Laparoscopic adrenalectomy

Transabdominal and retroperitoneal adrenalectomy: comparative study

BACKGROUND

Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal adrenalectomies (LTA), while retroperitoneoscopic adrenalectomies (RPA) in the prone position have certain advantages for patients. The aim of this study was to compare the effectiveness and safety of the transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.

MATERIALS AND METHODS

Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age ranged from 19 to 79 years, with a mean age of 50.5 ± 10.2 years. The patient pool consisted of 315 women and 157 men. Tumor sizes ranged from 1 to 10 cm.

RESULTS

In a study of 316 patients undergoing LTA versus 156 with RPA, the TLA averaged 82.5 min (70-98), while the RPA took 56.4 min (46-62) (P < 0.001). Intraoperative blood loss was 110 cc for the LTA group and 80 cc for the RPA group (P < 0.05) Conversion rates stood at 2.5% for transabdominal and 4.5% for retroperitoneoscopic procedures (P = 0.254). At 24 h post-operation, pain scores were 3.6 and 1.6, respectively (P < 0.001). Time to resume solid oral intake was 15.2 h for TLA and 8 h for RPA, with hospital stays at 4.5 days and 3 days respectively (P < 0.001). Short-term complications occurred in 8.9% of transabdominal and 12.2% of retroperitoneoscopic patients (P = 0.257).

CONCLUSIONS

For small tumors, RPA offers advantages over the transabdominal method in surgery time, blood loss, post-op pain, and recovery. These benefits are enhanced for patients with prior abdominal surgeries. However, large tumors present challenges in the retroperitoneal approach due to limited space and anatomical orientation. If complications emerge, surgeons can seamlessly switch to the LTA.

Clinical predictors and significance of adherent periadrenal fat in laparoscopic adrenalectomy

BACKGROUND

Adrenalectomy requires the anatomic preparation of the adrenal gland in the fat-rich retroperitoneal space. In the literature, it was shown that the retroperitoneal fat area affects surgical outcomes in laparoscopic adrenalectomy (LA). Besides the quantity of retroperitoneal fat, its qualitative properties play hypothetically a significant role in the safety profile and perioperative parameters of LA. In this study, we aimed to evaluate the factors associated with adherent periadrenal fat.

METHODS

The prospectively obtained demographic, preoperative, intraoperative, and postoperative data of 44 patients who underwent laparoscopic adrenalectomy in our clinic were analyzed retrospectively. The patients were divided into two groups as adherent periadrenal fat (APAF) and non-APAF group. Periadrenal fat tissue was defined as adherent or non-adherent by the attending surgeon according to the difficulty in dissection of the adrenal gland from the surrounding fat tissue during the operation.

RESULTS

The rate of female gender and presence of diabetes mellitus (DM) was higher in the APAF group (respectively, p = 0.038 and p = 0.001). A ROC curve analysis showed that the cut-off point was - 97 HU for APAF. On multivariable analysis using a stepwise regression model, we identified the presence of DM (OR = 5.073; 95% Cl = 2.192-12.387; p = 0.006) and ARFD > -97 HU (OR = 3.727; 95% Cl = 1.898-11.454; p = 0.008) as an independent predictor of APAF.

CONCLUSION

APAF seems to affect the perioperative outcomes of LA in terms of operation duration but not perioperative complications.

Cancer risk in adrenalectomy: are adrenal lesions equal or more than 4 cm a contraindication for laparoscopy?

Background

Some authors consider adrenal lesions size of less than 4 cm as a positive cut-off limit to set the indications for minimally invasive surgery due to a lower risk of malignancy. Aim of this study is to report the risk of cancer for adrenal lesions measuring 4 cm or more in diameter, assessed as benign at preoperative workup (primary outcome), and to evaluate the feasibility and safety of laparoscopic adrenalectomy (LA) in these cases (secondary outcome).

Methods

From January 1994 to February 2019, 579 patients underwent adrenalectomy. Fifty patients with a preoperative diagnosis of primary adrenal cancer or metastases were excluded. The remaining 529 patients were included and divided in five subgroups based on adrenal lesion size at definitive histology: group A, 4–5.9 cm (137 patients); group B, 6–7.9 cm (64 patients); group C, 8–9.9 cm (13 patients); group D, ≥ 10 cm (11 patients); group E, < 4 cm (304 patients). Each group was further divided based on diagnosis of benign or malignant lesions at definitive histology.

Results

Four (2.9%) malignant lesions were observed in group A, 5 (7.8%) in group B, 2 (15.4%) in Groups C and D (18.2%) and 13 (4.3%) in Group E. Comparing the cancer risk among the groups, no statistically significant differences were observed. Operative time increased with increasing lesion size. However, no statistically significant differences were observed between benign and malignant lesions in each group comparing operative time, conversion and complication rates, postoperative hospital stay and mortality rate.

Conclusions

Adrenal lesions measuring 4 cm or more in diameter are not a contraindication for LA neither in terms of cancer risk nor of conversion and morbidity rates, even if the operative time increases with increasing adrenal lesion diameter. Further prospective studies with a larger number of patients are required to draw definitive conclusions.

Risk factors for prolonged hospitalization in patients undergoing laparoscopic adrenalectomy

Introduction

Even though laparoscopic adrenalectomy is currently a standard, there are important variations between different centres in short-term treatment results such as length of hospital stay (LOS) or morbidity.

Aim

To determine the factors affecting LOS in patients after laparoscopic transperitoneal lateral adrenalectomy (LTA).

Material and methods

The study enrolled 453 patients (173 men and 280 women, mean age 57 years) who underwent LTA between 2009 and 2017. Discharge from hospital after more than median hospital stay was considered as prolonged LOS. We evaluated factors that potentially may influence LOS (primary length of stay after surgery, excluding readmissions). Logistic regression models were used in univariate and corrected multivariate analyses, in order to identify the factors related to prolonged LOS.

