Trans- and retroperitoneal endoscopic adrenalectomy: experience in 26 consecutive adrenalectomies

OBJECTIVE: To assess our current concept and results of transperitoneal laparoscopic adrenalectomy (TPLA) and retroperitoneal endoscopic adrenalectomy (ERA) for a variety of benign disorders of the adrenal glands. BACKGROUND DATA: According to the literature, minimal invasive adrenalectomy has shown to be a safe and effective surgical alternative to open adrenalectomy. Both, transperitoneal and retroperitoneal endoscopic minimal invasive access are currently used for surgical removal of benign adrenal tumors. There is still some debate about the indications and the access used for a minimal invasive approach. PATIENTS AND METHODS: Treatment and clinical outcome of all patients who underwent either transperitoneal laparoscopic or endoscopic retroperitoneal adrenalectomies for benign diseases from February 1997 to August 2002 were analyzed retrospectively. RESULTS: Twenty-six minimal invasive adrenalectomies were performed in 23 patients with a mean age of 57 years. Whereas 11 patients underwent unilateral right- sided ERA, unilateral TPLA was performed in 9 patients on the left side. Three patients had bilateral TPLA. The mean operating time for unilateral ERA and TPLA was 114 and 79 min, respectively. Bilateral TPLA was prolonged to 223 min operating time. There were only two minor postoperative complications. The mean hospital stay for unilateral TPLA, ERA and bilateral TPLA was 4.7, 5 and 6 days, respectively. There was no mortality. CONCLUSION: Both, ERA and TPLA are safe and clinically effective treatment modalities for benign disorders of the adrenal glands. We currently favor a transperitoneal laparoscopic approach for bilateral and left-sided adrenal tumors, whereas right-sided tumors <8 cm are removed by a retroperitoneal approach. Large right-sided tumors >8 cm are better removed by transperitoneal access.     

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients

Background

Aim was to evaluate the results in 62 patients undergoing laparoscopic adrenalectomy (LA) for the treatment of pheochromocytoma (PHE), with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left-sided lesions.

Methods

Sixty-two patients underwent LA for the treatment of PHE at two centers in Rome and Ancona (Italy). Two patients had bilateral lesions, for a total of 64 adrenalectomies. Sporadic PHE occurred in 57 patients (91.9 %) and in 5 (8.0 %) it was familiar. Thirty-six patients (58.0 %) underwent right adrenalectomy, 24 (38.7 %) left adrenalectomy, and in 2 cases (3.2 %) LA was bilateral. In 38 cases of right adrenalectomy (59.3 %) and in 5 cases of left adrenalectomy (7.8 %), the approach was a transperitoneal anterior one. A transperitoneal anterior submesocolic approach was used in 21 left adrenalectomy cases (32.8 %).

Results

Mean operative time for right and left transperitoneal anterior LA was 101 min (range 50–240) and 163 min (range 50–190), respectively. Mean operative time for left transperitoneal anterior submesocolic LA was 92 min (range 50–195). For bilateral adrenalectomy, mean operative time was 210 min (range 200–220). Conversion to open surgery occurred in 2 cases (3.22 %) due to extensive adhesions (1) and hemorrhage (1). One major and three minor complications were observed. Mobilization occurred on the first postoperative day. Hospitalization was 4.8 days (range 2–19). The lesions had a mean diameter of 4.5 cm (range 0.5–10).

Conclusions

Early identification with no gland manipulation prior to closure of the adrenal vein is the main advantages of the transperitoneal anterior approach. PHE may be treated safely and effectively by a laparoscopic transperitoneal anterior approach for right-sided lesions and with a transperitoneal anterior submesocolic approach for left-sided ones.     

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

Background The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route. Methods 204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19–75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic). Results Mean operative time was 80 minutes for right (40–150), 109 minutes for left (64–300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5–12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1–8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing’s adenoma 58, Conn’s adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1. Conclusions LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.     

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm?

Background Laparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm. Patients and methods 18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm. Results The mean tumor size was 8.3 cm (range 7–13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100–550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery. Conclusions LA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.     

