Complications of laparoscopic adrenalectomy in 75 patients treated by the same surgeon

Tips and Tricks in Laparoscopic Adrenalectomy for Pheochromocytoma. How We Do It

"Pheochromocytomas are rare neuroendocrine tumors that frequently have genetic involvement and can present a particular risk in terms of the anesthetic-surgical procedure. Current worldwide medical recommendations state that laparoscopic adrenalectomy is the conventional treatment for pheochromocytoma, however, the ideal surgical strategy is still being developed as specialized surgeons gain experience with these rare tumors. The study's purpose was to thoroughly evaluate our film library and identify the best surgical steps that represent our standardized procedure. We developed a comprehensive set of surgical critical strategies for either a left or right adrenalectomy, providing helpful advice on patient positioning, port placement, the adrenal gland approach, as well as other surgical methods specifically designed for tumor mobilization and dissection. The current paper aims to synthesize our clinical experience in terms of preoperative preparation, patient positioning, intraoperative complications, causes of conversion, and specimen extraction. The main conclusions concern both the best surgical approach and the importance of surgical experience in the clinical management of these rare tumor types. "

A 10-Year Tertiary Care Center Experience With Adrenalectomies for Adrenal Tumors

Background

Due to limited data, our understanding of the trends and outcomes of adrenalectomy in the Saudi surgical practice is limited and insufficient. The aim of this study was to review the clinical data regarding the diagnosis and management of patients with adrenal masses and to assess the effect of surgeon specialty on the outcomes.

Materials and methods

The study included all adult patients who underwent an adrenalectomy for tumors from 2011 to 2021. The patient characteristics, tumor profile, and preoperative, perioperative, and post-operative variables were collected. Frequency and percentage were generated for the categorical variables, and mean and standard deviation were generated for the quantitative variables.

Results

A total of 55 patients were identified. Most of the patients had a well-defined (58.2%, n = 32), benign (85.5%, n = 47) mass located in the cortex (58.2% n = 32). The majority of the sample were asymptomatic (52.7%, n = 29), and the most frequent diagnosis was adrenal adenoma (47.27%, n = 26). The most frequent indication for surgery was tumor functionality (69.1%, n = 38). Surgeries were mostly laparoscopic (69.1% n = 38) and performed by a urologist (52.7%). The conversion to open surgery was 13%, the intraoperative complication rate was 9.1%, the post-operative complication rate was 7.3%, and the 30-day readmission rate was 3.6%. Intraoperative complications, post-operative complications, and conversion to open surgery were more frequent among general surgeons, while 30-day readmissions were more frequent among urologists. However, a statistically accurate association could not be found due to the small population size.

Conclusion

Open surgery was replaced by laparoscopic adrenalectomy as the surgery of choice for different adrenal pathologies. The findings reported in this study are substantiated by current literature, adding to our comprehension of adrenal tumor presentation. There are, however, some inconsistencies regarding the influence of gender on tumor development and the association between surgeon specialty and outcome in the literature that merit research. However, evidence regarding the contribution of comorbidities, such as hypertension, diabetes, and hypothyroidism, is lacking.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]

Hintergrund

Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen.

Methodik

Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen.

Ergebnisse

In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %.

Schlussfolgerung

Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.

Risk factors for hypertensive attack during pheochromocytoma resection

Purpose

We aimed to retrospectively evaluate the risk factors for hypertensive attack during adrenalectomy in patients with pheochromocytoma. Despite the development of newer surgical and anesthetic techniques for the management of pheochromocytoma, intraoperative hypertensive attack continues to present a challenge.

Materials and Methods

Data from 53 patients diagnosed with pheochromocytoma at Kyungpook National Uriversity Medical Center between January 2000 and June 2012 were retrospectively analyzed. The subjects were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery. Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack. A univariate analysis was conducted, and a multivariate logistic regression analysis was also performed.

Results

In the univariate analysis, systolic blood pressure at presentation, preoperative hormonal status (including epinephrine, norepinephrine, vanillylmandelic acid, and metanephrine levels in a 24-hour urine sample), tumor size, and postoperative systolic blood pressure were significantly associated with the development of hypertensive attack. In the multivariate analysis, preoperative epinephrine level and tumor size were independent factors that predicted hypertensive attack. The highest odds ratio for tumor size (2.169) was obtained at a cutoff value of 4.25 cm and the highest odds ratio for preoperative epinephrine (1.020) was obtained at a cutoff value of 166.3 µg/d.

Conclusions

In this study, a large tumor size and an elevated preoperative urinary epinephrine level were risk factors for intraoperative hypertensive attack in patients with pheochromocytoma.

Laparoscopic Adrenalectomy for Large Adrenocortical Carcinoma

Background:

Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas. However, the oncological effectiveness of LA remains unclear. This review presents the current knowledge of the feasibility and oncological effectiveness of laparoscopic surgery for ACC, with an analysis of data for outcomes and other parameters.

Database:

A systematic review of the literature was performed by searching the PubMed and Medline databases for all relevant articles in English, published between January 1992 and August 2014 on LA for adrenocortical carcinoma.

Discussion:

The search resulted in retrieval of 29 studies, of which 10 addressed the outcome of LA versus open adrenalectomy (OA) and included 844 patients eligible for this review. Among these, 206 patients had undergone LA approaches, and 638 patients had undergone OA. Among the 10 studies that compared the outcomes obtained with LA and OA for ACC, 5 noted no statistically significant difference between the 2 groups in the oncological outcomes of recurrence and disease-free survival, whereas the remaining 5 reported inferior outcomes in the LA group. Using a paired t test for statistical analysis, except for tumor size, we found no significant difference in local recurrence, peritoneal carcinomatosis, positive resection margin, and time to recurrence between the LA and OA groups. The overall mean tumor size in patients undergoing LA and OA was 7.1 and 11.2 cm, respectively (P = .0003), and the mean overall recurrence was 61.5 and 57.9%, respectively. The outcome of LA is believed to depend to a large extent on the size and stage of the lesion (I and II being favorable) and the surgical expertise in the center where the patient undergoes the operation. However, the present review shows no difference in the outcome between the 2 approaches across all stages. A poor outcome is likely to result from inadequate surgery, irrespective of whether the approach is open or laparoscopic.

Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience

PURPOSE

Adrenocortical carcinoma (ACC) is a rare and clinically aggressive cancer. Previous studies reported increased recurrence rates associated with laparoscopic adrenalectomy (LA). We evaluated a single-center experience of LA versus open adrenalectomy (OA) for the management of ACC.

METHODS

Between 1993 and 2011, 44 consecutive patients with primary ACC were treated at our institution. Baseline patient characteristics and surgical and pathological outcomes were compared between OA and LA groups. Multivariable Cox proportional hazards analysis was used to estimate the association between OA versus LA with recurrence-free and overall survival.

RESULTS

Eighteen and 26 patients underwent LA and OA, respectively. Patients who underwent OA had larger tumors and more advanced clinical stage compared with LA group. During a median follow-up of 22 months, 22 recurrences and 26 deaths were observed. The 2-year, recurrence-free and overall survivals for OA and LA were 60 vs. 39 % (P = 0.7) and 54 vs. 58 % (P = 0.6), respectively. After adjusting for clinical stage, OA was associated with lower risk of recurrence (hazard ratio (HR) 0.4; 95 % confidence interval (CI) 0.2-1.2; P = 0.099) and improved overall survival (HR 0.5; 95 % CI 0.2-1.2; P = 0.122) compared with LA, although differences were not statistically significant.

CONCLUSIONS

A nonstatistically significant increase in recurrence and death was observed among patients undergoing LA versus OA after adjusting for clinical stage. The rarity of this disease limits the ability to assess for significant differences in a single-institution series. Patients with suspected ACC should be considered for OA.

Laparoscopic adrenalectomy: A single center experience

AIMS:

To evaluate the efficacy and safety of laparoscopic adrenalectomy in benign adrenal disorders.

METHODS AND MATERIAL:

Since July 2007, twenty patients have undergone laparoscopic adrenalectomy for various benign adrenal disorders at our institution. Every patient underwent contrast enhanced CT-abdomen. Serum corticosteroid levels were conducted in all, and urinary metanephrines, normetanephrines and VMA levels were performed in suspected pheochromocytoma. All the patients underwent laparoscopic adrenalectomy via the transperitoneal approach.

RESULTS:

The patients were in the age range of 18-57 years, eleven males and nine females, seven right, eleven left, two bilateral. The mean operative time was 150 minutes (120-180), mean hospital stay four days (3-5), mean intraoperative blood loss 150 ml and mean post-operative analgesic need was for 36 (24-72) hours. One out of twenty-two laparoscopic operations had to be converted into open adrenalectomy due to intra-operative complications.

CONCLUSIONS:

Laparoscopic adrenalectomy is a safe, effective and useful procedure without any major post-operative complication and is the gold standard for all benign adrenal disorders.

Efficacy of radiofrequency ablation in the treatment of small functional adrenal neoplasms

PURPOSE

To evaluate the use of radiofrequency (RF) ablation as a primary treatment for symptomatic primary functional adrenal neoplasms and determine the efficacy of treatment with use of clinical and biochemical follow-up.

MATERIALS AND METHODS

After obtaining institutional review board approval, the authors retrospectively evaluated images and medical records from 13 consecutive patients with symptomatic functional adrenal neoplasms (<3.2 cm in diameter) who underwent RF ablation during a 7-year period. There were six men and seven women with a mean age of 54.1 years (range, 42-71 years). Cross-sectional images, findings from clinical examination, and adrenal biochemical markers were available for all patients. Ten of the 13 patients (77%) had an aldosteronoma and one patient each had a cortisol-secreting tumor, testosterone-secreting tumor, and pheochromocytoma. RF ablation was performed by two radiologists using an internally cooled electrode and a pulsed technique according to manufacturer's specifications. Clinical and laboratory follow-up was performed for all patients. Three patients underwent imaging follow-up for other reasons.

RESULTS

All patients demonstrated resolution of abnormal biochemical markers after ablation (mean biochemical follow-up, 21.2 months). In addition, all patients experienced resolution of clinical symptoms or syndromes, including hypertension and hypokalemia (in patients with aldosteronoma), Cushing syndrome (in the patient with cortisol-secreting tumor), virilizing symptoms (in the patient with testosterone-secreting tumor), and hypertension (in the patient with pheochromocytoma). For the patients with aldosteronoma, improvements in hypertension management were noted. The mean blood pressure before ablation was 149/90 mm Hg with a mean (±standard deviation) of 3.1 ± 0.6 blood pressure medications, and this decreased to 122/77 mm Hg at a mean of 2.8 months after ablation with 1.3 ± 0.9 medications (P < .001) and 124/75 mm Hg at a mean of 41.4 months. There were two minor complications: one small pneumothorax and one limited hemothorax, neither of which required overnight admission. There were two episodes of transient self-remitting procedural hypertension-one in a patient with aldosteronoma and one in the patient with a cortisol-secreting tumor; however, none of these patients required further therapy during overnight observation.

CONCLUSION

RF ablation may be an effective, minimally invasive method for treating small functional primary adrenal tumors.

Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients

BACKGROUND

The role of laparoscopic adrenalectomy in the treatment of patients with adrenocortical carcinoma (ACC) is controversial.

OBJECTIVE

Our aim was to compare oncologic outcome in patients with ACC who underwent either open adrenalectomy (OA) or laparoscopic adrenalectomy (LA) for localised disease.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective analysis of 152 patients with stage I-III ACC with a tumour < or =10 cm registered with the German ACC Registry.

INTERVENTION

Patients were stratified into two groups according to the surgical procedure (LA or OA). For comparison, we used both a matched pairs approach by selecting for each patient from the LA group (n=35) one corresponding patient from the OA group (n=117) and multivariate analysis in all 152 patients.