Results

The median LOS after LTA in the studied group was 2 days. One hundred seventy-five (38.5%) patients required prolonged hospitalization. Univariate logistic regression showed that the following factors were related to prolonged LOS: presence of any comorbidity, cardiovascular disease, intraoperative complications, postoperative complications, day of the week of operation (surgery on Thursday or Friday), intraoperative blood loss, need for transfusion, hormonal activity, postoperative drainage, ASA (III–IV) and histological type – pheochromocytoma. Multivariate logistic regression showed that only complications (OR = 3.86; 95% CI: 1.84–8.04), day of the week of operation (Thursday or Friday) (OR = 4.85; 95% CI: 3.04–7.73), need for drainage (OR = 3.63; 95% CI: 1.55–8.52), and histological type – pheochromocytoma (OR = 2.48; 95% CI: 1.35–4.54) prolonged LOS.

Conclusions

Prolonged length of hospital stay following laparoscopic transperitoneal lateral adrenalectomy is strongly associated with the presence of postoperative complications, day of the week of operation (Thursday or Friday), need for drainage, and histological type – pheochromocytoma.

Laparoscopic adrenalectomy for pheochromocytoma is more difficult compared to other adrenal tumors

Introduction

Laparoscopic adrenalectomy is the gold standard for the treatment of benign adrenal tumors. However, some authors raise the problem of differences in surgery for pheochromocytoma in comparison to other lesions.

Aim

To compare laparoscopic adrenalectomy for pheochromocytoma and for other tumors.

Material and methods

Four hundred and thirty-seven patients with adrenal tumors were included in the retrospective analysis. Patients were divided into two groups: 1 (124 patients treated for pheochromocytoma) and 2 (313 patients with other types of tumor). The two groups were compared with respect to mean operative time, intraoperative blood loss, conversion rate, complication rate and the relationship of tumor size with operative time.

Results

The mean operative time in group 1 was 91 min, and in group 2 it was 82 min (p = 0.016). In both groups 1 and 2, tumor size correlated with operative time (p < 0.0001 and p = 0.0003, respectively). The mean blood loss in groups 1 and 2 was 117 ml and 54 ml, respectively (p = 0.0011). The complication rate in groups 1 and 2 was 4% and 4.2%, respectively (p = 0.9542). In groups 1 and 2, conversion was necessary in 2 (1.6%) and 5 (1.6%) cases, respectively (p = 0.9925).

Conclusions

Longer operative time and higher blood loss after laparoscopic adrenalectomy for pheochromocytoma indicate its greater difficulty. However, despite these drawbacks, minimally invasive surgery still seems to be an effective and safe method.

Acute hypercortisolism: what can the surgeon offer?

Rapid onset or acute hypercortisolism is a rare critical illness requiring emergency management. The majority of patients will have underlying malignancy with surgery an obvious choice in the minority with resectable disease. For those with unresectable disease, medical management alone has been the traditional approach. However, this often proves inadequate raising interest in the role of surgery as palliation in this setting. Patient selection, timing of surgery and optimal surgical technique are areas of current controversy with little literature available to provide answers. Decisions regarding management of patients with acute hypercortisolism are complex, and these patients are best managed in a subspecialized setting.

Symptomatic cycling Cushing disease managed by simultaneous bilateral laparoscopic adrenalectomy in a 11-year-old boy

We report symptomatic cycling Cushing disease in a 11-year-old boy that was managed with simultaneous bilateral laparoscopic adrenalectomy. Positioning and the surgical technique have been fully described. Excellent results were achieved. Recent application of laparoscopic adrenalectomy for various adrenal pathology is highly effective and offers better results than open surgery. Post-operative recovery after laparoscopic technique is significantly shorter than the open technique.

Laparoscopic adrenalectomy: 10 years experience

PURPOSE

Laparoscopic adrenalectomy is considered the standard technique for the surgical removal of the adrenal gland. Shorter length of stay, decrease in postoperative pain and reduced complication are all the advantages of the laparoscopic approach. This report is about a 10-year single experience with laparoscopic adrenalectomy.

MATERIALS AND METHODS

A total of 34 lateral transperitonial laparoscopic adrenalectomies were performed. 24 right-sided lesions and 10 left-sided lesions were removed. The indications for surgery were aldosteronoma in 20 patients and nonfunctioning adenoma in 10 patients, and 1 child underwent bilateral adrenalectomy for bilateral adrenal hyperplasia.

RESULTS

All except one had successful laparoscopic adrenalectomy. Complication occurred in one patient who required open conversion because of bleeding. In addition, one patient suffered a pancreatic injury where the patient was managed conservatively. The average operative time was 2 hours and 30 minutes and the hospital stay was 2.5 days.

CONCLUSION

Laparoscopic adrenalectomy is technically feasible and reproducible. Lateral transperitoneal approach offers advantages including better visibility and easy access to other organ systems. There is always a learning curve for the urological laproscopy.

Laparoscopic resection of a large (11 cm) adrenal phaeochromocytoma

Pheochromocytoma is a rare cause of hypertension. Usually the tumour arises in the adrenal and the only cure is surgical extirpation. Laparoscopic adrenalectomy is the gold standard. Traditionally, laparoscopic removal of adrenal tumour of more than 5-6 cm in size is contraindicated. The authors removed a 11×8 cm phaeochromocytoma by laparoscopic approach without any complications. A 52-year-old male presented with complaints of throbbing headache with palpitations. On evaluation, he was found to be severely hypertensive and his blood sugar levels were moderately elevated. Radiological investigations revealed a 11×8 cm left supra renal mass. A provisional diagnosis of left pheochromocytoma was made which was strengthened by the fact that 24 hourly urine sample revealed elevated vanillylmandelic acid levels. The authors decided to surgically extirpate the adrenal mass. This was successfully accomplished by a laparoscopic transperitoneal approach. No complications were encountered. Histopathology showed pheochromocytoma of left adrenal gland without capsular involvement.

Laparoscopic adrenalectomy: Gaining experience by graded approach

INTRODUCTION

Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success.

MATERIALS AND METHODS

The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used.

RESULTS

The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months).

CONCLUSION

LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

Posterior retroperitoneoscopic adrenalectomy: a contemporary American experience

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy (PRA) is an excellent surgical option for adrenal gland removal. The operation requires that surgeons learn a new approach with few similarities to anterior adrenalectomy. This study reports a large series of PRAs incorporated into surgical care using a team-model approach.

