Bilateral laparoscopic adrenalectomy

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has become the gold standard in the surgical management of adrenal pathology. Bilateral adrenalectomy is indicated in patients with Cushing's disease secondary to macroadenoma or hypophysial hyperplasia in whom medical treatment and transsphenoid surgery have failed. Also, it is the first choice for bilateral benign tumors and metastatic neoplasia. We present our experience with bilateral laparoscopic adrenalectomy, analyzing its indications, feasibility, results, and complications. PATIENTS AND METHODS: Between November 1999 and December 2005, 221 laparoscopic adrenalectomies were performed by the same surgeon (OAC) at our institution. Of the 221 adrenalectomies, 44 were bilateral. A total of 20 patients underwent bilateral synchronic laparoscopic adrenalectomy (91%); the remaining 2 had two-stage procedures. There were 6 cases of bilateral pheochromocytoma, 6 patients with Cushing's disease, 3 cases of metastasis, 3 congenital adrenal hyperplasias, 2 hyperaldosteronisms, and a single case each of adrenal adenoma and myelolipoma. The average patient age was 41.6 years (range 17-72 years), and the male-to-female ratio was 1:2.6. RESULTS: Total laparoscopic adrenalectomy and partial adrenalectomy were performed on 37 and 7 occasions (84% and 16%), respectively. The mean tumor size was 4.15 cm (range 1-11 cm). The mean operative time for each adrenalectomy was 79.2 minutes (range 25-210 minutes). The estimated intraoperative blood loss was on average 65.4 mL (range 0-500 mL). Only one patient required a blood transfusion. There was only one intraoperative complication (2.2%), a renal-vein injury that was controlled with intracorporeal suturing. There were no open conversions. The mean hospital stay was 3.19 days (range 2-5 days). CONCLUSIONS: Bilateral laparoscopic adrenalectomy is technically feasible and can be performed with minimal bleeding in a reasonable surgical time.     

Laparoscopic bilateral simultaneous adrenalectomy: results of 11 operations

BACKGROUND: This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy. MATERIALS AND METHODS: This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin. RESULTS: Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96). CONCLUSIONS: Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.     

Laparoscopic adrenal surgery in children

PURPOSE: The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, more than 400 studies have been published, comprising hundreds of adults. There are few reports of laparoscopic adrenalectomy in the pediatric population. We reviewed our experience with laparoscopic adrenal surgery in children. MATERIALS AND METHODS: Laparoscopic adrenalectomy was performed in 8 girls and 5 boys 15 years or younger (mean age 6.3) between December 1994 and August 2001. The clinical diagnosis before surgery was virilizing tumor in 5 cases, nonfunctioning solid adrenal tumor in 3, Cushing's syndrome in 2, pheochromocytoma in 2 and Cushing's pituitary disease in 1. Unilateral adrenal lesions were 15 to 80 mm. at the longest axis (mean 41.4) on computerized tomography. RESULTS: Two of the 13 procedures (15.4%) were converted to open surgery. No deaths occurred. No patients presented with postoperative complications. Average operative time in unilateral nonconverted procedures was 107 minutes (range 25 to 195). Blood transfusion was required in 1 case (7.7%). Average hospital stay was 5.5 days (range 1 to 17). Average postoperative followup was 16 months (range 1 to 60). The final clinicopathological diagnosis was virilization in 4 cases, Cushing's syndrome in 2, pheochromocytoma in 2, neuroblastoma in 2, Cushing's pituitary disease in 1, teratoma in 1 and primary carcinoma in 1. CONCLUSIONS: Laparoscopic adrenalectomy is feasible and shows positive results in select pediatric patients.     

