Innovation in endocrine surgery: robotic versus laparoscopic adrenalectomy. Meta-analysis and systematic literature review

Robot-assisted adrenalectomy: Step-by-step technique and surgical outcomes at a high-volume robotic center

Objective

In the last years, robotic surgery was introduced in several different settings with good perioperative results. However, its role in the management of adrenal masses is still debated. In order to provide a contribution to this field, we described our step-by-step technique for robotic adrenalectomy (RA) and related modifications according to the type of adrenal mass treated.

Methods

We retrospectively analyzed 27 consecutive patients who underwent RA at Onze-Lieve-Vrouw hospital (Aalst, Belgium) between January 2009 and October 2022. Demographic, intra- and post-operative, and pathological data were retrieved from our prospectively maintained institutional database. Continuous variables are summarized as median and interquartile range (IQR). Categorical variables are reported as frequencies (percentages).

Results

Twenty-seven patients underwent RA were included in the study. Median age, body mass index, and Charlson's comorbidity index were 61 (IQR: 49-71) years, 26 (IQR: 24-29) kg/m2, and 2 (IQR: 0-3), respectively, and 16 (59.3%) patients were male. Median tumor size at computed tomography scan was 6.0 (IQR: 3.5-8.0) cm. Median operative time and blood loss were 105 (IQR: 82-120) min and 175 (IQR: 94-250) mL, respectively. No intraoperative complications were recorded. Overall postoperative complications rate was 11.1%, with a postoperative transfusion rate of 3.7%. A total of 10 (37.0%) patients harbored malignant adrenal masses. Among them, 3 (11.1%) had adrenocortical carcinoma, 6 (22.2%) secondary metastasis, and 1 (3.7%) malignant pheochromocytoma on final pathological exam. Only 1 (10.0%) patient had positive surgical margins.

Conclusion

We described our step-by-step technique for RA, which can be safely performed even in case of high challenging settings as malignant tumors, pheochromocytoma, and large masses. The standardization of perioperative protocol should be encouraged to maximize the outcomes of this complex surgical procedure.

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

BACKGROUND

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

METHODS

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

CONCLUSIONS

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

Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve

BACKGROUND

Robotic adrenalectomy is feasible and safe, yet concerns over increased operative times and the learning curve (LC) for proficiency have limited its adoption. This study aimed to assess the LC for robotic adrenalectomy.

METHODS

This is a two-institution retrospective review of consecutive unilateral minimally invasive adrenalectomies performed by four high-volume adrenal surgeons between 2007 and 2022. Two surgeons transitioned from laparoscopic to robotic adrenalectomy, and two surgeons adopted the approach, with proctoring, after completion of fellowship training without robotic experience. Operative time and complications were analyzed. Multivariable regression was used to identify factors associated with operative time. The number of cases required to overcome the LC was determined using the LC-cumulative-sum (LC-CUSUM) analysis.

RESULTS

Of 457 adrenalectomies, 182 (40%) were laparoscopic and 275 (60%) robotic. The robotic approach was associated with shorter median operative time (106 vs 119 min; p = 0.002), fewer complications (6% vs 13%; p = 0.018), and fewer conversions to open adrenalectomy (1% vs 4%; p = 0.030), with no difference between the senior and junior surgeons. On adjusted analysis, factors associated with increased operative time were male sex (p < 0.001), BMI > 30 kg/m² (p < 0.001), and higher gland weight (p < 0.001). The LC-CUSUM analysis showed proficiency after 8-29 procedures. Compared with the first 10 cases, there was a mean reduction in operative time of 14 min after 10-20 cases, 28 min after 20-30 cases, and 29 min after > 30 cases, regardless of surgeon experience.

DISCUSSION

With dedicated teams and proctoring, robotic adrenalectomy can be safely adopted at high-volume centers with a minimal LC.

Management of the incidental adrenal mass, continued surveillance versus surgical excision: analysis of US claims data on contemporary socio-demographic predictors and perioperative outcomes

BACKGROUND

Incidentally diagnosed adrenal masses represent an entity that can result in either long term follow-up, surgical excision, or both. Understanding when and which adrenal masses are ultimately excised surgically is not well understood. We sought to understand the ultimate fate of these incidentalomas using a large population-based dataset.

METHODS

The primary outcome of the study was determining the trend in adoption of surveillance vs. surgical excision according to socio-demographic, economic, and pathologic indices, and also provider specialty. Secondary outcomes were the assessment of perioperative complications, operative time, surgical approach, hospital stay, and provider specialty (general surgery vs. urology) among the cohort that underwent excision.

RESULTS

Out of a total of N.=91,560 adrenal masses, ultimately N.=3375 (3.83%) of these underwent surgical excision. In the surgical excision cohort, the incidence of aldosteronoma, functional adenoma/Cushing's disease, and adrenocortical carcinoma was higher than in the surveillance cohort. Those patients who were older, female, and with higher Charlson Comorbidity indexes (CCI) were less likely to undergo surgical resection. Factors that predicted for an increased probability of resection included obtaining more CT/MRI scans as well as general surgeons as primary physician providers. Over the study period, the vast majority of surgeries were performed by surgeons other than urologists (12.9%) and open and laparoscopic approaches dominated, with the robotic-assisted approach accounting for a minority of the surgical cases (23.9%). The minimally invasive surgery (MIS) approach independently predicted for both lower rates of complications and shorter hospital stay.

CONCLUSIONS

In the US, adrenal incidentalomas are more likely to undergo surveillance rather than surgical resection. In our study, surgery is mainly offered for functional or malignant disease and the receipt of surgery can vary by physician specialty. A MIS approach independently predicted for both lower rates of complications and shorter hospital stay.