STUDY DESIGN

The prospective endocrine surgery database was queried to identify patients who underwent PRA during a recent 4-year period. Demographic, operative, and pathologic data were recorded. The authors' initial experiences with PRA (group 1) are compared with our contemporary experience (group 2).

RESULTS

One hundred and eighteen PRAs were successfully performed (100 unilateral and 9 bilateral). Indications were pheochromocytoma in 21 patients, Cushing's syndrome or Cushing's disease in 22 patients, aldosteronoma in 22 patients, virilizing tumor in 3 patients, isolated metastasis in 28 patients, and nonfunctional mass in 19 patients. Forty-eight percent of patients had undergone earlier abdominal surgery. Forty-eight percent were obese (body mass index [calculated as kg/m(2)] ≥30). No significant differences were found in operative time (110 versus 118 minutes, p = 0.30), tumor size (2.59 versus 2.85 cm, p = 0.44), or body mass index (29.63 versus 29.93, p = 0.82) between groups 1 and 2. Both complications (15.9% versus 7.7%, p = 0.29) and conversion rates (9.5% versus 1.9%, p = 0.19) were lower in group 2, although this was not statistically significant.

CONCLUSIONS

PRA is a technique safely performed for a variety of adrenal lesions, is ideal for patients who have undergone earlier abdominal surgery, and is feasible in obese patients. Proficiency can be obtained during a short period, leading to low conversion and complication rates. This technique should be incorporated into the armamentarium of the endocrine surgeon. A team approach to learning new surgical techniques is effective.

Laparoendoscopic single-site (LESS) retroperitoneal adrenalectomy using a homemade single-access platform and standard laparoscopic instruments

BACKGROUND

This study aimed to evaluate laparoendoscopic single-site (LESS) adrenalectomy via the retroperitoneal approach using the Alexis wound retractor with standard laparoscopic instrumentation.

METHODS

Since October 2009, seven LESS retroperitoneal adrenalectomies have been completed successfully with a homemade single port created using an Alexis wound retractor as an access platform through a 3-cm incision beneath the tip of the 12th rib.

RESULTS

All the LESS procedures for these seven patients with adrenal tumors (size, 1.3-6.0 cm; 4 right, 1 left) were completed successfully without traditional laparoscopic conversion or complication. The average operative time was 159 min, and the estimated blood loss was 100 ml. The average hospital stay was 2 days (range, 1-3 days).

CONCLUSIONS

The preliminary results show that LESS retroperitoneal adrenalectomy is a safe and feasible procedure for functional adrenal tumors using standard laparoscopic instruments.

Aldosteronomas--state of the art

Primary aldosteronism (PA) is the most common cause of secondary hypertension in nonsmokers. Widespread screening of unselected hypertensives has identified PA in as many as 15% of patients. With such screening efforts using the PAC/PRA ratio and PAC, the widespread prevalence of the disease has become apparent while the relative percentage of APA has decreased. PA is confirmed by demonstrating lack of aldosterone suppressibility with sodium loading. Subtype evaluation is best achieved with high resolution CT scanning and AVS in the appropriate setting. In patients with PA and a unilateral source of aldosterone excess, laparoscopic adrenalectomy is the treatment of choice with excellent outcomes and low morbidity as compared with older open approaches. Patients with IHA, or those not amenable or agreeable to surgery, are best managed with a MR antagonist.

Posterior retroperitoneoscopic adrenalectomy

PRA has become our preferred technique for resection of relatively small, benign adrenal masses and isolated metastases to the adrenal glands. PRA offers a direct, minimally invasive approach to the adrenal glands and avoids the need to enter the peritoneal cavity, deal with intraabdominal adhesions, and mobilize adjacent organs-steps necessary during anterior laparoscopic adrenalectomy. In addition, some patients tolerate retroperitoneal CO2 insufflation better than intraperitoneal CO2 insufflation from a hemodynamic and respiratory perspective. Finally, bilateral PRA can be performed without the need for patient repositioning. PRA requires the surgeon to become comfortable with the anatomy of the adrenal gland and surrounding structures from the posterior perspective. In addition, the surgeon must become adept at working in the retroperitoneal space, which is relatively restricted compared with the large cavity created by insufflation of the intraperitoneal space. However, in our experience, the learning curve can be overcome in a relatively short period, and the posterior approach is particularly advantageous in patients who have undergone prior open abdominal surgery or who are moderately obese. Proper patient positioning and trocar placement, high-pressure CO2 insufflation, and mobilization of the inferior aspect of the adrenal gland from the superior pole of the kidney before dividing its other attachments are critical technical details that greatly facilitate the procedure. In experienced hands, PRA is safe and is an ideal option for patients who are candidates for minimally invasive adrenalectomy.

Posterior retroperitoneoscopic adrenalectomy: preferred technique for removal of benign tumors and isolated metastases

OBJECTIVE

Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive approach to removal of the adrenal gland. This anatomically direct approach, popularized by Walz, minimizes dissection and affords early access to the adrenal vein. We report the largest experience to date of PRA in the United States.

METHODS

The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent PRA between October 2005 and February 2008. All PRA procedures were performed using a 3-trocar technique with the patient in a prone jackknife position.

RESULTS

Sixty-eight PRAs were performed in 62 patients; there were 6 conversions (3 video-assisted and 3 open). Indications for adrenalectomy were functional tumors in 43 patients (20 pheochromocytomas, 13 Cushing disease or syndrome, and 10 others), nonfunctional cortical adenomas in 4, and isolated adrenal metastases in 15. Mean tumor size was 3.4 cm. Complications occurred in 11 patients (16%), with no perioperative deaths. In 34 (55%) patients, there was a relative contraindication to an anterior approach. Additionally, 20 patients (38%) had a body mass index greater than 30. Median operating time was 121 minutes.

CONCLUSION

PRA is safe, avoids intra-abdominal adjacent organ mobilization, is unaffected by the presence of intra-abdominal adhesions, and is possible in obese patients. PRA may be the preferred technique for removing benign adrenal tumors and isolated metastases.

Single access retroperitoneoscopic adrenalectomy (SARA)--one step beyond in endocrine surgery

INTRODUCTION

Today, endoscopic adrenalectomy has become a gold standard in endocrine surgery.

