative procedures. The demographic data and perioperative outcomes of the patients were statistically analysed. The single-plane and three-plane groups were comparable in terms of estimated blood loss, time to oral intake, hospital stay, and incidence of complications among patients with similar baseline demographics. The single-plane group had a significantly shorter operation time (46.9 ± 5.8 vs 54.8 ± 7.0 mins, P < 0.0001) and lower analgesia requirement (56/251 vs 33/98, p = 0.03). For obese patients with a BMI of ≥30 kg/m², single-plane adrenalectomy was also associated with a significantly shorter operation time(48.1 ± 6.2 vs 64.1 ± 5.1 mins, p < 0.0001). Single-plane retroperitoneoscopic adrenalectomy is feasible, safe, and effective in the treatment of adrenal masses <5 cm in size and provides a shorter operation time and better pain control than anatomical retroperitoneal adrenalectomy, especially in obese patients.

Targeted treatment of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism

BACKGROUND/PURPOSE

Even with the increasing recognition of primary aldosteronism (PA) as a cause of refractory hypertension and an issue of public health, the consensus of its optimal surgical or medical treatment in Taiwan has not been reached. Our objective was to develop a clinical practice guideline that is feasible for real-world management of PA patients in Taiwan.

METHODS

The Taiwan Society of Aldosteronism (TSA) Task Force recognized the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics and constraints into PA management.

RESULTS

In patients with lateralized PA, including aldosterone producing adenoma (APA), laparoscopic adrenalectomy is the 'gold standard' of treatment. Mini-laparoscopic and laparoendoscopic single-site approaches are feasible only in highly experienced surgeons. Patients with bilateral adrenal hyperplasia or those not suitable for surgery should be treated by mineralocorticoid receptor antagonists. The outcome data of PA patient management from the literature, especially from PA patients in Taiwan, are reviewed. Mental health screening is helpful in early detection and management of psychopathology among PA patients.

CONCLUSION

We hope this consensus will provide a guideline to help medical professionals to manage PA patients in Taiwan to achieve a better quality of care.

Mini-Laparoscopic Versus Conventional Laparoscopic Surgery for Benign Adnexal Masses

BACKGROUND

Minimally invasive endoscopic surgery has become an acceptable method for gynecologic indications for more than 20 years. We aimed to compare clinical and surgical outcomes between mini-laparoscopic surgery (MLS) and conventional laparoscopic surgery (CLS) for benign adnexal masses. As far as we know, no comparative study exists between these two minimal invasive procedures.

METHODS

During the period between January 2014 and December 2016, a total number of 132 laparoscopic surgeries were performed for bening adnexal masses in our clinic. Seventy women underwent CLS and 62 women underwent MLS. Pathological results and operating time of procedures, estimated blood loss, preoperative and postoperative complications, patient scale and observer scale (POSAS) and length of hospital stay were recorded.

RESULTS

There was no difference between the two groups regarding preoperative diagnosis, intraoperative surgical procedure performed, and length of hospital stay. The groups were compared in terms of postoperative pathological diagnosis using the Chi-square test, and there was a statistically significant difference between the two groups. Comparing the operation time and hematocrit change, there were statistically significant differences between the two groups. Both patient and observer PSOAS scar scores were better in MLS group (P < 0.05).

CONCLUSIONS

Mini-laparoscopy can be safely and effectively used to perform benign adnexal mass surgery.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology

OBJECTIVE

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.

METHODS

A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.

RESULTS

Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.

CONCLUSIONS

Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal?

AIM

To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp).

METHODS

Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS).

RESULTS

Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites.

CONCLUSIONS

The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.

Nerve-sparing minilaparoscopic versus conventional laparoscopic radical hysterectomy plus systematic pelvic lymphadenectomy in cervical cancer patients

AIM

To present our preliminary experience with nerve-sparing minilaparoscopic radical hysterectomy plus pelvic lymphadenectomy for the surgical treatment of cervical cancer and to compare outcomes with those of the conventional laparoscopic approach.

METHODS

Data of 87 consecutive women who underwent minimally invasive surgery for early and locally advanced stage cervical cancer were prospectively collected. Ten women who underwent laparoscopic surgery using a nerve-sparing technique performed through 3-mm ancillary ports were compared with the 77 patients who had standard laparoscopic surgery previously with 3 sovrapubic 5-mm trocars.