The new robotic platform Hugo™ RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases

Robotic assisted surgery is the most rapidly developing field of minimally invasive surgery. Its wide diffusion has led to the development and standardization of robotic-assisted approaches also for adrenalectomy. In this study, we present the first five robotic-assisted lateral transabdominal adrenalectomies performed with the new Hugo RAS™ system (Medtronic, Minneapolis, MN, USA). After an official training course of the surgical team, five consecutive patients scheduled for unilateral adrenalectomy, underwent robotic-assisted operations in our institution. Patients that were candidates for partial adrenalectomy were excluded. A description of the operating theatre, robotic arms and docking setup is provided. Four female and one male patient underwent lateral transabdominal adrenalectomy, three for lesions on the left side and two on the right. Median lesion size was 3.9 cm (range: 30-90) and preoperative diagnosis was Cushing's syndrome in three patients, an adrenal cystic lesion and a pheochromocytoma. The median docking time was 5 min (range: 5-8) and the median console time was 55 min (range: 29-108). Procedures were performed without intraoperative complications and no conversions or additional ports were needed. System's function and docking were uneventful. Based on our initial experience, adrenalectomy with the Hugo™ system is feasible. This study provides technical notes for other centres that wish to perform robotic-assisted adrenalectomies with the Hugo™ RAS as well as general information and our preliminary insights on this new platform.

Comparison of the effectiveness and safety of robotic-assisted and laparoscopic in adrenalectomy: A systematic review and meta-analysis

OBJECTIVE

To compare the safety and effectiveness of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA).

METHODS

We performed a systematic review and cumulative meta-analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. Five databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, were systematically searched. The search timeframe was set from the creation of the database to December 2021.

RESULTS

There were 26 studies including 2985 patients. Our study found that the robotic technique was superior to conventional laparoscopy for estimated blood loss (WMD = -18.25, 95% CI [-27.85, -8.65], P < 0.01), length of stay (WMD = -0.45, 95% CI [-0.57, -0.33], P < 0.01), and conversion to open (OR = 0.31, 95% CI [0.12, 0.78], P = 0.01), while complications and readmissions were comparable. Interestingly, there was no difference in operative time between the two surgical modalities, but subgroup analysis found that the retroperitoneal route robotic technique took longer (WMD = 14.64, 95% CI [0.04, 29.24], P < 0.05), whereas the study of the mixed surgical modality (RA versus LA with mixed transabdominal and retroperitoneal surgical routes) found that the robot required less time (WMD = -12.29, 95% CI [-22.86, -1.72], P < 0.05). For pheochromocytoma, RA was superior to LA in terms of length of stay (WMD = -0.49, 95% CI [-0.83, -0.15], P < 0.01), with no difference in other indicators.

CONCLUSION

robotic-assisted adrenalectomy is a superior technique to conventional laparoscopy in managing adrenal tumors, even in the case of a specific adrenal tumor - pheochromocytoma.

Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry

BACKGROUND

Adrenalectomy is routinely performed via the minimally invasive approach. Safety of adrenalectomy using the robot-assisted technique has been widely demonstrated by several series, but the literature is scarce regarding the comparison of conventional laparoscopic versus robot-assisted approach. We decided to carry out a multicenter study to compare clinical and surgical outcomes between laparoscopic and robotic adrenalectomy.

METHODS

This is a retrospective case-control study, including data from centers affiliated to the Surgical Registry EUROCRINE. Patients undergoing laparoscopic surgery for adrenal tumors and registered between 2015 and 2018 were included. Robot-assisted versus laparoscopic adrenalectomy was compared. All comparisons were carried out in terms of complication rate, conversion rate and duration of stay.

RESULTS

A total of 1,005 patients from 46 clinics underwent robotic or conventional laparoscopic adrenalectomy. Median age was 55 (interquartile range: 45-65) years. Robotic adrenalectomy was performed in 189 (18.8%) patients. According to Clavien-Dindo classification, complication rate was lower in the robotic surgery group (1.6% vs 16.5%, P < .001). Laparoscopic surgery and active hormonal status were significantly correlated with complications, both in univariate and multivariate analysis. There was no significant difference between laparoscopic and robotic surgery groups, in terms of conversion rate (2.1% vs 0.5%, respectively, P = .147). Duration of stay was shorter in the robotic adrenalectomy group (82.1% vs 28.8%, P < .001).

CONCLUSION

Analysis of the EUROCRINE database supports that robotic adrenalectomy resulted in a lower complication rate and shorter duration of stay, compared with laparoscopic adrenalectomy. Granular data to support this is warranted.

Robotic Adrenalectomy Using the da Vinci SP Robotic System: Technical Feasibility Comparison with Single-Port Access Using the da Vinci Multi-arm Robotic System

BACKGROUND

Laparoscopic adrenalectomy is the gold standard for adrenal tumor; however, robotic adrenal surgery has gained interest recently. For minimally invasive surgeries, we first reported on robotic adrenalectomy using a single-port access performed using the da Vinci multi-arm robotic system (RA-SA) in 2011. Since its introduction in 2018, we first performed robotic adrenalectomy using the da Vinci SP robotic system in 2020.

OBJECTIVE

We aimed to introduce the novel single-port robotic system (RA-SP) for adrenalectomy and evaluate its technical feasibility by comparing it with the surgical outcomes of patients who underwent robotic adrenalectomy using the RA-SA.

METHODS

Eight patients who underwent robotic adrenalectomy using the RA-SP from February 2020 to June 2021 were compared with 11 patients who underwent RA-SA from 2011 to 2015 by a single surgeon.

RESULTS

The two groups were similar in age, sex, body mass index, type of operation, and final pathologic diagnosis. Despite no significant differences, RA-SP resulted in moderately less mean operation time, estimated blood loss, and length of hospitalization.

CONCLUSIONS

The Da Vinci SP robotic system is a novel, safe, and feasible technique to improve the convenience of operation and cosmetic effect for adrenalectomy.

A comparison of robotic and laparoscopic minimally invasive adrenalectomy for adrenal malignancies

BACKGROUND

Although guidelines recommend open adrenalectomy for most resectable adrenal malignancies, minimally invasive adrenalectomies are performed. Robotic adrenalectomies have become more popular recently, but there is a paucity of literature comparing laparoscopic and robotic resections.