Laparoscopic ultrasound imaging of adrenal tumors during laparoscopic adrenalectomy

BACKGROUND: The purpose of this study was to determine the usefulness of laparoscopic ultrasound (LUS) during laparoscopic adrenalectomy (LA) and to define the ultrasound imaging characteristics of various adrenal tumors. METHODS: LUS was utilized in 27 patients who underwent LA (including one bilateral adrenalectomy) from May 1994 to October 1998. Tumor size ranged from 1.0 to 5.5 cm (mean 3.3 cm), and a transabdominal lateral approach to LA was used. RESULTS: LUS localized the adrenal gland and tumor in all 28 adrenalectomies and demonstrated the relationship of the tumor to the kidney and adjacent vascular structures (renal artery/vein and inferior vena cava). The adrenal vein was visualized sonographically in only six cases (21 %). Pheochromocytomas were mild to markedly heterogenous, whereas most aldosteronomas and cortical adenomas were homogenous. LUS provided useful information to the surgeon in 11 of 28 cases (39%) by: 1) localizing the adrenal gland and tumor and/or guiding the dissection; 2) demonstrating that tumors > or =4 cm were confined to the adrenal gland; and 3) investigating suspected pathology in other organs. Mean operating time for LUS was 10.9 min (range 5 to 24 min) and calculated hospital charges were $602. CONCLUSIONS: LUS accurately localizes adrenal tumors, helps define their relationship to adjacent structures, and provides confirmation that larger tumors are amenable to laparoscopic resection. LUS is a useful adjunct to laparoscopic adrenalectomy in selected patients.     

Laparoscopic adrenalectomy: the New York-Presbyterian Hospital experience

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland. The advantages of the laparoscopic approach include shorter length of stay (LOS), a decrease in postoperative pain, faster return to preoperative activity level, improved cosmesis, and reduced complications. We report our experience with laparoscopic adrenalectomy via a lateral transperitoneal approach. PATIENTS AND METHODS: Between September 1993 and April 2001, we performed 100 lateral transperitoneal adrenalectomies in 91 patients. In 82 cases, the adrenalectomy was unilateral and in the other 9, it was bilateral. A total of 59 left-sided lesions and 41 right-sided lesions were removed. The indications for surgery were Cushing's syndrome (24), aldosteronoma (34), pheochromocytoma (17), nonfunctioning adenoma (13), Carney's syndrome (1), and a metastasis from colon cancer (1) RESULTS: The overall success rate was 98%. Complications occurred in the two patients who required open conversion. In addition, three patients suffered pneumothoraces because of direct iatrogenic injury to the diaphragm during laparoscopic dissection. One additional patient suffered a splenic laceration. Operative time, blood loss, and intraoperative complications were similar in the laparoscopic and open surgery control group (N = 32). CONCLUSIONS: Laparoscopic adrenalectomy is technically feasible and reproducible. The lateral transperitoneal technique offers distinct advantages to the laparoscopist, including better visibility of familiar anatomic landmarks, easy access to other organ systems, the use of gravity to retract the spleen and liver, and a wide exposure, which allows removal of large adrenal lesions.     

Laparoscopic adrenalectomy

BACKGROUND: Laparoscopic adrenalectomy is a good option for removal of the adrenal gland that is becoming preferred over the conventional open technique. METHODS: We reviewed the initial 30 laparoscopic adrenalectomies (in 27 patients) that were performed at our institution from 1995 to 1998. We used the lateral decubitus transperitoneal approach in 26 cases and the retroperitoneal approach in only one case. The indications for adrenalectomy were Conn's adenoma in eight patients, pheochromocytoma in six, Cushing's syndrome in five, nonfunctional adenomas in seven, and metastasis in one case. RESULTS: Only two patients (7%) were converted to laparotomy. Operating time ranged from 75 to 240 min. Average adrenal gland size was 6.1 cm (range, 4-9 cm). There was no mortality, and morbidity occurred in only two patients (8%)-one case of self-limited gastrointestinal bleeding and one case of hypercapnia and subcutaneous emphysema (in the only patient operated by the retroperitonal approach). Mean hospital stay was 3 days (range, 1-6). CONCLUSIONS: Laparoscopic adrenalectomy is a safe and useful procedure for nearly all adrenal pathologies. Lateral decubitus transperitoneal approach is the procedure of choice in most cases.     