RESULTS

Minilaparoscopic radical hysterectomy was successfully accomplished in every case with no conversion to standard laparoscopy or open surgery. Two (2.6%) conversions to open surgery occurred in the conventional laparoscopy group. Surgical characteristics (operative time, estimated blood loss, and length of stay) and complication rate were similar between the 2 groups. No differences in the amount of parametrial and vaginal tissue removed were observed. The number of lymph nodes retrieved through minilaparoscopy was higher than conventional laparoscopy (30 [range = 26-38] vs 22 [range = 8-49]; P = .002). However, no difference was observed when the analysis was restricted to the last 10 conventional procedures (30 [range = 26-38] vs 29 [range = 24-49]; P = .81).

CONCLUSIONS

Our data show that minilaparoscopic radical hysterectomy with pelvic lymphadenectomy is a feasible procedure if performed by skilled surgeons.

Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital

INTRODUCTION

Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy.

METHODS

Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port.

RESULTS

The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days).

CONCLUSION

Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.

Minilaparoscopy and laparoendoscopic single-site surgery: mini- and single-scar in urology

PURPOSE

To review the development of laparoscopic single-site surgery (LESS) and minilaparoscopy (ML), with particular attention to the urological field, focusing on nomenclature, history and outcomes.

METHODS

A literature search was conducted on laparoendoscopic single-site surgery, minilaparoscopy, needlescopy and microlaparoscopy. The most relevant papers were selected over the last 30 years.

RESULTS

830 manuscripts were found about LESS, 251 in urology, two CRTs and nine match-case controls. 258 papers were about ML and 55 in urology. ML is the main topic (169 papers), followed by needlescopy (58) and microlaparoscopy (32). The most significant articles are four non-randomized match-case control studies.

CONCLUSIONS

Over the last few years, many urological laparoscopic operations have been successfully performed by LESS. However, the actual role of LESS remains to be determined with controversial data about postoperative pain control and almost no results on cosmesis. We are facing second-generation ML with superior performance granted by new endoscopes and most effective instruments. ML has demonstrated in almost all urologic indications to be feasible, safe and able to improve cosmetic and postoperative pain control. Anyway, CRTs are still lacking and only studies from other discipline can corroborate this trend.

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.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

Background

Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure.

Methods

Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence.

Results

The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03).

Conclusions

The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.

Laparo-endoscopic single-site left transperitoneal adrenalectomy

A 53-yr-old woman presented with abdominal pain. Ultrasonography, computed tomography, and an endocrinologic work-up revealed a 4-cm nonfunctional left adrenal mass. A TriPort laparoscopic adrenalectomy was performed. The TriPort was inserted through a 3-cm subcostal incision. Using 5-mm instruments, a left adrenalectomy was performed. The specimen was dissected (harmonic scalpel) and extracted through a 10-mm bag. A TriPort adrenalectomy was successfully completed in 240 min (blood loss: 20 ml). The postoperative period was uneventful (discharge within 3 d). In our opinion, the TriPort adrenalectomy is feasible and safe, with favourable perioperative and short-term outcomes and a delighted patient at the 8-mo follow-up.

Which patients are suitable candidates for laparoscopic adrenalectomy with needlescopic instruments?

Laparoscopic adrenalectomy has become the standard surgical procedure for benign adrenal tumors. The benefits of this type of surgery are reduced blood loss and postoperative pain, improved cosmetic outcomes and a reduced hospital stay. All these features could potentially be improved further by use of needlescopic instruments, which have diameters < or =3 mm, in contrast to the 5-12 mm diameters of standard laparoscopic instruments. Liao and colleagues have presented comprehensive and objective results for laparoscopic adrenalectomy with needlescopic instruments (LANI) performed in 112 patients with presumptively benign adrenal tumors <5 cm in diameter. Their results provide evidence to support the use of LANI in this setting and show that the technique is feasible for surgeons who have extensive experience in performing laparoscopic surgery. Prospective comparisons of LANI with traditional laparoscopic adrenalectomy are awaited.