Outcomes for laparoscopic bilateral adrenalectomy

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has become the preferred surgical approach to manage adrenal disorders. Bilateral adrenalectomy is performed for diseases that are unresponsive to medical management and, frequently, for neoplastic disease. The aim of this study was to review our experience with laparoscopic bilateral adrenalectomy and to evaluate its safety, efficacy, and outcomes. PATIENTS AND METHODS: Between July 1996 and May 2001, five male and two female patients with a mean age of 46 years (range 15-69 years) presented for bilateral adrenalectomy (pheochromocytoma [N = 3], Cushing's disease [N = 3], and metastatic cancer [N = 1]). All procedures were performed using a lateral transperitoneal approach. One gland was excised, the patient was repositioned to the opposite lateral decubitus position, and the remaining gland was removed. RESULTS: Laparoscopic bilateral adrenalectomy was completed in all seven patients. The mean tumor/gland size on the right was 5.0 cm (range 3.1-7.0 cm) and on the left was 5.6 cm (range 3.6-7.0 cm). The mean operative time was 308 minutes (range 190-430 minutes), and the mean estimated blood loss was 138 mL (range 30-300 mL). One patient with a pheochromocytoma experienced intraoperative hypertension necessitating treatment. There were no postoperative complications. The mean postoperative hospital stay was 5.1 days (range 3-9 days). All patients have been treated postoperatively with daily hydrocortisone and fludrocortisone replacement. After a mean follow-up of 33 months (range 2-45 months), six patients are alive. The patient undergoing bilateral adrenalectomy for metastatic lung cancer died from recurrent disease 13 months after resection. CONCLUSION: Laparoscopic bilateral adrenalectomy is safe and effective. Patients are discharged postoperatively in a relatively short time with few complications. Appropriate steroid replacement and close follow-up allows these patients to return to self-reliance.     

Laparoscopic Adrenalectomy for Pheochromocytoma Versus Other Surgical Indications

Objective:

Laparoscopic adrenalectomy is widely recognized as the preferred technique for surgical removal of adrenal masses. This study aimed to evaluate the outcomes of consecutive laparoscopic adrenalectomies performed at a high-volume referral center and compare operative results for pheochromocytomas with that of other adrenal diseases.

Materials and Methods:

We retrospectively reviewed a single surgeon''s experience with laparoscopic adrenalectomy performed between July 2002 and June 2007. Patient records were analyzed in regards to demographics, pathology diagnoses, operative time, postoperative complications, tumor size, hospital stay, among others.

Results:

Seventy-two consecutive laparoscopic adrenalectomies were performed on 70 patients, including 2 bilateral adrenalectomies and one partial adrenalectomy. Surgical indications included pheochromocytoma (n=11), aldosteronoma (n=26), malignant adrenal disease (n=4), nonfunctioning adenomas (n=17), Cushing''s disease (n=6), and other adrenal disease (n=8). No mortality was observed. Perioperative complications occurred in 7 cases (9.7%). When a comparison between pathological diagnosis groups was made, no statistical differences were seen between pheochromocytomas and other adrenal neoplasms with respect to estimated blood loss, open conversion rate, length of stay, preoperative and postoperative hemoglobin values, blood transfusion rates, peri-operative complication occurrence, tumor size, and ASA class.

Conclusion:

Laparoscopic adrenalectomy is a safe and appropriate surgical technique for most adrenal lesions, including pheochromocytomas.     

Laparoscopic approach to adrenalectomy: review of perioperative outcomes in a single center