Laparoscopic resection of large adrenal tumors

Background The maximum size of adrenal tumors that should be removed with a laparoscopic approach is controversial. It has been suggested that laparoscopic adrenalectomy is appropriate only for adrenal tumors <6 cm in size. We report our experience with laparoscopic adrenalectomy in patients with adrenal tumors of ≥6 cm compared with patients with smaller tumors. Methods We retrospectively reviewed a consecutive series of patients who had a laparoscopic adrenalectomy. Patients were considered candidates for laparoscopic adrenalectomy if their computed tomography (CT) scan showed a well-encapsulated tumor confined to the adrenal gland. Results Sixty laparoscopic adrenalectomies were performed in 53 patients. Twelve of the adrenalectomies (20%) were for tumors that were ≥6 cm (median, 8 cm; range, 6 to 12 cm). There have been no local or regional recurrences but one patient with adrenocortical carcinoma developed pulmonary metastases. When the 12 patients with large tumors were compared with the 36 patients with tumors <6 cm, the median operative time (190 vs. 180 minutes;P=.32), operative blood loss (100 vs. 50 mL;P=.53), and postoperative hospital stay (2 vs. 2 days;P=1.0) were similar. Conclusions The size of an adrenal tumor should not be the primary factor in determining whether a laparoscopic adrenalectomy should be performed. Large adrenal tumors that are confined to the adrenal gland on CT can be removed with a laparoscopic approach.     

Eight-year experience with transperitoneal laparoscopic adrenal surgery

PURPOSE: Laparoscopic adrenalectomy is currently the technique of choice for removing benign adrenal lesions. Various laparoscopic techniques and approaches have been reported using the transperitoneal or retroperitoneal approach. We present our 8-year experience with and long-term results of transperitoneal laparoscopic adrenalectomy. MATERIALS AND METHODS: Between October 1992 and October 2000, 161 laparoscopic approaches to the adrenal gland were performed, including 145 unilateral and 10 bilateral adrenalectomies, and 6 conservative operations. Patients were placed in the 60-degree flank position with the bed flexed to increase the surgical field. To avoid hypertensive crisis, especially in patients with pheochromocytoma, the first step involved early ligation of the adrenal vein. RESULTS: The laparoscopic procedure was successfully completed in all except 4 cases, which were converted to open surgery. Mean operative time was 160 minutes in the unilateral, 245 in the bilateral and 90 in the conservative group. Delayed complications included hemoperitoneum in 3 patients, which was drained surgically, severe blood loss in 3 treated with blood transfusion and wound infection in 2. Patients were ambulatory on the morning of postoperative day 1 and were discharged home 2.8, 5 and 1.8 days after unilateral, bilateral and conservative surgery, respectively. CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe, effective, minimally invasive approach in patients with benign functioning or nonfunctioning adrenal masses. This technique involves low morbidity, minimal postoperative analgesic requirements and a short hospital stay.     

Laparoscopic adrenalectomies: A nationwide single-surgeon experience

Background Laparoscopic adrenalectomy (LA) was first performed in Iceland in 1997. Since then, all procedures for presumed benign lesions of the adrenals have been performed laparoscopically in a single center. Compared with conventional adrenalectomy, LA appears to achieve superior results in terms of recovery, hospital stay, and morbidity. This study aimed to evaluate the results of LA in Iceland. Methods The hospital records of all patients who underwent LA in Iceland from 1997 through 2005 were reviewed. The preoperative diagnosis was documented, as well as the pathologic diagnosis, operative details, complications, and length of hospital stay. Results In 49 operations, 53 adrenal glands were removed from 48 patients (37 women and 11 men). The mean patient age was 53.6 years (range, 24.4–78.8 years). The left adrenal was removed from 29 patients, the right adrenal from 14 patients, and both adrenals from 5 patients. The most common indications and diagnoses included 17 nonsecreting tumors (12 adenomas, 3 hyperplasias, 1 complex adrenal cyst, and 1 hemangioma), 12 aldosteronomas (10 aldosteronomas and 2 nodular hyperplasias), and 10 pheochromocytomas (9 confirmed, 1 adrenal hyperplasia). Other indications and diagnoses were less common. The mean operative time was 168 min (range, 87–370 min) for unilateral operations and 412 min (range, 345–480 min) for bilateral operations. The mean blood loss was 117 ml (range, 0–650 ml) for unilateral operations and 200 ml (range, 0–350 ml) for bilateral operations. The complications were mild pancreatitis (n = 1), urinary tract infection (n = 1), atelectasis (n = 1), mild congestive heart failure (n = 2), and transient corneal abrasion (n = 1). No conversion to open procedure was needed. The mean tumor size was 3.5 cm (range, 1.5–6.2 cm), and the mean postoperative hospital stay was 2.6 days (range, 1–6 days). Conclusion The results of laparoscopic adrenalectomies in Iceland for benign lesions of the adrenals are comparable with published results from large referral centers.     