MEASUREMENTS

Disease-specific survival was chosen as the predefined primary end point. Secondary end points were recurrence-free survival, frequency of tumour capsule violation and postoperative peritoneal carcinomatosis, and incidence and reasons for conversion from LA to OA.

RESULTS AND LIMITATIONS

LA and OA did not differ with regard to the primary end point using either the matched pairs approach (hazard ratio [HR] for death: 0.79; 95% confidence interval [CI], 0.36-1.72; p=0.55) or multivariate analysis (HR for death: 0.98; 95% CI, 0.51-1.92; p=0.92). Similarly, adjusted recurrence-free survival was not different between LA and OA (HR: 0.91; 95% CI, 0.56-1.47; p=0.69). Frequency of tumour capsule violation and peritoneal carcinomatosis were comparable between groups. In 12 of 35 patients of the LA group, surgery was converted to open surgery with no impact on the clinical outcome.

CONCLUSIONS

For localised ACC with a diameter of < or =10 cm, LA by an experienced surgeon is not inferior to OA with regard to oncologic outcome.

Laparoscopic adrenalectomy for large adrenal masses

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

Previously unreported high-grade complications of adrenalectomy

BACKGROUND

Serious complications of adrenalectomy are rare but the incidence may be underestimated if they occur outside major referral centers. We report five cases of high-grade complications after adrenalectomy that have not been previously described.

METHODS

The records of five cases of adrenalectomy performed at outside hospitals were reviewed. Four cases were referred for management of complications and one for medical-legal review. The nature of the adrenal lesion, operative approach, complication(s), and subsequent clinical course and complication management were assessed. Both open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) cases were included.

RESULTS

Operative indications were pheochromocytoma (N = 3), aldosteronoma (N = 1), and a nonfunctioning 6-cm hypervascular mass (N = 1). Complications of adrenalectomy included: case 1--complete transection of the porta hepatitis during right LA resulting in hepatic failure requiring emergent liver transplantation; case 2--ligation of the hepatic artery during right OA resulting in recurrent cholangitis and bile duct sclerosis requiring liver transplantation; case 3--ligation of the left ureter during LA resulting in postoperative hydronephrosis and loss of renal function; case 4--loss of left kidney function after OA, likely secondary to renal artery ligation ultimately requiring laparoscopic nephrectomy; case 5--LA of a normal adrenal gland for a 6-cm hypervascular mass thought to be arising from the adrenal gland. Three-month postoperative imaging demonstrated a persistent mass and the patient underwent hand-assisted laparoscopic nephrectomy for a left upper pole renal cell carcinoma that was missed at the time of LA.

CONCLUSION

Despite the generally low morbidity of adrenalectomy, serious and potentially life-threatening complications can occur. Surgeon inexperience may be a factor in the occurrence of some of these complications which have not been previously described.

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

OBJECTIVE

To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5cm.

METHODS

Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods.

RESULTS

All 112 operations were completed without any mortality or reoperation. Mean operative time was 151min and mean blood loss was 30ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147+/-5.1min, mean+/-standard error of mean) was significantly shorter than that of the initial 12 cases (183+/-8.8min, p=0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushing's adenomas, 12 pheochromocytomas, and 20 incidentalomas).

CONCLUSION

The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.

Laparoscopic adrenalectomy

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

Dispelling inhibition for laparoscopic surgery in younger children with Cushing's syndrome. Case report and literature review

Laparoscopic adrenalectomy (LA) is now the gold standard for the treatment of small, benign adrenal tumors in adults. In Cushing's syndrome (CS), LA is difficult and seldom done, especially in younger children. A 6-year-old girl was diagnosed with CS due to a juxtaadrenal tumor. She underwent LA and made an uneventful recovery. The histopathology was reported as paraganglioma which is a very rare cause of CS. LA is seldom done in younger children with CS owing to extreme obesity, abundant perinephric fat and a high incidence of pre- and postoperative complications.

Malignant adrenal tumors

Adrenal tumors, apart from neuroblastoma, are relatively rare in infancy and childhood. Most adrenal lesions are benign, and both benign and malignant tumors may be hormonally active thus, making accurate preoperative diagnosis difficult. The two main malignant tumors are adrenocortical carcinoma and pheochromocytoma. In both tumors, it may be difficult to determine benign from malignant and the biologic behavior and degree of invasion may portend a more malignant course. Surgical excision is the primary therapy for both tumors, including excision of metastatic and recurrent tumor. An open procedure should be considered for invasive adrenocortical carcinoma and in pheochromocytomas in which preoperative imaging demonstrates metastatic nodal disease. A laparoscopic approach is preferred for lesions in which preoperative imaging demonstrates a localized lesion. Chemotherapy, although without proven efficacy, is utilized in some children with metastatic or unresectable disease.

Transperitoneal laparoscopic adrenalectomy: outline of the preoperative management, surgical approach, and outcome

The laparoscopic approach to the adrenal gland has evolved to be the gold standard for most cases of adrenal conditions requiring surgical treatment. There is general consent about the safety, efficacy, and reproducibility of laparoscopic adrenal surgery. Compared to the open surgery, significant advantages with regard to shorter hospitalization time, decreased postoperative morbidity, improved cosmetics, and quicker convalescence are evident. The anatomic location of the adrenal gland led to the development of various approaches, including lateral transperitoneal, anterior transperitoneal, lateral retroperitoneal, posterior retroperitoneal, and even transthoracic approaches. The lateral transperitoneal approach is the technique most frequently used for laparoscopic adrenalectomy. A large operative field provides good orientation and visualization of familiar landmarks known from open surgery. In particular in the early learning curve this represents an advantage of the transperitoneal laparoscopic approach. This article describes in detail the indications, contraindications, preoperative evaluation, surgical technique, management of intraoperative complications, and outcome after lateral transperitoneal adrenalectomy.