METHOD AND RESULTS

To minimize the morbidity and improve cosmesis, a single access retroperitoneoscopic adrenalectomy (SARA) has been developed. Patients were placed in prone position. Through a single 1.5 cm skin incision at the tip of the 12th rib the creation of the retroperitoneal space and the dissection of the adrenal gland were performed. SARA was used in five patients with adrenal tumors (size: 1-4 cm; four right, one left). Operating time ranged from 35 to 70 min, mean blood loss was <10 ml. No perioperative or postoperative complications were noticed. Mean hospital stay was 2 days.

CONCLUSIONS

SARA is feasible and represents a new horizon in endocrine surgery.

Prospective randomized comparison of laparoscopic versus open adrenalectomy for sporadic pheochromocytoma

BACKGROUND

Laparoscopic adrenalectomy for pheochromocytoma remains subject of debate, owing to the systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors.

METHODS

A prospective randomized study was conducted (2000-2006), evaluating cardiovascular instability during open (n = 9, group A) or laparoscopic (n = 13, group B) adrenalectomy for pheochromocytoma. Haemodynamic parameters were recorded by invasive monitoring.

RESULTS

Haemodynamic instability was observed in 3/9 (group A) and 6/13 patients (group B), with a mean of 1.8 and 2.2 hypertensive peaks per patient (p = n.s.). Blood loss (164 +/- 94 cc versus 48 +/- 36 cc, p < 0.05) and operative time (180 +/- 40 versus 158 +/- 45 min, p = n.s.) favored laparoscopic procedures. Postoperative morbidity and mortality were nil. Hospital stay was shorter in group B (p < 0.05). Long-term follow-up was always normal.

CONCLUSIONS

Laparoscopic approach for pheochromocytoma can be as safe as open surgery; intraoperative haemodynamic instability, although usually controlled with success, remains a source of concern.

Laparoscopic adrenalectomy --- is it any different in phaeochromocytoma and non-phaeochromocytoma?

BACKGROUND

Laparoscopic adrenalectomy (LA) for phaeochromocytoma is a feasible, safe and effective treatment. The effects of associated catecholamine release render LA more challenging, although with comparable morbidity to LA for other diseases of the adrenal gland.

METHODS

Data from case records of 44 patients who underwent LAs between May 2002 and May 2006 were analysed retrospectively. The patients were divided into a phaeochromocytoma group (Group I) and a non-phaeochromocytoma group (Group II). The aim of this study was to assess the operative course and outcome of LA in the two groups.

RESULTS

The mean operating time and blood loss were slightly higher in LA for phaeochromocytomas compared to LA for other pathologies, but these differences were not statistically significant. The mean hospital stay was 3.84 days in both groups. The phaeochromocytoma group had a slightly higher complication rate of 21% compared to 12%. None of the procedures needed open conversion. A terminal hand assist was employed in two patients in Group I and one patient in Group II. Two patients with bilateral phaeochromocytoma had single stage bilateral LA.

CONCLUSION

LA is feasible and effective in phaeochromocytoma. It is associated with a slightly longer operating time, more blood loss and complications when compared with non-phaeochromocytoma masses. LA can be done in a single operation for bilateral masses. Terminal hand assist is a viable and effective option for very large masses.

Laparoscopic adrenalectomies: A nationwide single-surgeon experience

BACKGROUND

Laparoscopic adrenalectomy (LA) was first performed in Iceland in 1997. Since then, all procedures for presumed benign lesions of the adrenals have been performed laparoscopically in a single center. Compared with conventional adrenalectomy, LA appears to achieve superior results in terms of recovery, hospital stay, and morbidity. This study aimed to evaluate the results of LA in Iceland.

METHODS

The hospital records of all patients who underwent LA in Iceland from 1997 through 2005 were reviewed. The preoperative diagnosis was documented, as well as the pathologic diagnosis, operative details, complications, and length of hospital stay.

RESULTS

In 49 operations, 53 adrenal glands were removed from 48 patients (37 women and 11 men). The mean patient age was 53.6 years (range, 24.4-78.8 years). The left adrenal was removed from 29 patients, the right adrenal from 14 patients, and both adrenals from 5 patients. The most common indications and diagnoses included 17 nonsecreting tumors (12 adenomas, 3 hyperplasias, 1 complex adrenal cyst, and 1 hemangioma), 12 aldosteronomas (10 aldosteronomas and 2 nodular hyperplasias), and 10 pheochromocytomas (9 confirmed, 1 adrenal hyperplasia). Other indications and diagnoses were less common. The mean operative time was 168 min (range, 87-370 min) for unilateral operations and 412 min (range, 345-480 min) for bilateral operations. The mean blood loss was 117 ml (range, 0-650 ml) for unilateral operations and 200 ml (range, 0-350 ml) for bilateral operations. The complications were mild pancreatitis (n = 1), urinary tract infection (n = 1), atelectasis (n = 1), mild congestive heart failure (n = 2), and transient corneal abrasion (n = 1). No conversion to open procedure was needed. The mean tumor size was 3.5 cm (range, 1.5-6.2 cm), and the mean postoperative hospital stay was 2.6 days (range, 1-6 days).

CONCLUSION

The results of laparoscopic adrenalectomies in Iceland for benign lesions of the adrenals are comparable with published results from large referral centers.

Laparoscopic Adrenalectomy is Feasible for Large Adrenal Masses > 6cm

OBJECTIVE

Laparoscopic adrenalectomy (LA) has become the established procedure for adrenal masses less than 6 cm. The role of LA for large adrenal masses is well defined to a lesser extent.

METHODS

Thirty-six LAs were performed in 32 patients (including four patients with single stage bilateral adrenalectomies) over a period of 3 years, from May 2002 to 2005. Patients were divided into two groups based on the tumour size, i.e. masses less than 6 cm (group I) and masses 6 cm or more (group II).The results with respect to mean (95% confidence interval) operative time, blood loss, postoperative course and complications were compared.