Change in the surgical treatment of benign adrenal gland tumors. Laparoscopic adrenalectomy

Since 1995 fifty-two patient was operated on the Ist Department of the Surgery (DEOEC) due to uni- and bilateral tumor of the adrenal gland. Between May 1999, and December 2000 the authors performed 11 transperitoneal laparoscopic adrenalectomies (LA). Conversion due to bleeding in 3 cases and due to suspected malignancy in 1 case was necessary. This malignant lesion could have been resected during the open surgery after only the temporary dissection of the right renal vein. Complete resection was carried out in 9 cases. In 2 cases where a well circumscribed adenoma or teratoma was visualized, only enucleation was performed. The complication rate was low (1 ptx). Blood replacement was not necessary. The operation mean time was not any longer in LA compared to the open surgical approach. Preoperatively adrenaline (A), noradrenaline (NA), metadrenaline (metA), normetadrenaline (normetA) and vanillylmandelic acid (VMA) were measured in 24-h urine samples. Adrenal imagery consisted in all patients of abdominal computed tomography and in 4 patients adrenal magnetic resonance imaging but [131I] metaiodobenzylguanidine (MIBG) and octreotide scintigraphy were not performed. CONCLUSION: In the authors experience laparoscopic adrenalectomy is absolutely superior to the open surgery for the benign diseases of the adrenal gland not bigger than 6 cm. A short, uncomplicated and painless postoperative period can be achieved for the patients, with the same efficacy and safety compared to the conventional surgery. Enucleation without the whole adrenal gland excision is also possible.     

Laparoscopic right and left adrenalectomies

Background: Laparoscopic approach for adrenalectomy was recently described and the operative technique is not yet well defined. Methods: Twenty-seven laparoscopic adrenalectomies were performed between 1992 and 1995. There were 18 women and nine men ranging in age from 31 to 70 years (mean, 50.8 years). The surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one. Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, nonfunctional adenoma in four patients, Cushing adenoma in two, and an adrenal cyst in one. Median adrenal gland size was 2.0 cm (range 0.5–8 cm). Results: Five patients were converted to laparotomy (18%)—for dissection problems in four and for an unrecognized gland in one. The median anesthesia time was 200 min and the median surgical time was 140 min. Operative morbidity was one adrenal vein injury sectioned close to the vena cava. The hemorrhage was controlled by laparoscopic suturing without conversion. This patient required a three-unit blood transfusion. No mortality occurred and postoperative morbidity was one minor chest infection. The median postoperative in-hospital stay was 4.6 days (range 2–8) for nonconverted patients. Conclusions: Laparoscopic adrenal gland removal is safe and offers fast recovery and short in-hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.     

Simultaneous Bilateral Laparoscopic Adrenalectomy for Adrenocorticotropic Hormone-Independent Macronodular Adrenal Hyerplasia: Report of a Case

Cushing's syndrome caused by adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH) is an extremely rare disease, which shows bilateral macronodular adrenal hypertrophy and autonomous cortisol production. We herein report a case of AIMAH treated successfully by minimally invasive simultaneous bilateral laparoscopic adrenalectomy. A 73-year-old woman with hypertension, diabetes mellitus, and osteoporosis was referred to our hospital because of an incidentally found huge bilateral adrenal mass. An abdominal computed tomography scan showed large bilateral adrenal glands with multiple nodules. A diagnosis of AIMAH was made and a simultaneous bilateral laparoscopic adrenalectomy was thus performed. The total operation time was 310 min and blood loss was 70 g. Both glands were hypertrophic (right 5 × 3 cm, 48.5 g and left 4 × 2 cm, 39.2 g) and consisted of multiple golden yellow macronodules. The postoperative course was uneventful. A simultaneous bilateral adrenalectomy for AIMAH performed by an experienced surgical team is therefore considered to be a safe and minimally invasive procedure.     