Laparoscopic Adrenalectomy: A Single-Center Experience of 43 Cases

PURPOSE

To evaluate the surgical feasibility of laparoscopic adrenalectomy and what laparoscopy offers for the surgeon and the patient.

PATIENTS AND METHODS

From March 1996 to June 2004, 43 transperitoneal laparoscopic adrenalectomies were performed for various pathological states. Functioning adrenal masses and solid masses>5 cm were the most common indications. The mean size of the masses on abdominal CT was 6.8 cm in the largest diameter. All patients were assessed regarding the operative time, blood loss, complications, and conversion to open surgery. The postoperative course was reported with special attention to the complications and hospital stay.

RESULTS

The mean operative time was 125 minutes with a mean blood loss of 60 mL. Intraoperative complications occurred in 3 cases (6.9%), necessitating conversion to open surgery in 2 to control bleeding from the avulsed right adrenal vein. A third case of conversion was elective because of difficult dissection of a large left pheochromocytoma from the renal hilum, so there was a 6.9% rate of conversion to open surgery. All patients showed early ambulation, early start of eating, and a short hospital stay (mean 2.6 days).

CONCLUSION

Laparoscopic adrenalectomy is surgically feasible and can be applied for different adrenal pathologies. The procedure can be performed with a reasonable operative time, minimal blood loss, and an acceptable rate of complications. Laparoscopic adrenalectomy provides excellent postoperative recovery and convalescence with a short hospital stay.

Laparoscopic telementored adrenalectomy: The Italian experience

BACKGROUND

Laparoscopy is widely accepted as the gold standard for adrenalectomy. Telementoring has been developed to reduce the complications associated with surgeon inexperience. We report our preliminary experience with laparoscopic telementored adrenalectomy.

METHODS

From July 2002 to May 2003, eight laparoscopic telementored adrenalectomies were performed between two separate operating sites 430 km apart. Six of these procedures were monolateral laparoscopic adrenalectomies, and one was bilateral. All cases were performed by an expert open surgeon who was skilled in laparoscopic procedure but who had no experience in laparascopic adrenalectomy

RESULTS

All the procedures were successfully performed in a telementored fashion. The mean operative times, blood loss, and postoperative morbidity results were comparable to those for standard laparoscopic adrenalectomies reported in the literature.

CONCLUSIONS

This preliminary experience has demonstrated the feasibility of national telementoring. It is a viable method that can potentially add to surgical education and decrease the likelihood of complications due to inexperience with new techniques.

[Laparoscopic adrenalectomy--experience of 10 years]

INTRODUCTION

The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan and North America. We reviewed our 10-year experience with laparoscopic adrenal surgery.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was carried out in 113 patients, 77 females and 36 males, between January 1994 and January 2004. The age ranged from 1 to 76 years (43.1 +/- 16.2 years). Ten (8.8%) patients were 20 years old or younger, 19 (16.8%) patients had unilateral tumor larger than 4 cm, 25 (22.1%) patients had Body Mass Index > or = 30 kg/m2, and 13 (11.5%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (3.3 +/- 1.6 cm). One hundred and sixteen operations were performed, of which 109 were unilateral and 7 were bilateral, adding up to a total of 123 adrenalectomies. Among the 116 procedures, the lateral transperitoneal approach was employed in 113 cases, whereas lateral retroperitoneal approach enabled 3 adrenalectomies.

RESULTS

Unilateral procedures lasted 107 +/- 33.7 min (45-250 min); bilateral procedures lasted 180 +/- 90.6 min (100-345 min); 5 (4.3%) cases were converted to open surgery. Twenty (17.7%) patients suffered complications, being 8 (7.0%) intraoperative and 12 (10.6%) postoperative complications. Six (5.3%) cases were considered major complications. No deaths occurred due to the surgical procedures. Blood transfusion rate was 3.5%. Hospital stay was 5.7 +/- 15.0 days (1-140 days). Follow-up period was 23 +/- 12.8 months (1-60 months) and all these patients were followed for a minimum of 6 months.

CONCLUSIONS

Laparoscopic adrenalectomy is feasible and has excellent results in selected patients.

Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: experience with initial 30 cases

AIM

To assess the feasibility of portless endoscopic adrenalectomy via a single minimum incision that narrowly permits extraction of the specimen.

METHODS

For 30 cases of adrenal tumor, portless endoscopic surgery through a single flank incision (3-9 cm; mean, 5.6 cm) was performed without gas inflation or trocar port placement. All of the instruments used during surgery were reusable. The cases included primary aldosteronism (12), Cushing's syndrome (6), preclinical Cushing's syndrome (3), pheochromocytoma (1), non-functioning cortical adenoma (6), adrenocortical carcinoma (1) and adrenocortical hemorrhage (1).

RESULTS

Resection of the tumor was successfully completed, without complications, in all of the cases. Operative time was between 83 and 240 min (mean, 147 min). Estimated blood loss was 5-470 mL (mean, 139 mL). None of the patients required blood transfusion. Postoperative course was uneventful. Wound pain was mild and walking and full oral feeding were resumed on the first and second postoperative day, respectively, in the majority of cases.

CONCLUSIONS

Adrenal tumors are good candidates for portless endoscopic surgery, which is safe, cost-effective, minimally invasive and matches favorably with laparoscopic surgery.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Laparoscopic surgery for pheochromocytoma

OBJECTIVE

To evaluate the feasibility of laparoscopic adrenalectomy for pheochromocytoma.

MATERIAL

Between January 1998 and March 2002, 12 patients aged from 19 to 76 (average age 54 years) underwent 13 adrenalectomies (7 right and 6 left, 1 bilateral) using laparoscopic surgery. A specific anti-hypertensive preparation was begun prior to the operation. Peaks of blood pressure were treated by bolus Nicardipine and sinus tachycardia by bolus Esmolol. Catecholamines were dosed at different times during the intervention. As far as surgery was concerned, the adrenalectomies were performed 11 times using the transperitoneal route and twice using the retroperitoneal route. The adrenal vein was found and ligatured before manipulation of the adrenal gland.