RESULTS

Group II included 11 LAs performed in 10 patients including one bilateral LA for bilateral phaeochromocytomas in multiple endocrine neoplasia 2A. The mean size (+/-standard deviation) of masses was 8 cm (+/-1.47). In comparison, 22 patients in group I underwent 25 adrenalectomies (including three bilateral single stage procedures for Cushing's syndrome). The mean size of masses was 4.1 cm (+/-1.27). There were eight and six phaeochromocytomas in groups I and II, respectively. By comparing groups I and II, only minimal increase in blood loss and operating time was noted with no significant difference in hospital stay and morbidity. Two cases required conversion to hand assistance towards the end of the procedure in view of their large size.

CONCLUSION

LA is the procedure of choice for small adrenal masses but is also feasible for large functioning and nonfunctioning adrenal masses with equally good results. Even bilateral large functioning tumours can be treated safely by LA in a single stage when sufficient experience with the procedure is attained.

Bilateral Laparoscopic Transperitoneal Adrenalectomy in Three Children

BACKGROUND

This study focuses on the clinical presentation, surgical technique, and results of bilateral laparoscopic adrenalectomy in three girls aged 6, 13, and 14.

MATERIALS AND METHODS

This retrospective study included two girls with bilateral tumors (pheochromocytomas in one case, recurrent leiomyosarcomas in the other case) and a girl with micronodular hyperplasia associated with Cushing's syndrome.

RESULTS

Six transperitoneal laparoscopic adrenalectomies were performed with no conversions. The average operative time was 137 minutes (range 125-148); the mean estimated blood loss was 75 mL; the mean size of the adrenal lesions was 8 cm (range, 0.5-9); and the mean length of hospital stay was 3 days (range, 2-4). Resolution of clinical and biochemical parameters of adrenal hyperfunction was accomplished in the patients with adrenocortical hyperplasia and pheochromocytoma. No tumor recurrence has been so far found in the case of the leiomyosarcomas.

CONCLUSION

Bilateral laparoscopic adrenalectomy can be performed safely and effectively with a shorter hospital stay, minimal blood loss, and excellent functional outcome in the pediatric population.

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.

Laparoscopic adrenalectomy for pheochromocytoma

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland for functional adrenal tumors including aldosteronoma, glucocorticoid, and androgen/estrogen-producing adenomas. Many laparoscopic surgeons also think that for small to moderately sized pheochromocytomas, the laparoscopic approach is as safe and effective as the open technique. Several physiologic considerations specific to pheochromocytoma must be addressed before and during surgery regardless of the operative approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy remain the same for pheochromocytomas as for other pathologic conditions of the adrenal gland. These include a shorter length of stay, a decrease in postoperative pain, a shorter time to return to preoperative activity level, and improved cosmesis.

Is laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis?

OBJECTIVE

To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.

PATIENTS AND METHODS

The study included patients who underwent LA from 1995 to 2002, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structures, or solitary metastasis with well-controlled primary cancer. The variables evaluated were: size of the lesion, operative duration, estimated blood loss, intraoperative complications, local, port-site and intra-abdominal recurrence, distant metastasis, and survival time.

RESULTS

Fourteen malignant adrenal lesions in 205 LAs (7%) were confirmed with histological diagnoses that showed a primary ACC in six and metastasis in another seven (in one there was bilateral metastasis). The mean (sd) size of the malignant lesions was 5.9 (2.8) cm. The 12 unilateral procedures required a mean operative duration of 164 (47) min; the bilateral procedure lasted 215 min. There was one conversion to open surgery caused by local infiltration, whereas there were no intraoperative complications. The mean follow-up was 30 months, during which three patients died, one from endoperitoneal and trocar port-site seeding.

CONCLUSION

When the malignancy is confined to the adrenal gland, LA seems to be a feasible option if the principles of oncological surgery are respected. Nevertheless, further investigations are required to evaluate the appropriateness of this operation.

Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery

We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.

Laparoscopic adrenalectomy

BACKGROUND

Soon after its introduction, laparoscopic adrenalectomy (LA) became the procedure of choice in the surgical management of most adrenal tumors. The aim of this study was to assess the outcome and learning curve of the first 100 cases operated by the same surgical team.

METHODS

Retrospective analysis of prospectively collected data of 100 consecutive LAs was performed. The parameters studied were indication for surgery, side and length of operation, intra- and postoperative complications, size of tumor, conversion to open surgery, final diagnosis, and length of stay.

RESULTS

Between 1996 and 2002, 100 LAs were performed in 90 patients. The procedures included 45 left, 35 right, and 10 bilateral resections for pheochromocytoma (29), Cushings syndrome (27), Conns syndrome (16), nonfunctioning adenoma (13), and others (5). Mean tumor size was 4.16 cm (range, 0.3-11). Overall major morbidity occurred in eight patients (9%); there was one mortality due to cerebrovascular accident in an elderly patient. Five cases (5%) were converted to open surgery. The mean length of stay for the whole group was 4.7 days (range, 2-25). In order to assess the learning curve, procedures were divided into three, equal consecutive groups (n = 33, 33, and 34). Intraoperative complications in the intermediate and late groups were significantly less compared to those in the early group (2/33, 2/34, and 7/33, respectively; (p < 0.05). Similarly, the mean operating time was significantly reduced between the early (169 min) and both intermediate (116 min) and late (127 min) groups (p < 0.005). The conversion rate was reduced between the three groups (3/33, 2/33, and 0/34), but this was not significant (p = 0.06).

CONCLUSIONS

As expected, the outcome of LA is associated with a steep learning curve. According to this study, it seems that performance of approximately 30 cases by an experienced laparoscopic surgeon is required to master the procedure.

Computed tomography-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenoma

We reported the outcomes of computed tomography (CT)-guided percutaneous acetic acid injection therapy for functioning adrenocortical adenomas. With the patient in a prone position, the puncture needle was inserted vertically downward into the adenoma with frequent CT scanning. After confirmation by pilot injection with contrast medium, a small aliquot of 40-50% acetic acid was injected and repeated. Between 1997 and 2002, 18 sessions of CT-guided injection therapy, including one session of ethanol injection, were performed on 10 patients (five patients with primary aldosteronism and five patients with Cushing's or subclinical Cushing's syndrome) without any complications except transient upper abdominal pain during the acetic acid injection. The follow-up period ranged from 5-69 months. The treatment resulted in almost an extirpation of the adrenocortical hyperfunction in seven patients after one or two sessions. CT-guided percutaneous acetic acid injection might be a simple, cost-effective, and far less invasive treatment for small functioning adrenocortical adenomas.