Laparoscopic expertise increases the volume of adrenalectomies at referral centers. We report our 10-year experience with laparoscopic adrenalectomy. All laparoscopic adrenalectomies at a single institution were prospectively recorded in a surgical outcomes database. Patient demographics, operative/perioperative outcomes, and adrenal pathology were reviewed retrospectively. From March 1999 through July 2009, 154 laparoscopic adrenalectomies were performed in 150 patients. Average patient age was 49.9 years (range 15-82); mean body mass index was 31.1 kg/m(2) (range 17-56). Pathologic diagnoses included hyperaldosteronism (n = 69), nonfunctional adenoma (n = 28), pheochromocytoma (n = 23), hypercortisolism (n = 14), malignancy (primary n = 3, metastasis n = 9), and cyst (n = 4). Seventy-three per cent (n = 110) occurred on the left, 23 per cent (n = 35) on the right, 2.6 per cent (n = 4) bilateral, and 0.6 per cent (n = 1) as extra-adrenal. The average tumor measured 3.6 cm (range 0.4-12). The average operative time was 156 minutes (range 62-409), the mean estimated blood loss was 60 mL (range 10-400), and mean American Society of Anesthesiologists score was 2.6 (range 1-4). Three operations (0.2%) were converted to open. Three patients (0.2%) experienced perioperative complications (respiratory failure, urinary tract infection, line sepsis, and readmission within 30 days). The average length of stay was 3.4 days (range 1-44) and mean follow-up was 96.9 days (5-2567). No wound-related complications or deaths occurred. Pathologic diagnosis was not associated with a particular side or development of a complication (P > 0.5). Patients with pheochromocytomas had the longest operative times, highest estimated blood loss, and highest American Society of Anesthesiologists scores (218.2 minutes, 128 mL, 3.0; P < 0.004). Laparoscopic adrenalectomy is safe and effective. Removal of pheochromocytomas is more challenging and may be more appropriate for referral to a specialized center for optimal outcomes.     

Transperitoneal laparoscopic adrenalectomy: experience in 72 procedures

PURPOSE: To evaluate the safety and effectiveness of transperitoneal laparoscopic adrenalectomy for a variety of adrenal diseases. PATIENTS AND METHODS: Seventy-two patients underwent laparoscopic adrenalectomy from January 1995 until March 1999. The indications for the treatment were limited to either functioning or nonfunctioning adrenal masses without radiologic evidence of involvement of the surrounding tissues. The indication for bilateral adrenalectomy was Cushing's disease after the failure of other therapies or Cushing's syndrome secondary to ectopic ACTH secretion without the discovery of a primary neoplasm. RESULTS: Thirty-five of the adrenalectomies were performed on the left side and 33 on the right side, and 4 were performed bilaterally. The right-sided procedures required a mean operating time of 130 minutes (range 85-200 minutes), the left-sided procedures required a mean operating time of 140 minutes (range 95-200 minutes), and the bilateral procedures required a mean operating time of 240 minutes (range 210-290 minutes). A conversion from laparoscopy to laparotomy was necessary for 3 patients (4%). Intraoperative complications were reported in 6 patients (8%). Postoperative complications likewise occurred in six patients. CONCLUSIONS: These procedures proved to be safe and able to remove the majority of either functioning or nonfunctioning benign adrenal masses. Some controversy remains regarding the safety of laparoscopic adrenalectomy for large lesions and the safety of bilateral laparoscopic adrenalectomy because of bleeding risks, anesthetic risks, and long operative times. The effectiveness of laparoscopic adrenalectomy for nonfunctioning adrenal masses with histologic findings of carcinoma has not yet been proved.     

Laparoscopic adrenalectomy: the optimal surgical approach

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has emerged as the treatment of choice for most adrenal surgical disorders. We describe our experience with 176 laparoscopic operations. PATIENTS AND METHODS: The patients were treated for hyperaldosteronism (N = 62), pheochromocytoma (N = 43), "incidentaloma" (N = 21), Cushing's syndrome (N = 20), suspected adrenal metastasis (N = 16), Cushing's disease (N = 8), adrenal hemorrhage (N = 3), or virilizing tumor (N = 1). In 154 of the 176 laparoscopic operations, a lateral transabdominal approach (15 bilateral, 76 left, and 63 right) was used. In the remaining 22, a posterior laparoscopic approach (3 bilateral, 10 left, and 9 right) was used. RESULTS: The average total operating time for unilateral laparoscopic adrenalectomy was 2.8 hours, and for bilateral adrenalectomy, it was 5.2 hours. The mean tumor size was 4.6 cm (range 1-15 cm). There was no significant difference in operating time according to the tumor size. The average length of hospitalization was 1.7 days (range 1-9 days). The perioperative complication rate was 5.1%. There were no conversions to an open procedure. The operating time, length of hospitalization, and perioperative complication rate were stable over the period. Although we used the posterior laparoscopic approach only for smaller tumors (<6 cm), we found no differences in patient outcome between the lateral and posterior laparoscopic approaches. CONCLUSION: For almost all adrenal surgical disorders, an initial laparoscopic approach is optimal. It is safe and is associated with the best patient outcome.     