RESULTS

Average length of operation was 127 minutes (75 to 195). Average blood loss was 105 ml (0 to 1000). Catecholamines dosed throughout showed a variable increase in plasma rates during peritoneal insufflation and manipulation of the gland. They were responsible for 5 cases of hypertensive bouts and 2 cases of tachycardia which were treated with medication. No surgical conversions were necessary. Average length of hospital stay was 4.18 days (3 to 6); average size of adrenal tumours was 44 mm (30 to 72); average follow-up, 18.4 months.

CONCLUSION

This study showed the feasibility of adrenalectomy for pheochromocytoma using laparoscopic surgery, subject to specific medical preparation to reduce the consequences of peroperative bouts of hypertension and sinus tachycardia during peritoneal insufflation and manipulation of the adrenal gland despite initial ligature of the main adrenal vein.

One Hundred Laparoscopic Adrenalectomies: A Single Surgeon’s Experience

BACKGROUND

Since the first laparoscopic adrenalectomy was performed in 1992, it has quickly gained acceptance as the standard of care for the treatment of benign adrenal neoplasms. We report a single surgeon's experience with 100 consecutive laparoscopic adrenalectomies.

METHODS

The records of all patients having adrenalectomy at the Johns Hopkins Hospital from 1993 until 2000 were reviewed. We examined the length of stay, time to diet resumption, perioperative morbidity, operative cost, and total cost of 100 consecutive laparoscopic adrenalectomies. These data are compared with those of 20 patients within our institution having open adrenalectomy and with 428 patients statewide having all forms of adrenalectomy during the same time period.

RESULTS

A total of 93 patients had unilateral laparoscopic adrenalectomy and 7 had bilateral procedures. The mean age was 49 years (11 to 70). Indications were aldosteronoma (n = 40), pheochromocytoma (n = 22), glucocorticoid-producing adenoma (n = 14), nonfunctioning adenoma (n = 12) Cushing's disease (n = 5), and others (n = 7). The median length of stay for this series was 1.0 day. Average length of stay and time to resumption of diet were 1.8 and 1.0 days, respectively. Patients having open procedures during this same time period had an average length of stay of 6.5 days.

CONCLUSIONS

Laparoscopic adrenalectomy provides clear advantages over open adrenalectomy. Patients having laparoscopic adrenalectomy have decreased length of stay, shorter time to resumption of diet, and lower total hospital charges when compared with those having open adrenalectomy.

Adrenocorticotropin-independent macronodular adrenal hyperplasia treated by simultaneous bilateral laparoscopic adrenalectomy

A 61-year-old woman was admitted to our hospital with hypertension and diabetes mellitus, and was found to have Cushing's syndrome. Radiological and endocrinological findings suggested adrenocorticotropic hormone-independent macronodular adrenal hyperplasia. Simultaneous bilateral laparoscopic adrenalectomy was performed, minimizing the number of trocar sites and operation time. Success was attributed to the careful selection of trocar sites to permit safe dissection.

Review of surgical management of aldosterone secreting tumours of the adrenal cortex

AIMS

To evaluate the investigation and surgical management of primary hyperaldosteronism. Retrospective case note analysis of thirty-three patients who underwent adrenalectomy for primary hyperaldosteronism between 1982 and 2001 and a current relevant literature review.

METHODS

The records of twelve male and twenty-one female patients, age range 18 to 81 (mean 48 years) were reviewed. Eleven operations were performed by an open approach and twenty-two laparoscopically. Preoperative investigations included computed tomography (CT), magnetic resonance imaging (MRI), selective venous sampling and seleno-cholesterol isotope scanning, along with biochemical and hormonal assays. Twenty-six benign adenomas, three nodular hyperplastic lesions, one primary adrenal hyperplasia and three functional carcinomas were excised. Mean follow up was 12 months.

RESULTS

Patients had a mean blood pressure of 185/107 mmHg for 6.2 years mean duration. The mean severity of hypokalaemia was 2.7 mmol/l. Sensitivity of CT scanning was 85%, and of MRI 86%. Fifty percent of seleno-cholesterol scans were accurate. Mean operating time was 158 min for laparoscopic adrenalectomy whilst open surgery took 129 min (p=0.2, NS). Two cases commenced laparoscopically required open access for control of primary haemorrhage whilst one other bleed was managed via the operating ports. Mean postoperative stay was significantly shorter for the laparoscopic group (3 days compared with 7.9 days, p<0.0001). Thirty day mortality was zero. There were three infective complications in the open group (two chest, one wound) with no postoperative complications in the laparoscopic group. All patients were cured of hypokalaemia, whilst 62% cure of hypertension was achieved. Of those patients whose blood pressure was improved preoperatively by spironolactone 78% were cured by adrenalectomy. Adrenalectomy led to an overall reduction in the mean number of anti-hypertensive medications (2.3 drugs preoperative to 0.6 postoperative, p<0.0001). Of those not cured, 58% had improved blood pressure control requiring less medication on average (1.6 drugs compared with 2.6 drugs, p=0.08). Mean age of patients not cured by surgery was 55 years, whilst those cured was 44 years (p=0.03).

CONCLUSIONS

Primary hyperaldosteronism is a rare but important cause of hypertension. Selective venous sampling is a useful tool where investigations are inconclusive and fail to lateralise secretion. Patients with primary hyperaldosteronism enjoy lower complication rates and earlier discharge with the advent of laparoscopic surgery. Most patients will be cured of their hypertension and all of hypokalaemia. Laparoscopic adrenalectomy is now the accepted method of surgery for benign hyperaldosteronism. Those with bilateral disease due to idiopathic hyperaldosteronism (IHA) are not candidates for surgery and should be treated medically.