METHODS

Patients who underwent a planned minimally invasive adrenalectomy for adrenal malignancies (adrenocortical carcinoma, malignant pheochromocytoma, other carcinoma) were identified in the National Cancer Database. The primary outcome was the conversion rate from minimally invasive to open. Other post-operative outcomes and survival were compared.

RESULTS

416 patients (76.5%) underwent a laparoscopic adrenalectomy and 128 (23.5%) underwent a robotic operation. Demographics and clinical characteristics were similar. Approximately 19% of tumors resected by a minimally invasive approach were > 10 cm. The intra-operative conversion rate was decreased among robotic adrenalectomies relative to laparoscopic on univariate (7.8% vs. 18.3%, p = 0.005) and multivariable (odds ratio 0.39, p = 0.01) analyses. Using marginal standardization, there was a stepwise increase in the conversion rate as tumor size increased (< 5, 5-10, > 10 cm) for laparoscopic (7.5%, 18.0%, 33.2%) and robotic (3.1%, 8.3%, 17.3%) adrenalectomies. Operations which required conversion had a greater margin positivity rate, greater length of stay, and an association with poor overall survival.

CONCLUSION

In contrast to most clinical guidelines, minimally invasive adrenalectomies are being performed on large malignant tumors. A laparoscopic approach was associated with a greater conversion rate and subsequent poor outcomes. If a surgeon is not planning an open adrenalectomy, but adrenal malignancy is a possibility, robotic adrenalectomy may be the preferred approach for resectable adrenal tumors.

Application of retroperitoneal laparoscopy and robotic surgery in complex adrenal tumors

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

Robotic Versus Laparoscopic Adrenalectomy: Pluriannual Experience in a High-Volume Center Evaluating Indications and Results

Background: Robotic adrenalectomy offers several clinical benefits if compared with laparoscopic adrenalectomy; however, its superiority is still under debate. The aim of this study was the investigation of differences between the two techniques, and a comparison when approaching right or left side adrenal lesions was further conducted. Materials and Methods: All patients undergoing laparoscopic and robotic unilateral adrenalectomy at our institution from January 2006 to December 2019 were collected and retrospectively analyzed. Statistical analysis was conducted; differences between the two cohorts were reported. Results: A total of 160 cases were included (84 patients in laparoscopic adrenalectomy-group [LA-g] 76 cases in robotic adrenalectomy-group [RA-g]). The groups were homogeneous for demographic data. No intraoperative complications were reported; mean amount of intraoperative blood loss was comparable. No cases of conversion to open surgery were required. RA-g presented a longer operative time than LA-g for right adrenalectomy (P = .05), no differences were noted for left side (P = .187). Overall morbidity was 21% for LA-g and 10.5% for RA-g (P = .087), with an inferior rate of surgical complications for RA-g (P = .024), and for robotic left adrenalectomy than robotic right procedure (P = .03). Length of hospital stay was shorter for RA-g (P = .005). Conclusions: Robotic adrenalectomy presents similar outcomes as laparoscopic approach with some benefits for selected cases. Left adrenal lesions seem to receive greater advantages from robotic technique. Large randomized controlled trials are required to determine the role of robotic adrenal surgery and if the indication can be standardized based on the laterality of adrenal procedure.

Splenic lymphoma with complex gastro-spleno-diaphragmatic fistula: 3D laparoscopic multivisceral resection. The first literature case report

INTRODUCTION

Gastrosplenic fistula is a rare disease involving stomach and spleen that can lead to dangerous complications like massive gastrointestinal bleeding. Diffuse large B-cell lymphoma (DLBC) is the principal pathological cause of gastrosplenic fistula.

CASE REPORT

We report a case of A 76-year-old caucasian woman came to the emergency room with fever for two week and gravative pain in left upper quadrant of the abdomen. CT scan of thorax and abdomen demonstrated an inhomogeneous hypodense large lymphomatous mass (10 × 6 cm) of upper pole of the spleen deformating medial profile and infiltrating gastric fundus and left diaphragm. with the diagnosis of complex gastro-splenic-diaphragmatic fistula we performed an en-block resection using a 3D laparoscopic vision system.

DISCUSSION

Gastrosplenic fistula is a rare complication of several clinical conditions. Among the different causes diffuse large B-cell lymphoma is the most frequent although diffuse histiocytic lymphoma, Hodgkin's lymphoma and extranodal NK/T-cell lymphoma are also described. After a literature review we found less then 30 cases of gastrosplenic fistula secondary to lymphoma. In our case report we do the first description of three-organs fistula envolvement, stomach, spleen and diaphragmatic dome, managed with 3D laparoscopic approach.

CONCLUSION

Gastrosplenic fistula can represent a fatal evolution of splenic or gastric lymphoma independently from chemotherapy treatment. The diagnosis of this condition is very difficult and related to its rarity. To our opinion, laparoscopy represents a valid and safe alternative to open surgery in management of these patients.

Robot-assisted adrenalectomy: state of the art

Currently, laparoscopic adrenalectomy is worldwide considered the gold standard technique. Both transperitoneal and retroperitoneal approaches have proved their efficacy with excellent outcomes. Since the introduction of da Vinci System (Intuitive Surgical, Sunnyvale, CA), robotic surgery has made many steps forward gaining progressively more diffusion in the field of general and endocrine surgery. The robotic technique offers advantages to overcome some laparoscopic shortcomings (rigid instruments, loss of 3D vision, unstable camera). Indeed, the robotic system is provided of stereoscopic 3D-magnified vision, additional degree of freedom, tremor-filtering technology and a stable camera. Recently, several case series have demonstrated the feasibility and the safety of robot-assisted adrenalectomy in high-volume centers with outcomes comparable to laparoscopic adrenalectomy. Notwithstanding, the technical advantages of the robotic system have not yet demonstrated significant improvements in terms of outcomes to undermine laparoscopic adrenalectomy. Moreover, robotic adrenalectomy harbor inherits drawbacks, such as longer operative time and elevated costs, that limit its use. In particular, the high cost associated with the use of the robotic system is primarily related to the purchase and the maintenance of the unit, the high instruments cost and the longer operative time. Notably, these aspects make robotic adrenalectomy up to 2.3 times more costly than laparoscopic adrenalectomy. This literature review summarizes the current available studies and provides an overview about the robotic scenario including applicability, technical details and surgical outcomes.