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures.

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.     

Bilateral laparoscopic transperitoneal adrenalectomy in three children

Background: This study focuses on the clinical presentation, surgical technique, and results of bilateral laparoscopic adrenalectomy in three girls aged 6, 13, and 14. Materials and Methods: This retrospective study included two girls with bilateral tumors (pheochromocytomas in one case, recurrent leiomyosarcomas in the other case) and a girl with micronodular hyperplasia associated with Cushing's syndrome. Results: Six transperitoneal laparoscopic adrenalectomies were performed with no conversions. The average operative time was 137 minutes (range 125-148); the mean estimated blood loss was 75 mL; the mean size of the adrenal lesions was 8 cm (range, 0.5-9); and the mean length of hospital stay was 3 days (range, 2-4). Resolution of clinical and biochemical parameters of adrenal hyperfunction was accomplished in the patients with adrenocortical hyperplasia and pheochromocytoma. No tumor recurrence has been so far found in the case of the leiomyosarcomas. Conclusion: Bilateral laparoscopic adrenalectomy can be performed safely and effectively with a shorter hospital stay, minimal blood loss, and excellent functional outcome in the pediatric population.     

An institutional experience with 40 first lateral transperitoneal laparoscopic adrenalectomies

Laparoscopic adrenalectomy is gaining widespread acceptance. To evaluate this new approach, the authors evaluated 40 laparoscopic adrenalectomies. Between June 1995 and February 1999, 40 lateral transperitoneal laparoscopic adrenalectomies were performed in 38 patients. The clinical diagnoses were primary aldosteronism (20 patients), Cushing adenoma (2 patients), cortical hyperplasia with hypercortisolism (2 patients), pheochromocytoma (8 patients), and other conditions (6 patients). There were no deaths or subsequent procedures. The mean operative time was 121 minutes. One procedure performed for hypercortisolism was converted to open adrenalectomy because of hepatomegaly and postoperative adhesions. Seven patients had complications: one patient with small pulmonary embolus with transient dyspnea, one patient with pneumothorax, two patients with postoperative bleeding, two patients with prolonged pain at a trocar wound, and one patient with a urinary tract infection. Lateral transperitoneal laparoscopic adrenalectomy seems to be a safe and effective minimally invasive approach for adrenal surgery, and the authors consider it to be the standard surgical procedure for benign adrenal tumors.     

Laparoscopic adrenalectomy — a review of initial 24 consecutive patients

Aim

To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department.

Methods

Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25–68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing’s syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing’s syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The clinical and intraoperative characteristics, complications and outcomes of all patients were analyzed.

Results

The mean operative time for laparoscopic adrenalectomy was 136 minutes. Intraoperative hypertension occurred in 8 patients. Intraoperative hypotension occurred in 2 patients. One patient required conversion due to dense adhesions and hemorrhage. Postoperative complications were seen in six patients — immediate postoperative hypotension (2 patients), features of steroid withdrawal (2 patients) and postoperative pyrexia (2 patients). Five patients with pheochromocytoma required antihypertensive drugs in the postoperative period. There was no mortality in our series.

Conclusions

Laparoscopic adrenalectomy is a safe operation that incorporates all the benefits of minimal access surgery and is associated with a satisfactory postoperative outcome. A careful preoperative preparation in functioning adrenal tumours aids in the faster recovery of these 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 in the elderly.

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.     