Benign retroperitoneal schwannoma mimicking an adrenal mass

Adrenal tumors are frequently incidental discoveries, and the therapy for them is the subject of controversial discussions. We report herein on such an incidentaloma, which proved to be a benign retroperitoneal schwannoma. A 48-year-old female with an unclear adrenal mass underwent retroperitoneoscopic tumor extirpation. A well-defined tumor that displaced the adrenal gland and adhered firmly to only one retroperitoneal nerve was discovered. The en bloc resection was performed without problem. The histopathologic examination revealed a benign schwannoma. Retroperitoneal schwannomas can mimic a multitude of different conditions. Because imaging methods frequently do not yield distinct results, quite often only the operative exploration can establish a definitive diagnosis. In a case of unclear retroperitoneal findings, an endoscopic extirpation should be considered.

Laparoscopic adrenal surgery in a Brazilian center

BACKGROUND AND PURPOSE

The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan, and North America. We reviewed our 7-year experience with laparoscopic adrenal surgery. This is the first large series presented from Latin America.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was carried out in 61 female and 33 male patients between January 1994 and February 2001. Their ages ranged from 1 to 72 (42.8 +/- 16.4 years) years. Ten patients (10.6%) were 20 years or younger, 10 (10.6%) had unilateral tumors >4 cm, 22 (23.4%) had a Body Mass Index >/= 30, and 10 (10.6%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (2.9 +/- 4 cm). Ninety-seven operations were performed, of which 91 were unilateral and 6 were bilateral, adding up to 103 adrenalectomies. Among the 97 procedures, the lateral transperitoneal approach was employed in 94 cases, whereas a lateral retroperitoneal approach enabled 3 adrenalectomies.

RESULTS

Unilateral procedures lasted 117 +/- 43.7 minutes (range 45-250 minutes); bilateral procedures lasted 186 +/- 91.6 minutes (range 100-345 minutes). Five operations (5.1%) were converted to open surgery. Twenty patients (21.3%) suffered complications, 8 (8.5%) being intraoperative and 12 (12.8%) postoperative. Six cases (6.4%) were considered major complications. No deaths occurred. The blood transfusion rate was 4.2%. The hospital stay averaged 6.1 +/- 15.3 days (range 1-140 days). The follow-up period was 17 +/- 12.6 months (range 1-60 months).

CONCLUSIONS

Laparoscopic adrenalectomy is feasible and has excellent results in properly selected patients.

Adrenalectomia laparoscópica: análise de 11 pacientes

OBJETIVO: Analisar a experiência inicial da Divisão de Urologia do HCFMRP-USP na adrenalectomia transperitoneal videolaparoscópica. MÉTODOS: Análise retrospectiva de 11 casos de adrenalectomia transperitoneal laparoscópica realizados de fevereiro de 1999 a março de 2003 sendo 3 em homens( 27%) e 8 em mulheres (73%), idade média de 40,2 ± 13,1 anos. Os pacientes apresentavam os diagnósticos seguintes: adenoma - 5, síndrome de Cushing - 3, feocromocitoma - 1, hiperaldestorismo - 1 e síndrome de Carney - 1. RESULTADOS: A cirurgia foi bilateral em 05 pacientes (45,4%) e unilateral em 06 pacientes (54,6 %), destes 04 à direita (36,4%) e 02 à esquerda (18,2%). O tempo médio de internação foi de 3,6 ± 1,1 dias, o tempo médio de cirurgia foi de 220,5 ± 103,7 minutos e a taxa de conversão foi de 18,2%. CONCLUSÃO: Os resultados apresentados são similares aos relatados pela literatura, demonstrando que a adrenalectomia videolaparoscópia pode ser realizada de maneira segura e eficiente com benefícios: tempo cirúrgico aceitável, rápida recuperação pós-operatória e alta precoce.

Hand-assisted laparoscopic adrenalectomy: an alternative minimal invasive surgical technique for the adrenal gland

BACKGROUND

Presently the surgical approach to the adrenal gland is in a state of flux. While the traditional approach to the adrenal gland has been the open transabdominal technique, more recently laparoscopic approaches, particularly via the transabdominal route, have increasingly been utilized. However, laparoscopic intervention for the adrenal gland can be problematic in certain circumstances, particularly for large adrenal masses and in instances of adrenal malignancies.

METHODS

In this report we describe the use of hand-assisted laparoscopic adrenalectomy as an alternative minimal invasive surgical approach to the adrenal gland. Hand-assisted laparoscopic adrenalectomy using the HandPort system (Smith & Nephew, Sydney, Australia) was undertaken in three patients requiring adrenalectomy for mass lesions including one patient with Conn's syndrome.

RESULTS

In all three cases, surgery proceeded promptly and uneventfully. In the present paper, the details of the technique of hand-assisted adrenalectomy are described. This is the first report in the world literature of this new technique for the adrenal gland.

CONCLUSIONS

Hand-assisted laparoscopic adrenalectomy is an easily performed technique, which can be completed within a short operative time span and which has the advantage of providing intraoperative tactile localization for the adrenal gland. It may be particularly applicable for large adrenal tumours, yet only involves the performance of a small abdominal incision. Postoperative recovery is comparable with that reported for the laparoscopic-only technique. Hand-assisted adrenalectomy is a new technique which has great potential and which warrants further evaluation.

Cost-effectiveness of laparoscopic vs open adrenalectomy: small savings in an expensive process

BACKGROUND AND PURPOSE

Nowadays, laparoscopy has become the approach of choice for adrenalectomy, especially in cases of benign tumors <6 cm. The authors have studied, in a retrospective trial, two groups of patients who have undergone an adrenalectomy: 10 consecutive patients operated on by an open approach and 10 consecutive patients operated on by laparoscopy.

METHODS

Laparoscopic adrenalectomies were performed via a transabdominal lateral approach, whereas open adrenalectomies were performed via an anterior transabdominal or posterior retroperitoneal approach. Clinical outcomes were recorded, and special attention was paid to the costs of both techniques, collecting economic data from the costs in outpatient visits, blood and urine tests, diagnostic imaging, hospital admissions prior to surgery, hospital admission for surgery, and surgical expenses.