Laparoscopic adrenalectomy for pheochromocytoma

OBJECTIVE

To determine the safety and results of laparoscopic resection of benign pheochromocytomas.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of all patients who underwent laparoscopic adrenalectomy for benign pheochromocytomas at all 3 Mayo Clinic sites between January 1, 1992, and December 31, 2001. Demographics, comorbidities, clinical presentation, imaging studies, biochemical findings, operative intervention, and outcome were examined. Long-term follow-up was obtained via chart review and/or by direct telephone contact with the patient or a relative.

RESULTS

Twenty-four women and 23 men with a mean age of 53.1 years (range, 16-81 years) underwent attempted laparoscopic resection of pheochromocytomas. In 5 patients, the procedure was converted to open laparotomy because of bleeding (2), inadequate exposure (2), and adhesions (1). The mean tumor size was 4.3 cm. The mean operative time (181.8 vs 1405 minutes; P = .03), mean hospital stay (6.00 vs 2.64 days; P < .001), and mean blood loss (340 mL vs 80 mL; P < .001) were greater in patients who underwent open laparotomy vs those who underwent laparoscopic resection. All specimens were classified as benign. The mean follow-up was 41 months (range, 10-89 months). No patients experienced a recurrence or developed metastatic disease.

CONCLUSIONS

In light of surgical and anesthesia expertise, laparoscopic resection of benign pheochromocytomas is safe and effective with resultant short hospital stays. A low threshold to convert to an open procedure reduces operative times and decreases potentially serious complications. Although there have been no recurrences to date, long-term follow-up is required for all patients, especially those with hereditary forms of pheochromocytomas.

Laparoscopic bilateral adrenalectomy for Cushing's syndrome due to ACTH-independent macronodular adrenocortical hyperplasia

We performed simultaneous bilateral laparoscopic total adrenalectomy in two patients with Cushing's syndrome due to ACTH-independent macronodular adrenocortical hyperplasia (AIMAH). Preoperative serum cortisol in the patients was 29.5 and 53.2 microg/dl, respectively. The clinical symptoms of the latter patient were advanced, and respiration was labored with orthopnea. Laparoscopic adrenalectomies were performed transabdominally in the sequential lateral decubitus positions with extension of the lateral abdominal wall of the affected side. Three 12-mm and three 5-mm trocars were positioned, and two trocar sites in the midline were used on both sides. The flexible fiberscope was inserted through the umbilical port. The adrenal glands were large, fragile, and multinodular. The maximal diameters of the removed glands were 7.8 and 8.7 cm, respectively. In both patients, the adrenal glands were successfully removed without fragmentation. The operation times were 505 and 320 min, and the estimated blood loss was 150 and 5 ml, respectively. Neither intraoperative nor postoperative complications occurred, although the latter patient required muscle training before ambulation on postoperative day 42. The procedures resulted in marked clinical improvements. Compliance with the substitutive therapy remained excellent, and the patients expressed a very high degree of satisfaction with the laparoscopic adrenal surgery. The procedures of bilateral laparoscopic adrenalectomy were successful, and provided increased experience with the laparoscopic techniques.

Laparoscopic Adrenalectomy: A Worthwhile Procedure Performed in a General Surgery Department

A laparoscopic procedure is considered the treatment of choice for adrenalectomy. We report the experience of a nonreferring unit for adrenal pathology; we have evaluated its safety and feasibility in a series of 40 patients. From 1994 to 2001, forty consecutive patients underwent laparoscopic adrenalectomy, 37 with transperitoneal and 3 with retroperitoneal approach. The mean operative time was 129 ± 51.7 minutes (range 60–300): 107 ± 29 minutes (range 60–100) for the right-sided transperitoneal adrenalectomy and 144 ± 62 minutes (range 90–300) for the left-sided transperitoneal adrenalectomy. The mean intraoperative blood loss was 90 mL (range 40–200). The procedure laparoscopic was converted to open in one case for the presence of a voluminous angiolipoma arising from the retroperitoneal fat strictly adherent to the adrenal gland. The postoperative morbidity rate was 5.1 per cent. Pain medication was required for a mean period of 1.6 ± 0.6 days (range 1–3). The patients were able to resume solid food after an average time of 1.8 ± 0.7 days (range 1–4). Postoperative hospital stay was 3 ± 1.4 days (range 2–8). We believe that laparoscopic adrenalectomy is safe and effective in removing benign functioning or nonfunctioning adrenal masses and also in a general surgery department.

One hundred and ten consecutive uncomplicated retroperitoneal videoscopic adrenalectomies--Polish multicentre study

AIM

The authors evaluate the effectiveness of videoscopic adrenalectomy (VA) for a variety of endocrine disorders.

METHODS

One hundred and ten consecutive videoscopic adrenalectomies performed from October 1995 till December 2000 were reviewed and followed up for adequacy of surgical treatment in 2 surgical departments. There were 79 females and 31 males included in the study. The mean age was 48.0 years (range 23-71 years). Indications for the operations were: phaeochromocytomas (n=5), aldosterone-producing adenomas (n=19), cortisol-producing adenomas (n=10), Cushing's disease (n=3) and non-secreting tumours (n=72).

RESULTS

There was no mortality and no morbidity both intraoperatively and in the postoperative course. In 8 cases conversion to open surgery was instituted - in 4 cases due to an unintended lesion of pertioneum without damage to the intraperitoneal organs. Mean operative time was 156 min (range 52-280 min), and estimated blood loss was 73 ml (range 20-300 ml). The average length of hospital stay was 2.9 days (range 2-7 days). None of the patients revealed either recurrence of hormonal hypersecretion or tumour mass in imaging studies during the follow-up period (range 1-34 months).

CONCLUSION

1. VA is recommended in patients with hormonally active tumours and in patients with benign adrenal masses of a diameter up to 6 cm. 2. VA is a safe and feasible procedure if performed by a team experienced in endocrine and endoscopic surgery. 3. VA is a procedure better than open adrenalectomy in management of small, non-malignant tumours because of the reduction of operative trauma.