Robotic and Laparoscopic Approaches for Adrenal Surgery in Obese Patients

OBJECTIVE

Minimally invasive adrenalectomy is a challenging procedure in obese patients. Few recent studies have advocated against robot-assisted adrenalectomy, particularly in obese patients. This study aims to compare operative outcomes between the robotic and laparoscopic adrenalectomy, particularly in obese patients.

MATERIALS AND METHODS

A retrospective analysis was performed on all consecutive patients undergoing adrenalectomy for benign disease by a single surgeon using either a laparoscopic or robotic approach. Adrenal surgeries for adrenal cancer were excluded. Demographics, operative time, length of hospital stays, estimated blood loss (EBL), and intraoperative and postoperative complications were evaluated. Patients were divided into 2 groups; obese and nonobese. A sub-analysis was performed comparing robotic and laparoscopic approaches in obese and nonobese patients.

RESULTS

Out of 120, 55 (45.83%) were obese (body mass index ≥ 30 kg/m²). 14 (25.45%) of the obese patients underwent a laparoscopic approach, and 41 (74.55%) underwent a robotic approach. Operative times were longer in the obese vs. nonobese groups (173.30 ± 72.90 minutes and 148.20 ± 61.68 minutes, P = .04) and were associated with less EBL (53.77 ± 82.48 vs. 101.30 ± 122, P = .01). The robotic approach required a longer operative time when compared to the laparoscopic approach (187 ± 72.42 minutes vs. 126.60 ± 54.55 minutes, P = .0102) in the obese but was associated with less blood loss (29.02 ± 51.05 mL vs. 138.30 ± 112.20 mL, P < .01) and shorter hospital stay (1.73 ± 1.23 days vs. 3.17 ± 1.27 days, P < .001).

CONCLUSION

Robot-assisted adrenal surgery is safe in obese patients and appears to be longer; however, it provides improvements in postoperative outcomes, including EBL and shorter hospital stay.

Unusual giant chromophobe renal cancer totally managed with laparoscopic technique: Report of a case

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We describe a case report of giant renal cell chromophobe carcinoma totally treated by laparoscopic surgery.

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The size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

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A brief review of literature was performed to identify outcomes and potentially surgical advantages of laparoscopic approach for retroperitoenal liposarcoma.

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The possibility of the laparoscopic approach derives from from the preoperative identification of adipose cleavage, from the absence of invasion of major vascular axes, from the absence of distant metastatic lesions.

Introduction

Chromophobe carcinoma of the kidney is a rare pathological entity generally smaller and asymptomatic than other renal cell carcinomas and with a lower risk of metastatic disease. We describe a case of a giant renal chromophobe carcinoma successfully treated by laparoscopy.

Case report

A 37-years-old Caucasian man presented at physical examination a rigid elastic mass in right upper abdominal quadrant. CT abdominal scan revealed an enhancing well-defined heterogeneous large mass measuring 17 × 15 cm and originating from the upper pole of the right kidney, with necrotic and solid areas within the lesion. Considering the young age of the patient and the absence of local invasiveness, despite the large size of the lesion, we decided to perform a laparoscopic transperitoneal right nephrectomy. The morphological and immunophenotypic characteristics (CK7+, CD10+, CD117+) confirmed the diagnosis of chromophobe renal cell carcinoma.

Results

Chromophobe renal cell cancer is an unusual hystological entity. The pathological diagnosis of chromophobe tumor is based on atypia with nuclear irregularities, binucleation, and nucleolar prominence. In our case reports the pathological examination showed no tumor necrosis, mitosis or sarcomatoid differentiation and perirenal tissues were free from tumor infiltration with low risk of tumor progression after surgery.

Conclusion

Laparoscopic approach is today considered the standard treatment for localized renal cancer. Nevertheless, the size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

Laparoscopic near-total splenectomy. Report of a case

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We describe a case report of near total splenectomy managed by laparoscopy for a large lesion of the upper pole of the spleen.

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When total splenectomy is performed, an increased risk of potentially lethal infections arises. Asplenia and impaired splenic function are related to the increase of morbidity and mortality from infectious complications.

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The overwhelming post splenectomy infections (OPSI) are mostly represented by fulminating sepsis, meningitis or pneumonia.

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laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

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The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Introduction

Splenectomy is a surgical procedure indicated for the treatment of most benign and malignant splenic diseases, especially hematologic disorders. Laparoscopic approach is preferable to the open surgery for most indications because it reduces intra- and post-operative complications and shortens hospital stay. Laparoscopic approach is also feasible for partial splenectomy. Spleen-preserving techniques reduce the risk of severe infections and thromboembolic events that can occur after total splenectomy

Case presentation

We report a case of a 50-year old woman with an incidentally discovered voluminous lesion in the superior pole of spleen. A laparoscopic near-total splenectomy was performed.

Discussion

The evidence about the potential complications in splenectomised patients speaks in favour of performing spleen-sparing surgical techniques whenever possible. Most common indications for laparoscopic partial splenectomy are non-parasitic splenic cystic, benign splenic tumors, splenic haematological diseases, non-cystic intraparenchymal lesions, spleen rupture, splenic abscess, vascular abnormalities. Laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

Conclusion

LNTS seems to be a safe and effective technique for the management of benign spleen diseases. The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Laparoscopic treatment of mesenteric avulsion and intestinal perforation after blunt abdominal trauma: A report of a case

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Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen.

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The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

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We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion treated with laparoscopic approach.

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Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment.

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The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Introduction

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen. The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

Case report

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion. Since the patient was hemodynamically stable, a laparoscopic approach was carried on.