RESULTS

Operative time (110 vs 123 minutes), length of postoperative stay (3.7 vs 5.8 days), and time to oral intake (1 vs 2 days) were significantly lower in the laparoscopic group. From the economic point of view, however, there were no significant differences between laparoscopic and open groups (6,306 vs 7,581), and only surgical inhospital stay costs were significantly lower in the laparoscopic series (742 vs 1,191). All the costs generated by surgery (hospital admission for surgery plus surgical expenses) were smaller in the laparoscopic group but constituted only a small part of the general expenses for these patients. The more expensive part of the budget for every patient was the hospital admissions prior to surgery for diagnosis or preoperative treatment.

CONCLUSION

Laparoscopy is a safe and comfortable approach for adrenalectomy and should be the technique of choice. From the economic point of view, laparoscopic adrenalectomy is cheaper than open adrenalectomy, but in all cases, surgical costs are only a minimal part of the budget, and the greater savings must come from the reduction in the presurgical diagnostic process.

A single-centre experience of retroperitoneoscopy using the balloon technique

OBJECTIVE

To report the experience in one centre of the efficacy and safety of retroperitoneal laparoscopic procedures (RLPs).

PATIENTS AND METHODS

During 1991-2000, 351 RLPs using the balloon technique were undertaken in 340 patients (mean age 34.9 years, range 4-74); the details and outcome were reviewed. Initial access was by the mini-open digital dissection technique in 152 and by the closed percutaneous technique in the remaining 199 procedures. Patients had not undergone previous retroperitoneal procedures, except for nine who had a percutaneous nephrostomy and eight ipsilateral abdominal surgery. There were 172 renal, seven adrenal, 97 ureteric, 50 gonadal, 13 lymphatic system, three vesical, two autonomic nervous system and seven vertebral RLPs. Nitrous oxide was used for pneumo-insufflation in 103 procedures, instead of CO2.

RESULTS

The RLP was successful in 318 of the 351 procedures (90.6%). The operative duration was 0.5-5.5 h, depending on the difficulty of the procedure and the presence or absence of adhesions. The overall incidence of complications was 12.9%, but decreased to 9% for the last 100 procedures. There were only five major complications, e.g. avulsion of the ureter, torn renal pelvis, colonic injury and severe hypotension, but none were related to balloon dissection. The mean blood loss was 37.7 mL and the reason for transfusion in three patients was not operative blood loss but displacement of the ligature in two and severe hypotension after removing a phaeochromocytoma in one. The mean duration of analgesic use was 2.5 days, the hospital stay 3 days and return to work 14 days.

CONCLUSION

Retroperitoneal laparoscopy using the balloon technique is a reasonably safe, efficient and reliable minimally invasive procedure. The efficiency, efficacy and safety of RLPs depend more on experience than on the type of access technique, type of balloon or medium used to inflate the balloon. Balloon rupture causes no tissue damage, and expansion to approximately 800 mL in adults is safe if the retroperitoneal space has not previously been invaded. The use of nitrous oxide for pneumo-insufflation in the retroperitoneal space is safe if proper precautions are taken.

Surgical strategy in adrenal masses

OBJECTIVE

Endoscopic adrenalectomy represents the "New Golden Standard" in the surgical treatment of benign adrenal lesions up to 6 cm. Open adrenalectomy is recommended for patients with suspected malignant disease and tumors larger than 6 cm.

METHODS AND MATERIAL

The surgical technique of trans- and retroperitoneal adrenalectomy is described. Reviewing literature the importance of the endoscopic approach and its role in the surgical treatment of adrenal lesions is analyzed.

RESULTS

As in open adrenalectomy different endoscopic approaches to the adrenals were developed: adrenal tumors can be removed endoscopically using a transperitoneal (patient in a supine or lateral decubitus position) or extraperitoneal route (patient in a lateral decubitus or prone position). Reviewing literature the endoscopic transperitoneal adrenalectomy is documented in 1425 patients. 4.6% (66 patients) had to be converted to an open procedure. Five hundred and forty-four tumors were removed by an extraperitoneal access. The conversion rate was 4.4% (24 patients).

CONCLUSION

The basis of excellent results are careful patient selection, evaluation and preoperative preparation in a center with experience in the open techniques and at least 20 endoscopic adrenalectomies per year.

Multi-institutional study of complications in 1085 laparoscopic urologic procedures

OBJECTIVES

To assess the incidence of the complications in laparoscopic urologic procedures with regard to clinical presentation, etiology, and treatment.

METHODS

From January 1994 to December 2000, 1085 laparoscopic procedures were performed at three institutions in 1075 patients (702 men, 373 women). A referent surgeon for laparoscopy was at each institution. The major procedures were radical prostatectomy (n = 232), different types of nephrectomy (n = 171) and nephroureterectomy (n = 15), adrenalectomy (n = 130), pyeloplasty (n = 61), pelvic lymph node dissection (n = 130), genitourinary prolapse repair (n = 86), bladder neck suspension (n = 104), and treatment of benign kidney pathologic findings (lithiasis, cysts, and diverticula, n = 55). The complications were listed by incidence and etiology according to the procedure attempted.

RESULTS

A total of 75 complications (6.9%) occurred in this multi-institutional series. The mortality rate was 0.09%, and the conversion rate was 2.1%. Vascular (n = 7) and visceral injuries (n = 11) occurred in 24% of complications. Hematomas (n = 10), urinomas (n = 8), and wound infections (n = 7) at the trocar sites were the most frequent postoperative surgical complications. Pulmonary disorders (n = 9) and urinary infections (n = 9) were predominant in the postoperative medical problems.

CONCLUSIONS

Even though it appears to be minimally invasive, laparoscopy remains major surgery, with serious complications possible. These complications should be preventable with better mastery of the different steps of the procedures. Increased knowledge of the possible complications is essential for urologists in laparoscopic training and may help them improve their learning curve.