Laparoscopic adrenal-sparing surgery for primary hyperaldosteronism due to aldosterone-producing adenoma

Background: Laparoscopic adrenalectomy has been shown to be safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma. Most laparoscopic adrenalectomies for aldosterone-producing adenomas involve total removal of the adrenal gland, and there have been few reports of laparoscopic adrenal-sparing surgery or partial adrenalectomies. Methods: A prospective review is performed on eight patients with primary hyperaldosteronism due to aldosterone-producing adenoma who underwent laparoscopic transperitoneal adrenal-sparing surgery in our institution over a 2-year period. Results: There were 1 male and 7 females with a mean age of 43.1 years. The mean diameter of the adenoma was 2 cm; there were six right-sided lesions and two left-sided lesions. The adenoma was located in the anterior margin of the adrenal gland in seven cases and was removed by laparoscopic enucleation. One patient had a partial adrenalectomy using the vascular stapler for an adenoma that was located posteriorly in the adrenal gland. Hemostasis was excellent in all cases. All patients were able to tolerate liquid orally on the day of operation and were on diet on the second postoperative day. Postoperative analgesic requirement was minimal. The mean hospital stay was 3.8 days. At a mean follow-up of 25 months, seven patients were cured of their hypertension and one patient had her antihypertensive medications significantly reduced. Conclusion: Laparoscopic transperitoneal adrenal-sparing surgery is safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma.     

Safety of Laparoscopic Adrenalectomy in Patients with Large Pheochromocytomas: A Single Institution Review

Background Laparoscopic adrenalectomy is the procedure of choice for small adrenal tumors, but some concerns have been voiced when this approach is adopted for larger tumors and pheochromocytomas. The aim of this study was to examine the results of the laparoscopic resection of large pheochromocytomas. Methods A retrospective review of adrenalectomies performed for adrenal pheochromocytomas >6 cm in diameter. We compiled and analyzed the early operative complications, histologic findings, and cure rates with a minimum of 1 year of follow-up after surgery. Results From 1996 to 2005, a total of 445 laparoscopic adrenalectomies were performed in our institution using the anterolateral transperitoneal approach. From this series we identified 18 procedures for pheochromocytomas with an average diameter on imaging of 78.2 mm (range 60–130 mm). All patients were rendered safe with a standard departmental protocol involving calcium-channel blockade initiated at least 2 weeks prior to surgery. The average peak intraoperative blood pressure was 187 mmHg. Capsular disruption occurred in two cases. One patient required an intraoperative blood transfusion due to intraoperative blood loss. No immediate conversions to an open procedure were required, but one patient underwent a delayed laparotomy for hematoma formation. Histologically, four of the adrenal tumors displayed evidence of vascular invasion. Biochemical cure was achieved in all patients after a median follow-up of 58 months (16–122 months). Conclusions Laparoscopic adrenalectomy appears to be a safe and effective approach for large pheochromocytomas when no preoperative or intraoperative evidence of local invasion is present. Paper Presented at the ISW Congress.     