Transabdominal laparoscopic adrenalectomy

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland at many centers worldwide. Functional adrenal tumors such as aldosteronoma, glucocorticoid, androgen/estrogen-producing adenomas, and small-to-moderate sized solitary pheochromocytomas are amenable to removal via a laparoscopic approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy are well documented and include a shorter hospital stay, a decrease in postoperative pain, shorter interval between surgery and return to preoperative activity level, and improved cosmesis. Various laparoscopic approaches to the adrenal gland have been described. Among these are the lateral transabdominal, anterior transabdominal, lateral retroperitoneal, and posterior retroperitoneal approaches. Each of these methods has specific advantages and disadvantages. This article reviews the transperitoneal approach to laparoscopic adrenalectomy, and discusses indications, operative technique, and a survey of the available literature.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

OBJECTIVES

To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma.

METHODS

A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results.

RESULTS

A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters.

CONCLUSIONS

Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Laparoscopic adrenalectomy: the New York-Presbyterian Hospital experience

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland. The advantages of the laparoscopic approach include shorter length of stay (LOS), a decrease in postoperative pain, faster return to preoperative activity level, improved cosmesis, and reduced complications. We report our experience with laparoscopic adrenalectomy via a lateral transperitoneal approach.

PATIENTS AND METHODS

Between September 1993 and April 2001, we performed 100 lateral transperitoneal adrenalectomies in 91 patients. In 82 cases, the adrenalectomy was unilateral and in the other 9, it was bilateral. A total of 59 left-sided lesions and 41 right-sided lesions were removed. The indications for surgery were Cushing's syndrome (24), aldosteronoma (34), pheochromocytoma (17), nonfunctioning adenoma (13), Carney's syndrome (1), and a metastasis from colon cancer (1)

RESULTS

The overall success rate was 98%. Complications occurred in the two patients who required open conversion. In addition, three patients suffered pneumothoraces because of direct iatrogenic injury to the diaphragm during laparoscopic dissection. One additional patient suffered a splenic laceration. Operative time, blood loss, and intraoperative complications were similar in the laparoscopic and open surgery control group (N = 32).

CONCLUSIONS

Laparoscopic adrenalectomy is technically feasible and reproducible. The lateral transperitoneal technique offers distinct advantages to the laparoscopist, including better visibility of familiar anatomic landmarks, easy access to other organ systems, the use of gravity to retract the spleen and liver, and a wide exposure, which allows removal of large adrenal lesions.

Laparoscopic adrenalectomy: comparison of transperitoneal and retroperitoneal approaches

OBJECTIVE

To compare the effectiveness and efficiency of transperitoneal anterior laparoscopic adrenalectomy with that of retroperitoneal posterior laparoscopic adrenalectomy.

PATIENTS AND METHODS

A retrospective comparison was undertaken of 28 patients who underwent transperitoneal anterior laparoscopy with 22 patients who underwent retroperitoneal posterior laparoscopy between April 1994 and November 2000. There were 18 men and 32 women (mean age 51.0 years, range 23-68) with varying diagnoses. Of the 50 patients, 31 had primary aldosteronism, eight had Cushing's syndrome, three had phaeochromocytoma, one had an 18-hydroxydeoxycorticosterone-induced adenoma and seven had non-functioning adrenal adenoma. Adrenal tumours were confirmed by hormonal assays, biochemical tests and computed tomography. To determine the site of the functioning adenoma, hormones were assayed from adrenal vein sampling. Thirty adrenal tumours were located on the right and 20 on the left.

RESULTS

There were no significant differences in general demographic variables between the transperitoneal and retroperitoneal groups. The mean duration of surgery for transperitoneal and retroperitoneal laparoscopy was 202 and 221 min, respectively, and the mean blood loss 113 and 192 mL, respectively. The time to first oral intake, days to full diet, time until ambulatory and duration of hospitalization did not differ significantly between the two approaches. As the body mass index increased, the duration of surgery increased for both approaches. As more procedures were performed the duration of surgery decreased for both approaches.

CONCLUSIONS

There were no significant differences between the transperitoneal and retroperitoneal approaches for laparoscopic adrenalectomy.

Laparoscopic adrenalectomy: a 6-year experience of 59 cases

BACKGROUND

The aims of this paper were to review our experience with laparoscopic transperitoneal adrenalectomy, report on outcomes in comparison with the published literature, and demonstrate any learning curve with the technique.

METHODS

A review of our database and patient records was carried out for the period April 1995 to December 2000. Patient demographics, tumour characteristics, operating times, outcomes and lengths of stay were studied. Diagnostic tools, including a comparison between tumour size on computed tomography scanning and on pathological section were reviewed. A comprehensive literature review was conducted using MEDLINE.

RESULTS

Indications for surgery included 33 patients with primary hyperaldosteronism (29 adenomas, 4 hyperplasias), 12 phaeochromo-cytomas, 7 cortisol-secreting adenomas, 4 non-secreting adenomas, 1 medullary cyst, 1 metastasis and 1 ganglioneuroma. The tumours ranged in size from 7 to 110 mm. All tumours were localized and lateralized preoperatively using standard techniques. Throughout the review period, six open procedures were undertaken electively, for various reasons. Three cases were converted to open procedures (5.1%). Thirty-eight left and 21 right procedures were undertaken. For all laparoscopic procedures, the average time in the operating theatre was 175.1 min. Men took 188.3 min compared with 165.7 min for women. Left-sided lesions took 178.72 min compared with 167.63 min for right-sided lesions. The average length of stay was 3.8 days. There was one wound infection, one blood transfusion and two readmissions: one for pain control in a patient with difficult home circumstances, and one patient suffered transient hypoadrenalism.

CONCLUSION

The results achieved in our initial experience with this technique are comparable with the published literature. The results confirm that laparoscopic adrenalectomy is the method of choice for resection of benign adrenal pathology. The procedure has a learning curve and should be performed by a surgeon experienced in both open and laparoscopic adrenal surgery.