Simultaneous bilateral laparoscopic adrenalectomy in ACTH-independent macronodular adrenal hyperplasia

Laparoscopic surgery for urological conditions has now become popular worldwide. The case is reported of a 56-year-old woman who underwent simultaneous bilateral laparoscopic adrenalectomy for adrenocorticotropic hormone-independent macronodular adrenocortical hyperplasia (AIMAH), followed by autotransplantation of resected adrenal gland fragments. Simultaneous laparoscopic adrenalectomies seem feasible for a patient with AIMAH because of its minimally invasive nature. However, autotransplantation of adrenal fragments failed in this patient with AIMAH.

Transperitoneal laparoscopic adrenalectomy

Laparoscopic adrenalectomy has been demonstrated by many institutions to be a safe and effective approach to benign adrenal lesions. As surgical skills improve, it will most likely be comparable with open adrenalectomy in overall cost. Although it is technically demanding and takes slightly longer than open surgery, the benefits to the patient in terms of hospital stay, convalescence, and cosmetic results have been conclusively reported. The decision to use a transperitoneal or retroperitoneal access is mostly a function of surgeon preference, with similar outcomes by either approach. It is more important that the surgeon be comfortable with the selected approach. Laparoscopic adrenalectomy has become the gold standard for benign adrenal lesions.

Laparoscopic adrenalectomy: retroperitoneal approach

The most important procedure in retroperitoneoscopic adrenalectomy is en bloc dissection of the perinephric fat, including the upper pole of the kidney and the adrenal gland, from the surrounding muscles (transversus abdominalis, psoas, and diaphragm) just inside Gerota's fascia. It is not recommended that the surgeon directly identify the adrenal gland at the start of the operation. After dividing the perinephric fat between the adrenal gland and kidney, the upper pole of the kidney is exposed, and dissection proceeds along the renal surface. The lateral retroperitoneoscopic approach promises to be a safer and less invasive treatment for patients with small unilateral adrenal tumors. In all cases, careful patient selection and correct choice of the surgical approach based on tumor size, the patient's condition, and the surgeon's skill are vital to avoid complications during laparoscopic adrenalectomy.

Adrenal masses in neoplastic patients: the role of laparoscopic procedure

BACKGROUND

The incidence of complications resulting from fine-needle biopsy of adrenal masses in patients already treated by radical procedures for primitive neoplasms of the lungs and kidneys substantiates our opinion concerning laparoscopy as both a diagnostic and therapeutic procedure.

METHODS

We performed 70 laparoscopic adrenalectomies from April 1995 to December 1999. In five patients, the adrenal mass appeared at follow-up evaluation in patients submitted to surgery for a spinocellular lung cancer. One patient underwent surgery for renal adenocarcinoma. In two patients, the adrenal mass was present already at the time primitive lung tumor was diagnosed, so adrenalectomy was performed at the first lung surgery in one patient and 2 weeks before lung surgery in the other patient. All the patients were placed in a lateral position for a transperitoneal approach. Right adrenal masses were present in seven patients, whereas one patient had an adrenal mass in a left location.

RESULTS

No laparotomy was required. The average surgical time was 160 min. (range, 115-120 min). No morbility or mortality occurred, and the average hospital stay was 4 days (range, 3-11 days). All the patients had a complete removal of their masses, which averaged 4.5 cm (range, 2.5-6 cm) in size. Histology confirmed the metastatic origin of the mass in five of seven patients with primary lung cancer, and in one patient with previous kidney cancer. At this writing, three patients were disease free and still alive respectively at 3, 5, and 18 months. Three patients died of brain metastases respectively at 16, 36, and 36 months. An adenoma was proved in the other two cases.

CONCLUSIONS

Laparoscopic adrenalectomy allows us to propose a much more aggressive approach to adrenal masses demonstrated at follow-up evaluation or in patients with primary lung or kidney cancer and no masses at other locations. Nevertheless a much larger study is required for definitive conclusions on a survival rate. We believe that a mini-invasive procedure such as laparoscopy may allow us to replace a rational surgical approach with a more certain pathologic diagnosis.

Retroperitoneal laparoscopic adrenalectomy: clinical experience in 52 procedures

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for removal of small adrenal tumors. The aim of this prospective study was to evaluate the retroperitoneal approach with regard to intraoperative complications, morbidity, and length of hospital stay.

METHODS

Between September 1996 and October 1999, we performed 52 laparoscopic adrenalectomies (31 left, 21 right) for benign lesions by a retroperitoneal approach in 44 patients (27 women, 17 men) with a mean age of 46.9 years (range 17 to 74). The average adrenal tumor size was 32 mm (range 10 to 63). All procedures required four trocars and a mean operative time of 135 minutes (range 75 to 240).

RESULTS

There was no mortality, conversion rate to open surgery was 1.9%, and estimated blood loss was 80 mL (range 30 to 200). With a mean follow-up of 16 months, morbidity was 17.2%, which included intraoperative complications (5. 7%) with two vascular injuries, and postoperative complications (11. 5%) with wound infections, deep hematoma, and parietal dehiscence. Average length of hospital stay was 5 days with a mean analgesic consumption of 2 days (range 1 to 5).

CONCLUSIONS

The retroperitoneal approach in laparoscopic adrenalectomy appears to be a minimally invasive and safe therapeutic option that may become the standard for unilateral or bilateral adrenal tumors not larger than 7 cm. However, a learning curve in laparoscopy is indispensable before starting this type of procedure.

Surgical management of pheochromocytoma

The early diagnosis and safe treatment of pheochromocytoma have become possible due to advances in preoperative imaging techniques and endocrine tests, as well as improvements in the control of blood pressure and hemodynamics before and during the operation using various drugs. This article outlines the use of meticulous surgical technique via various approaches for open surgery and gives a step-by-step description of the methods for laparoscopic surgery. Such techniques have made the excision of pheochromocytoma safe and easy, allowing hypertension to be surgically cured in these patients. Thus, pheochromocytoma is less likely to be fatal than before. However. it is necessary to follow these patients for a long period postoperatively because it is often difficult to distinguish benign from malignant tumors and recurrence has been reported even more than ten years postoperatively.