Discussion

Blunt abdominal trauma are responsible of 6–14.9% of all traumatic injuries (Galia et al., 2017). The frequency of small bowel lesions ranges from 5% to 15%, while small bowel mesenteric injuries are approximately found in 5% of patients after blunt abdominal trauma. There are different biomechanical reasons explaining how a blunt trauma can cause damages to small bowel and its mesentery. Clinical diagnosis of small bowel perforation after blunt abdominal trauma is often challenging for non-specific objective clinical signs and because peritoneal irritation symptoms are present only in collaborative patients.

Conclusion

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment. The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Duodenal perforation as presentation of gastric neuroendocrine tumour: A case report

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Gastric neuroendocrine neoplasms (g-NENs) represent the most frequent digestive NENs and are increasingly recognized thanks to diffusion of upper gastrointestinal endoscopy.

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g-NENs can be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present with a functional Zollinger-Ellison syndrome.

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We described a case of a 60 years old Caucasian male came to emergency room with diffuse abdominal pain and leukocytosis on blood tests.

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At the level of the pyloric portion we found irregularly thickened walls associated with a small fluid collection and bubbles of free air. On exploratory laparoscopy we found a large perforation (about 5 cm of size) in the first duodenum portion.

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Histological examination revealed a gastric NET perforation as a consequence of hypergastrinemia secondary to gastrinoma.

Introduction

Neuroendocrine tumors (NETs) represent uncommon neoplasms with different characteristics. They can be asymptomatic and benign or they can also proliferate and manifest themselves with neoplastic mass symptoms such as intestinal occlusion or with carcinoid syndrome. Gastric neuroendocrine neoplasms (g-NENs) are the most frequent digestive NENs while duodenal neuroendocrine neoplasms (d-NENs) may be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present a functional syndrome (e.g. gastrinoma with Zollinger-Ellison syndrome).

Presentation of case

We report a case of duodenal perforation due to a unknown gastrinoma responsible of Zollinger-Ellison Syndrome. He underwent an emergency contrast enhanced CT abdominal scan that showed a perforation. We performed a distal gastrectomy. The histopathological examination revealed a g-NET configuring a possible picture of Zollinger-Ellison Syndrome.

Discussion

The management of NETs is diffulcult and controversial because of their rarity. It is useful to know the pathologic assessment of tumor differentiation and/or grade, evaluate surgical resectability and control the carcinoid syndrome symptoms.

Conclusion

This case report shows that gastric NETs can be found in cases of duodenal perforation. Our future goal is to evaluate the possibilities to diagnose the Zollinger Ellison Syndrome as early as possible and to treat it with targeted therapy in order to prevent its related complications.

The colovescical fistula in diverticular disease: Laparoscopic approach in two different cases

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The colovescical fistula is one of the complications of diverticular disease.

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It can cause typical symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis.

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We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease.

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We performed a totally laparoscopic treatment with colonic resection and closure of the fistula with intracorporeal sutures.

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The presence of a colovescical fistula significantly increases the difficult of the laparoscopic colonic resection.

Introduction

The colovescical fistula is one of the complications of diverticular disease. It can cause significant symptoms like pneumaturia and fecaluria affecting the quality of life and sometimes leading to death, usually secondary to sepsis. We describe two cases of colovescical fistula treated by laparoscopic approach in patients with diagnosis of complicated acute diverticulitis.

Case report

We studied two patients with clinical, radiological and endoscopic diagnosis of colovescical fistula as a consequence of diverticular disease. We performed a totally laparoscopic treatment with colonic resection and colo-proctoanastomosis after the closure of the fistula with intracorporeal sutures.

Discussion

Colovescical fistula should be suspected in patients who present fever with persistent dysuria, pneumaturia or fecaluria. The diagnosis is confirmed by a CT abdominal scan, a colonoscopy in order to rule out a colon cancer and a cystoscopy to assess the grade of bladder involvement.

Conclusion

Although colovescical fistulas caused by diverticular disease were once considered a contraindication to laparoscopic resection, nowadays they are increasingly treated by experienced surgeons using laparoscopic techniques. Compared with laparoscopic surgery for uncomplicated diverticulitis the mini-invasive treatment of colovescical fistulas requires a longer operative time and advanced surgical skills.

Successful laparoscopic management of congenital diaphragmatic relaxation: A case report

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We describe a case report of congenital Diaphragmatic relaxation treated with totally laparoscopic plication of the left hemidiaphragm with nonresorbable sutures.

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In our case report the diaphragmatic relaxation seemed to be congenital and the laparoscopic approach resulted the most appropriate technique to obtain the repositioning of abdominal organs and diaphragmatic placation.

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A brief review of literature was performed to identify outcomes and potentially surgical advantages of laparoscopic approach for diaphragmatic relaxation. Laparoscopic approach can only be practiced in selected cases.

Introduction

Diaphragmatic relaxation is an infrequent condition characterized by a permanent elevation of all or part of an hemidiaphragm which maintains its insertions on the ribs and which does not have continuous solutions but a reduced thickness.

Presentation of case

We studied a 65 years old male patient with mild dyspnea and chest pain occurred during the last 12 months after moderate efforts. He underwent a contrast enhanced CT thorax scan that showed a left diaphragmatic relaxation with the transposition in the cranial sense of the hypochondriac abdominal organs associate with an ipsilateral subtotal atelectasia. A laparoscopic plication of the diaphragm was performed to repair the congenital defect.

Discussion

The relaxatio diaphragmatica is probably caused by a congenital defect, but there are also idiopathic causes or cases of acquired relaxation due to phrenic nerve damage because of neoformations, traumas, thoracic and cardiac surgery. In cases of asymptomatic relaxatio nothing is necessary, but in symptomatic cases it is possible the plication of the diaphragm with a remission of symptoms.

Conclusion

The plication can be performed through thoracotomy or laparotomy and recently also in thoracoscopy or laparoscopy. In our experience the laparoscopic repair of the relaxatio was accomplished successfully with a left pneumothorax compatible with the intervention, but the operative strategy should be always individualized with attention on diagnosis, patient characteristics, availability of resources and experience of surgical team.