A case of severe hypertension caused by ACTH-independent macronodular adrenal hyperplasia

This report describes a rare case of ACTH-independent macronodular adrenal hyperplasia (AIMAH) arisen with symptomatic severe hypertension and hypokaliemia. A 55-year-old man was admitted to hospital with a clinical picture characterized by several episodes of transient ischemic attacks (TIA) and right hemiplegia, related to severe arterial hypertension. Laboratory tests showed urinary levels of catecholamines, metanephrines and vanillylmandelic acid (VMA) in normal range; high urinary free cortisol excretion, elevated serum cortisol with loss of the circadian rhythm and low ACTH plasma levels. ACTH failed to respond to CRH administration. Serum cortisol levels were not modified after high doses of dexamethasone. MRI showed bilateral macronodular hyperplasia of adrenal glands, whereas pituitary-MRI did not show tumoral lesions. Therefore, ACTH-independent macronodular hyperplasia was suspected. Though obese, the patient had no typical Cushing habit, and symptomatic hypertension with hypokaliemia was the only clinical evidence for this rare kind of Cushing's syndrome. After obtaining a satisfactory control of blood pressure, the patient was successfully submitted to laparoscopic bilateral adrenalectomy and underwent complete clinical remission. The histology showed adrenal macronodular hyperplasia. During the twenty-four month follow-up, the patient had no further transient ischemic attacks or need of glucocorticoid replacement therapy and withdrew the antihypertensive drugs.

Unusual clinical manifestation of pheochromocytoma in a MEN2A patient

A case of unusual clinical manifestation of pheochromocytoma in a type 2A multiple endocrine neoplasia (MEN2A) patient is presented. A 27-year-old man affected by MEN2A syndrome, complaining of anxiety and depression, was admitted in our Division. Past medical history included a total thyroidectomy for medullary carcinoma in 1985, and left adrenalectomy for pheochromocytoma in 1994. Blood pressure was 130/ 85 mmHg without orthostatic hypotension and pulse rate was 72 beats/min. Laboratory data revealed thyroid hormones and carcinoembryonic antigen (CEA) in the normal range and high basal serum calcitonin levels (158 pg/ml). Plasma catecholamines and vanillylmandelic acid resulted in normal levels but epinephrine/norepinephrine ratio was elevated (0.65). The glucagon stimulation test showed positive clinical and biochemical response. Magnetic resonance imaging (MRI) and meta-iodobenzylguanidine (MIBG) scintiscan confirmed the presence of bilateral adrenal masses. Bilateral adrenalectomy by laparoscopic anterior approach was performed. Histology was consistent with adrenal pheochromocytomas. After surgical approach, psychiatric findings disappeared and did not recur at follow-up in spite of no medication for two years. In conclusion, bilateral pheochromocytoma is more frequent in MEN2A syndrome and probably understimated if the follow-up is not prolonged. In these cases clinical features are often aspecific and basal hormonal data may be normal in a great number of patients. Therefore long-term observation is justified in these patients. Pheochromocytoma was described as the "great mimic" for the numerous subjective manifestations. Differential diagnosis among typical features of neuropsychiatric disorders and pheochromocytoma must be considered.

Kidney morcellation in laparoscopic nephrectomy for tumor: recommendations for specimen sampling and pathologic tumor staging

Laparoscopic nephrectomy is a novel approach for small renal tumors in selected patients; however, removal of the kidney through the small laparoscopic abdominal wall incision site requires the kidney to be morcellated into small fragments while still in situ. Morcellation presents two problems for the pathologist. First, guidelines for optimal sampling of morcellated fragments have not been described. Second, morcellation precludes complete pTNM tumor staging, in particular, tumor size, margins, and renal vein involvement. Based on our initial experience with 23 laparoscopic nephrectomies/nephroureterectomies (13 clinically suspected neoplasms, confirmed pathologically as renal cell carcinoma [RCC, n = 7], urothelial carcinoma of the renal pelvis [n = 3], angiomyolipoma [n = 1], and cystic nephroma [n = 1], and 10 clinically benign entities) and a conservative statistical model, we present a decision analysis model of various specimen sampling protocols that optimize cost, labor, or time to diagnosis (single vs sequential sampling). Using the tumor-to-kidney volume ratio (TKR), calculated from preoperative radiologic imaging and specimen gross weight, several specimen sampling algorithms were compared. For the average situation in which TKR is > or =0.15, the algorithm that most significantly optimizes cost and labor is one that initially samples 5% of the morcellated specimen. However, additional sampling may be required in one fourth of the cases. The optimal amount of sampled tissue may indeed be less than 5% because this assumes no suspicious tissue is grossly visible and in all our cases of RCC grossly visible tumor was identified. Additional nomograms for a spectrum of TKR, sampling success, and cost are presented to allow pathologists their own discretion in determining optimal sampling of the morcellated kidney. Tumor staging is severely limited by morcellation. Tumor size, renal capsule involvement, and renal vein involvement cannot be fully pathologically evaluated for RCC, whereas invasion cannot be definitively assessed for urothelial carcinoma of the renal pelvis. Knowledge of the radiologic features (lesion size, capsule, and vein involvement) is important in sampling and staging morcellated kidneys removed laparoscopically.

Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis

PURPOSE

To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches.

MATERIALS AND METHODS

From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40.

RESULTS

To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive.

CONCLUSIONS

Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.

Minimally invasive adrenal surgery

The adrenals can be approached endoscopically using either transperitoneal or retroperitoneal access, most surgeons favouring the transperitoneal flank approach with the patient in the lateral decubitus position. Endoscopic retroperitoneal adrenalectomy can be performed via either a posterior or a lateral approach. The main advantage of the retroperitoneal approach in the prone position is that it allows bilateral adrenalectomy without repositioning the patient. Although technically more demanding, endoscopic adrenalectomy provides clear advantages over open procedures for tumours less than 5-6 cm in diameter. The small working space provided by the retroperitoneal approach is a contra-indication for the dissection of tumours over 5-6 cm in diameter. Peritoneal adhesions caused by previous abdominal surgery or a large right lobe of the liver may contra-indicate transperitoneal access. For small benign tumours, the transperitoneal and retroperitoneal routes are safe and effective, and there is no clear advantage of one procedure over the other. Invasive adrenal carcinoma is an absolute contra-indication for endoscopic adrenalectomy. Whether large (>5-6 cm) and potentially malignant tumours should be removed laparoscopically remains debatable.