The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater

Background Laparoscopic adrenalectomy (LA) has been shown to reduce hospital stay and morbidity when compared to open adrenalectomy (OA). It is uncertain if the laparoscopic resection of large (≥6 cm) potentially malignant adrenal tumours is appropriate due to concern over incomplete resection and local recurrence. The aim of the present study was to compare the outcomes of LA for tumours ≥6 cm with those < 6 cm. Methods Details of all patients referred with adrenal tumours between January 1999 and January 2006 had been recorded prospectively on a database. LA was performed using a lateral transabdominal approach. Contraindications to LA were local invasion requiring en bloc resection of adjacent organs or the requirement of additional open procedures. Results 103 patients were referred for adrenal resection. Three with metastatic adrenal carcinoma and two with severe cardiorespiratory disease were deemed unsuitable for operation. One hundred and eleven adrenalectomies were performed: 101 LAs and 10 OAs. Thirty-nine LA were for tumours ≥6 cm while nine OA were for tumours ≥6 cm. There were no significant differences between the median total anaesthetic time, postoperative complications or postoperative stay for patients undergoing LA for tumours ≥6 cm versus tumours <6 cm. Of the six conversions, five were performed for adrenal tumours ≥6 cm [local invasion (n = 3), adhesions (n = 1), primary renal carcinoma (n = 1)]. All tumours in the LA group were resected with clear margins and at a median follow up of 50 months (range 38–74 months). There has been no evidence of local recurrence. Conclusions In the absence of local invasion, the outcomes of laparoscopic adrenalectomy for patients with tumours ≥6 cm were comparable to those with tumours <6 cm. This has helped confirm a policy of initial laparoscopic resection for all noninvasive adrenal tumours can be applied safely.     

Comparison of open posterior versus transperitoneal laparoscopic adrenalectomy.

BACKGROUND: This study reviewed the results of initial experiences of open posterior adrenalectomy and transperitoneal laparoscopic adrenalectomy in 46 patients. METHODS: Twenty-three adrenalectomies were performed using the open posterior approach. Detailed records of the patients' operative and postoperative progress were compared with those of the first 36 laparoscopic adrenalectomies undertaken for a similar range of conditions. RESULTS: Conversion to laparotomy was necessary in one of 23 open posterior adrenalectomies and five of 36 laparoscopic adrenalectomies. The mean operating time for laparoscopic unilateral adrenalectomy was nearly double that for open surgery (158 versus 85 min). Postoperative complications occurred more frequently in the open adrenalectomy series (12 of 23 versus two of 36) but one late unexplained death followed bilateral laparoscopic adrenalectomy. A mean reduction in hospital stay of 5 days was recorded after laparoscopic adrenalectomy (range 2-5 days for laparoscopic versus 6-11 days for open operation). CONCLUSION: Transperitoneal laparoscopic adrenalectomy was attended by a lower morbidity rate than open adrenalectomy and patients were discharged from hospital more quickly.     

Sub-mesocolic access in laparoscopic left adrenalectomy

Background This article reports an alternative laparoscopic access to left adrenal gland.Methods From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection.Results No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group.Conclusions Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.     

Bilaterale laparoskopische transperitoneale Adrenalektomie beim Phäochromozytom

Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with a very low morbidity. Comparative studies with the conventional access to the adrenal gland demonstrated the advantages of the endoscopic technique. The anterior transperitoneal approach yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily, while at the same time he may perform additional laparoscopic maneuvers. In two cases of bilateral pheochromocytoma a bilateral laparoscopic adrenalectomy was performed simultaneously by employing the transperitoneal approach. The duration of surgery was approximately 210 and 270 min, respectively, with an intraoperative blood loss of about 350 and 400ml. There were no complications following this procedure. Already on the 1st postoperative day, the patients could be fully mobilized. Furthermore, immunological data obtained perioperatively support the minimal invasiveness of this technique.     

Suprasplenic, transperitoneal approach for laparoscopic adrenalectomy on the left side

BACKGROUND: There are several minimally invasive means of exposing the adrenal glands. Each of them has its own advantages and disadvantages. A new approach was introduced for laparoscopic adrenalectomy on the left side. PATIENTS AND METHODS: Between June 1997 and January 2000, 23 transperitoneal unilateral laparoscopic adrenalectomies on the left side were performed. In 4 of these cases, only enucleation of a well-circumscribed adenoma was done. In a semilateral position, the gland was approached through the splenophrenic ligament with partial mobilization of the spleen. The left adrenal gland was quickly and safely exposed, thus avoiding the complications of transmesocolic exposure. There was no need for extensive mobilization of the spleen or the pancreas. RESULTS: In 20 cases the laparoscopic operation was successfully performed. In 3 cases conversion was necessary because of bleeding. The estimated blood loss was on average 150 ml. The mean operation time was 84 min, the mean postoperative stay 4.5 days. No other major complications were observed. CONCLUSION: This new method is a safe and quick technique for left-sided laparoscopic adrenalectomy, and it can be an alternative to the existing ones.