Small bowel obstruction after caesarean section: Laparoscopic management. Two case reports

Introduction

Caesarean section is the most common abdominal surgery performed on women worldwide. Adhesions represent a severe complication of cesarean section and can cause different degrees of bowel obstruction.

Case reports

We report two unusual cases of small bowel obstruction treated with laparoscopic approach after caesarean section performed for gynecological pathologies. In the first one small bowel obstruction was due to volvulus caused by a severe pelvic adhesion syndrome; in the second one, occlusive picture was related to presence of multiple adhesion phenomena between the sigmoid colon and the right ovary as result of abdominal hysterectomy.

Discussion

The incidence of small bowel obstruction after caesarean section is very low and postoperative adhesions represent the main cause. Diagnosis was established by clinical signs, radiological and intraoperative findings. Laparoscopic approach can be the treatment of choice only in selected patients. In presence of dense adhesions, inability to visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and technical difficulties, conversion to open surgery is mandatory.

Conclusion

In selected patients with small bowel obstruction laparoscopy is a safe and feasible procedure if conservative measures fail.

Ureteral injury during left colectomy for cancer: Laparoscopic management. A case report

INTRODUCTION

Iatrogenic ureteral lesions may occur after any abdominal and pelvic surgery. They are severe and can affect renal function and even vital prognosis. This study aimed to determine the clinical aspects and the therapeutic approaches of a lower third injury of the ureter during a laparoscopic left colectomy.

PRESENTATION OF CASE

An 81 year-old-man with left-sided colon cancer underwent laparoscopic left colectomy. During surgery there was a continuous full-thickness solution of the left ureter for which an end-to-end ureteral anastomosis was performed. In the postoperative period the patient underwent multiple urological and radiological interventional procedures due to the aforementioned injury.

DISCUSSION

Ureteral injury was defined as any laceration, transection or ligation of the ureter that required an unexpected procedure for repair, stent or drainage. It can be managed with several procedures. An appropriate repair should be chosen according to length and position of ureteral injuries. The lower third of the ureter, as the lesion of our patient, has a profuse blood supply resulting in this way less susceptible to ischemia.

CONCLUSION

In the last decade urological surgery, laparoscopy, ureteroscopic procedures and gynecological surgery are the main causes of iatrogenic ureteral lesions. Prognosis is conditioned by early diagnosis and the anatomic condition of the ureter. Laparoscopic end-to-end ureteral anastomosis could be considered a good option in the case of intraoperative iatrogenic lower ureteral injuries.

Three-dimensional (3D) system versus two-dimensional (2D) system for laparoscopic resection of adrenal tumors: a case-control study

PURPOSE

Laparoscopy is the standard technique for resecting adrenal tumors worldwide. The main drawbacks of conventional 2D laparoscopy are limited depth perception and tactile feedback. Currently available high-quality 3D laparoscopy systems might improve surgical outcomes for adrenalectomy. We compare the safety and efficacy of 3D versus 2D laparoscopy in the treatment of adrenal tumors.

METHODS

This case-control study analyzed prospectively collected data from patients with benign or malignant adrenal tumors treated laparoscopically at a single academic medical center between April 2003 and March 2020. We collected demographic, diagnostic, preoperative, and operative variables, and used multiple linear and logistic regression to analyze differences in various short-term outcomes between the two approaches while adjusting for potential confounders.

RESULTS

We included 150 patients: 128 with benign tumors and 22 with malignant tumors; 95 treated with 3D laparoscopy (case group); and 55 with 2D laparoscopy (control group). After adjustment for patient, surgical, and tumor characteristics, a 2D vision was associated with a longer operative time (β = 0.26, p = 0.002) and greater blood loss (β = 0.20, p = 0.047). There was no significant difference in rates of conversion to open surgery (odds ratio [OR] = 1.47 (95% CI 0.90-22.31); p = 0.549) or complications (3.6% vs. 2.1%; p = 0.624).

CONCLUSIONS

With experienced surgeons, laparoscopic adrenalectomy was safer and more feasible with the 3D system than with the 2D system, resulting in less operative blood loss and shorter operative time with no differences in rates of conversion to open surgery or postoperative complications. For adrenal tumors, 3D laparoscopy offers advantages over 2D laparoscopy.

Robotic transperitoneal adrenalectomy from inception to ingenuity: the perspective on two high volume endocrine surgery centers

Background

With increased utilization of robotic technology, robotic adrenalectomy (RA) became popular in certain high-volume centers as an alternative to conventional laparoscopic adrenalectomy (LA). The aim of the present study was to evaluate clinical and surgical outcomes of RA in two high-volume centers in Turkey.

Methods

Between 2012 and 2019, consecutive patients who underwent robotic transperitoneal adrenalectomy in two referral centers for surgical endocrine diseases in Turkey were analyzed retrospectively.

Results

A total of 111 patients were analyzed. Mean diameter of the tumor in preoperative imaging was 38.6±2.0 mm. Total operation time was 135.4±47.9 min. The analysis of the learning curve period and the post-learning curve period in both centers demonstrated that the total surgery time decreased from 152.68±48.6 to 118.8±37.1 min, and the console time decreased from 113.2±38.9 to 81.6±35.1 min (P<0.0001). In 8 patients, complications arose during the surgery and postoperative complications were observed in 10 patients. Intraoperative complication rate was 28% in patients with a tumor diameter of greater than 50 mm (P<0.0001). There was no mortality.

Conclusions

Our study demonstrated that RA is a safe and effective procedure with low-morbidity and without mortality in high number of cases.

Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma

BACKGROUND

Robotic adrenalectomy for pheochromocytoma is increasingly popular because of the advantage that have been proved by some researchers recently. However, prospective randomized clinical trials comparing robotic assisted laparoscopic adrenalectomy (RA) with traditional laparoscopic adrenalectomy (LA) for pheochromocytoma are rare. The aim of this study is to compare perioperative outcomes of RA versus LA for pheochromocytoma prospectively.

