Laparoscopic transperitoneal adrenalectomy using the LigaSure vessel sealing system

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience

BACKGROUND

The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery. The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others.

METHODS

A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate.

RESULTS

There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn't significant statistical difference (p = 0.178).

CONCLUSIONS

Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient's satisfaction.

Advanced sealing and dissecting devices in laparoscopic adrenal surgery

OBJECTIVES

This study sought to analyze the impact of advanced sealing/dissecting devices on operative and postoperative outcomes in laparoscopic adrenalectomy.

METHOD

Patients were divided into three groups according to the devices used during their procedures [electrothermal bipolar vessel system (EBVS), ultrasound shears (US), and monopolar electrocautery (ME)]. A comparison of the perioperative outcomes was performed.

RESULTS

Conversion rates and intraoperative and postoperative complication rates did not differ among the three groups. Major blood loss that required transfusion was registered in only two cases, all of which were performed with ME. Procedures with EBVS were shorter than those with US or ME. For left adrenalectomies only, operative times were similar for US and EBVS. The use of EBVS was found to be an independent predictor of decreased operative time.

CONCLUSION

The use of advanced sealing devices was associated with reduced operative time, with particular benefits in left adrenalectomy. EBVS and US may provide better hemostasis than ME.

Histopathological Response and Adhesion Formation After Omentectomy with Ultrasonic Energy, Bipolar Sealing, and Suture Ligation

This study was designed to evaluate the histopathological response and intra-abdominal adhesion formation after an omentectomy in rats using the bipolar vessel-sealing device, ultrasonic coagulator, and suture ligation techniques. Forty Wistar albino rats were used, divided into four random groups. The rats underwent a midline laparotomy, and a partial omentectomy was performed using a 3-0 silk suture with suture ligation in group 1, bipolar device in group 2, and ultrasonic coagulator in group 3; only a laparotomy was performed on the control group. Lateral thermal damage was examined the same day, and a piece of the omentum was left in the animals to be examined on postoperative day 15. A relaparotomy was performed to assess adhesion formation and histopathological response. In pairwise comparisons, there was no statistically significant difference among the ultrasonic device, bipolar device, and suture ligation groups in terms of microscopic adhesion scoring; however, the scores of the bipolar device and suture ligation groups were significantly higher compared with those of the control group (p < 0.01). Furthermore, the macroscopic adhesion scores were significantly lower for the ultrasonic device group when compared with those of the bipolar device and suture ligation groups (p < 0.05 and p < 0.01). The ultrasonic device seems to be superior to the bipolar device and suture ligation in terms of macroscopic adhesion formation, but no significant difference was found in terms of the histopathological response in rats following an omentectomy. Further research may be required.

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma

BACKGROUND

Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature.

CASE REPORT

We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively.

CONCLUSION

Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.

Energy-based hemostatic devices in laparoscopic adrenalectomy

PURPOSE

In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy.

METHODS

Forty-six patients, aged 54.6 +/- 46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27 +/- 4.8 kg/m(2). Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age.

RESULTS

Mean operating time was 126.5 +/- 52 min, blood losses were 101 +/- 169 mm, conversion rate was 6.5%, morbidity was 26%, and hospitalization was 5.3 +/- 2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p = 0.007) and had more complications (p = 0.016) than those undergone operation on the right side.

CONCLUSIONS

Obesity (BMI > 30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon's preference.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

USE OF THE LIGASURE VESSEL SEALING SYSTEM IN LAPAROSCOPIC ADRENALECTOMY

Laparoscopic adrenalectomy is the operation of choice for benign adrenal lesions. During laparoscopic surgery, vessels are usually ligated with diathermy, ligaclips, staplers or ultrasonic coagulators. Use of the electrothermal bipolar vessel sealer (LigaSure; Valleylab, Boulder, CO, USA) has recently been described in a variety of procedures, not including adrenalectomy. This article is a retrospective study of 28 patients undergoing laparoscopic adrenalectomy within the University of Sydney Endocrine Surgical Unit at the Royal North Shore Hospital using the LigaSure vessel sealing system. Between July 2004 and August 2005, 28 consecutive patients underwent laparoscopic adrenalectomy using the LigaSure vessel sealing system to divide feeding adrenal vessels as well as the adrenal vein. There were no bleeding complications. The LigaSure vessel sealing system can be safely used to secure haemostasis, including division of the adrenal vein, in laparoscopic adrenalectomy.