METHODS

From March 2016 to April 2019, all patients with pheochromocytoma suitable for laparoscopic adrenalectomy were assigned randomly to RA or LA. The primary endpoint was the operative (exclude docking time) time. Secondary endpoints were estimated blood loss and postoperative recovery. Demographics and perioperative data were prospectively collected.

RESULTS

A total of 140 (RA 70, LA 70) patients were enrolled in this prospective research. The following significant differences were identified in favor of RA: shorter median operative (exclude docking time) time (92.5 vs 122.5 min, P = 0.007), however, RA group has higher total hospitalization cost (8869.9 vs 4721.8 $, P < 0.001). Demographics and other perioperative outcomes were similar in both groups. The RA group showed a significant lower blood loss and operative (exclude docking time) time compared with LA group (P < 0.05) for patients with high Nor-Metanephrine (NMN).

CONCLUSIONS

Both RA and LA for pheochromocytoma are safe and effective. Patients with high NMN can benefit from less blood loss and operative time when a robotic surgery system was used, but RA has a significant higher cost.

[Surgery of adrenal diseases]

Incidentally discovered adrenal alterations should be separated into those without any clinical importance and adrenal diseases that have to be surgically or conservatively treated. Before operative treatment, in addition to the possible different functional activity of tumors, a differentiation must be made between sporadically arising singular or multiple adrenal tumors or nodular adrenal hyperplasia, adrenal tumors as part of a familial syndrome and metastases of other primary malignant tumors into the adrenal glands. Benign hormonally active adrenal tumors as well as questionable malignant tumors of the adrenal cortex are resected by minimally invasive techniques. For large malignant tumors infiltrating into surrounding tissues and tumors with proven lymph node metastases, the primarily open approach is indicated. Patients with adrenal diseases should always undergo an interdisciplinary assessment and in cases with clear indications for surgery, sometimes transferred to a center with experience in surgery and postoperative management of these patients.

Risk factors for complications after robotic adrenalectomy: a review

The application of adrenal surgery has been spreading steadily in recent years. With the increased use of robotics in surgery, robotic adrenalectomy (RA), especially for the posterior retroperitoneoscopic approach, has been taken on by many high-volume institutions as a good option over the standard laparoscopic approach (LA). This paper reviews the recent literature from May 2010 up to November 2019 with the aim of analyzing RA complications in order to identify risk factors for complications after RA. We analyzed 7 principal risk factors for complication: body mass index (BMI), age, tumor size, tumor side, pathology, previous surgery, and surgeon experience. In the review, some studies identified tumor size, malignancy type, completion of learning curve and, and less clearly, previous ipsilateral upper mesocolic or retroperitoneal surgery, as risk factors for postoperative complications and failure of robotic surgery. Whether RA is meaningfully superior to the standard minimally invasive approach is still a subject of discussion. RA appears safer by virtue of its reduction in hospital stay, lower blood loss, and equivalent complication rates, and surgeons should prefer adrenalectomy over the LA. Despite these advantages, the operative time and the overall cost of the robotic procedure are higher than the LA. Further high-quality trials, especially those analyzing the specific risk factors for complications in robotic surgery, should be conducted in order to optimize the stratification of patients eligible for robotic surgery.

Robotic adrenalectomy: evaluation of cost-effectiveness

Laparoscopic adrenalectomy (LA) is the preferred treatment option for adrenal lesions, considering the improved patients outcomes, due to the reduced postoperative morbidity and postoperative pain, the faster recovery and the shorter length of hospital stay. The widespread diffusion of robotic technology led to the development and standardization of robot-assisted approach to adrenalectomy. However, to date, no clear benefit from the use of the robot-assisted approach has been found. The higher costs remain an important drawback and limit the implementation of robot-assisted adrenalectomy (RA) programs. This review summarizes the current available data regarding RA including its operative outcomes, advantages and drawbacks in comparison with conventional LA, evaluating its cost-effectiveness.

Comparing the efficacy and safety of laparoscopic and robotic adrenalectomy: a meta-analysis and trial sequential analysis

PURPOSE

A systematic literature review and a meta-analysis were designed and conducted, in order to provide an up-to-date comparison of the robotic (RA) and laparoscopic (LA) adrenalectomy in terms of perioperative efficacy and safety.

METHODS

The present meta-analysis was completed in accordance with the guidelines provided by the PRISMA study group and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic scholar databases (Medline, Web of Science, Scopus) were screened. For the reduction of type I errors, a trial sequential analysis (TSA) was performed.

RESULTS

Overall, 21 studies and 2997 patients were included in this study. RA was associated with a significantly lower open conversion rate (OR: 1.79; 95%CI: 1.10, 2.92) and length of hospitalization (LOS WMD: 0.52; 95%CI: 0.2, 0.84). Marginal results regarding blood loss were recorded (WMD: 2.02; 95%CI: 0.0, 4.03). TSA could not validate the superiority of RA in open conversion rate and blood loss. LA and RA were similar in terms of operative duration (P = 0.18) and positive margin (P = 0.81), complications (P = 0.94) and mortality rate (P = 0.45).

CONCLUSIONS

Even though RA and LA were equivalent regarding perioperative safety, RA was associated with a favorable LOS.

Systematic review of learning curves in robot-assisted surgery

Background

Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery.

Methods

MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients.

Results

Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology.

Conclusion

Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.

Volume-outcome correlation in adrenal surgery-an ESES consensus statement

BACKGROUND

Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year.

PURPOSE

This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement.

RESULTS

The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres.

CONCLUSION

The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.

Robotic adrenalectomy

With the recent advances in equipment and surgical techniques, robot-assisted surgery has become accepted and efficient in the surgical field. It is an emerging technology that can safely be applied for a broad spectrum of surgical procedures. As a result of increased ergonomics, three-dimensional view of the operative area and improved moving capacity of the robotic arms with multi-articulation, robotic technology also has found place in adrenal surgery. Recently, robot-assisted adrenal surgery has been adopted widely in many high-volume tertiary centers. Although there are expected theoretical benefits to this approach, the literature is lacking regarding high level evidence. In this review, we will discuss implementation of robotic adrenalectomy as well as perioperative and postoperative measures that helped improved outcomes, offer a comparison of outcomes between conventional laparoscopic adrenalectomy and robotic adrenalectomy and summarize recent developments that may offer evidence for or against a paradigm shift in this specific field of endocrine surgery.

Primary Adrenal Squamous Cell Carcinoma in a Single Kidney Patient: Case Report and Review of Literature

The adrenal gland is a common metastatic site of squamous cell carcinoma (SCC), however primary adrenal SCC has not been reported in literature. In this case report, we presented the first case of primary adrenal SCC. A 53-year-old man presented with chronic right flank pain. Abdominopelvic computed tomography (CT) confirmed left kidney agenesis and a soft tissue density mass measuring about 40×30 mm in the right adrenal gland. Adrenal functional assessment including metanephrine, normetanephrine and vanillyl mandelic acid were normal. The patient underwent surgical resection of right adrenal mass. Pathology report revealed adrenal SCC. Immunohistochemistry evaluation demonstrated positive staining for P63, CK, CD10, CK7, chromogranin, neuron specific enolase, and negative staining for alpha-inhibin, neurofilament, CK20, and tyrosine hydroxylase that were compatible with SCC. All other assessments to find primary site of SCC including upper and lower gastro-intestinal endoscopy, chest CT scan, positron emission tomography scan, and bronchoscopy demonstrated normal findings. To our knowledge, this is the first case of primary adrenal SCC without any evidence of metastatic nature of such adrenal involvement by SCC.

Systemic schistosomiasis and large bowel perforation: An unexpected surgical urgency. Report of a case and literature review

In the presence of suggestive clinical picture (high eosinophil count and multiple CT scan granuloma-like lesions), schistosomiasis should be taken into account in case of suspected bowel perforation even if common risk factors are not identified through anamnesis.

Laparoscopic adrenalectomy: preoperative data, surgical technique and clinical outcomes

Background

laparoscopic adrenalectomy has become the standard treatment for adrenal lesions. The better clinical outcoms of laparoscopic technique are valid for treatment of small benign masses (< 5–6 cm), instead there are still open questions in literature regarding the correct management of larger lesions (> 6 cm) or in case of potentially malignant adrenal tumors. The aim of this study is to evaluate the outcomes of laparoscopic adrenalectomy in a referral surgical department for endocrine surgery.

Methods

at the University Hospital Policlinico “P. Giaccone” of Palermo between January 2010 and December 2017 we performed a total of 81 laparoscopic adrenalectomy. We created a retrospective database with analysis of patients data, morphologic and hormonal characteristics of adrenal lesions, surgical procedures and postoperative results with histological diagnosis and complications.

Results

Mean size of adrenal neoplasm was 7,5 cm (range 1.5 to 18 cm). The mean operative time was 145 min (range 75–240). In statistical analysis lenght of surgery was correlated to the lesion diameter (p < 0.05) but not with pre-operative features or histological results. 5 intraoperative complications occurred. Among these patients 4 presented bleeding and 1 a diaphagmatic lesion. No conversion to open surgery was necessary and no intraoperative blood transfusion were required. Mean estimated blood loss was 95 ml (range 50–350). There was no capsular disruption during adrenal dissection. Mean length of hospital stay was 3.7 days (range 3–6 days).

Conclusions

Laparoscopic adrenalectomy is a safe procedure with low rate of morbidity. An accurate preoperative radiological examination is fundamental to obtain a stringent patients selection. The lesion diameter is related to longer operative time and appeares as the main predictive parameter of intraoperative complications but these results are not statistically significant. On the other side secreting adrenal tumors require more attention in operative management without increased rate of postoperative complications.

Dedifferentiated retroperitoneal large liposarcoma and laparoscopic treatment: Is it possible and safe? The first literature case report

INTRODUCTION

Soft tissue sarcomas are rare neoplasms often characterized by local invasiveness and distant metastasis with poor prognosis for affected patients. Among the most frequent sarcomas we find well-differentiated and dedifferentiated liposarcomas characterized by a better survival compared to the other histological types. When it is possible the only curative treatment for these neoplasms is surgical resection.

CASE REPORT

We report a case of a 62-year-old caucasian woman with CT abdominal scan that demonstrated a voluminous solid oval mass in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. We performed a laparoscopic surgical resection of the retroperitoneal mass in block with kidney and left adrenal gland.

DISCUSSION

When possible, surgical resection with adequate margins represents the only curative therapeutic option for this pathology. Only a few papers are available in literature which take into consideration the possibility of laparoscopic approach for retroperitoneal masses with better vision of surgical field, reduction of post-operative pain and better cosmesis.

CONCLUSION

A retroperitoneal mass represents a serious diagnostic challenge. The choice of the best surgical procedure can benefit to the patient prognosis. To our opinion laparoscopy can be a safe and successful treatment and it can represent a valid alternative to open surgery. However, we have no randomized controlled trials that compare laparoscopic versus open resection for retroperitoneal liposarcomas.

A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy

Background

Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO₂ insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy.

Methods

A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates.

Results

Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy.

Conclusions

While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.

Imaging features of adrenal masses

The widespread use of imaging examinations has increased the detection of incidental adrenal lesions, which are mostly benign and non-functioning adenomas. The differentiation of a benign from a malignant adrenal mass can be crucial especially in oncology patients since it would greatly affect treatment and prognosis. In this setting, imaging plays a key role in the detection and characterization of adrenal lesions, with several imaging tools which can be employed by radiologists. A thorough knowledge of the imaging features of adrenal masses is essential to better characterize these lesions, avoiding a misinterpretation of imaging findings, which frequently overlap between benign and malignant conditions, thus helping clinicians and surgeons in the management of patients. The purpose of this paper is to provide an overview of the main imaging features of adrenal masses and tumor-like conditions recalling the strengths and weaknesses of imaging modalities commonly used in adrenal imaging.