Lateral transperitoneal laparoscopic adrenalectomy

Several laparoscopic approaches to the adrenal gland have been described. The lateral transperitoneal approach has several distinct advantages when contrasted with other techniques for laparoscopic adrenalectomy (LA). We present our technique and results obtained in 50 consecutive transperitoneal LAs. We review 50 consecutive laparoscopic adrenalectomies (28 female, 19 male) performed from 1993 to 1998. S.J. Shichman or R.E. Sosa was either the primary surgeon or the first assistant for all cases. The lateral transperitoneal approach described below was used in all cases. Indications for adrenalectomy included Cushing's syndrome (13), aldosteronoma (15), pheochromocytoma (7), nonfunctioning adenoma (11), hyperplasia (2), and 1 case each of Carney's syndrome and metastasis to the adrenal gland. We performed 5 bilateral, 22 left, and 18 right laparoscopic adrenalectomies. The average time needed for bilateral adrenalectomy was 503 min (range 298–690 min); for left adrenalectomy, 227 min (range 121–337 min); and for right LA, 210 min (range 135–355 min). We demonstrated a yearly trend in lower operative times. The largest adrenal gland removed measured 13.8 × 6.7 × 3.5 cm. Intraoperative blood loss was low. Only one patient received a blood transfusion. Conversion to open adrenalectomy was not required. Postoperative analgesic requirements were low. The average length of stay was 3.8 days for bilateral LA and 3 days for unilateral LA. Complications occurred in 5 patients (2 wound infections, 2 hematomas, and 1 pleural effusion). There was no mortality. Lateral transperitoneal adrenalectomy is a safe and efficient technique for the removal of functional and nonfunctional adrenal masses. This technique is associated with low morbidity, a minimal postoperative analgesic requirement, and a short hospital stay and, in our opinion, is more versatile than the retroperitoneal approach.     

Applicability and outcome of laparoscopic adrenalectomy

Laparoscopic adrenalectomy has been shown to be as safe and effective as conventional open surgery for small and benign adrenal lesions. With increasing experience with laparoscopic adrenalectomy, this approach has become the procedure of choice for the majority of patients requiring adrenalectomy, although careful selection of patients accounts for the favourable clinical outcome observed. Laparoscopic adrenalectomy was adopted as the procedure of choice for patients requiring adrenalectomy in our institution in 1995. From 1995 to 2001, 82 consecutive patients underwent adrenalectomies for various adrenal pathologies. The laparoscopic approach was used for 60 of these patients, whose selection was based on the preoperative size and/or benign nature of the adrenal lesion. The procedures were successfully performed in 57 patients (54 unilateral, 3 bilateral), while three (5%) patients required conversion to open surgery. There was no hospital mortality and complications occurred in two (3%) patients. The median hospital stay was 3 days (range, 2-8 days) and analgesic requirement was minimal. Laparoscopic adrenalectomy can be done for all patients with small and benign adrenal pathologies, and has become the gold standard for patients undergoing adrenalectomies. When successfully performed, the laparoscopic approach offers the advantages of a minimally invasive procedure with improved patient comfort and faster postoperative recovery.     

Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment?

BACKGROUND: Laparoscopic adrenalectomy has become the gold standard for removing adrenal masses, but several authors still debate the role of laparoscopic adrenalectomy in pheochromocytoma. The purpose of this study was to evaluate the short- and long-term outcomes of laparoscopic versus open adrenalectomy for pheochromocytomas and to compare the feasibility and safety of laparoscopic adrenalectomy for neoplasms that are smaller than 6 cm versus those that are larger than 6 cm. METHODS: From January 1990 to December 2005, the same team in our department carried out 221 adrenalectomies in 211 patients. A total of 64 of these patients underwent 71 adrenalectomies for pheochromocytoma, 24 patients (37%) had open adrenalectomy, and 40 patients (63%) had laparoscopic adrenalectomy. Sex, age, side and size of lesion, operating time, duration of hospital stay, need for intensive care, intraoperative blood pressure variations, blood loss, postoperative analgesia, return to oral nutrition, and complications were compared among groups. RESULTS: An advantage of laparoscopic adrenalectomy over open adrenalectomy was observed in mean operating time, hospital stay, need for intensive care, intraoperative hypertension, intraoperative blood loss, postoperative analgesia, and return to oral nutrition (P 6 cm) in laparoscopic adrenalectomy showed that none of the variables differed significantly, except for intraoperative blood loss, which was greater for the larger neoplasms (P = .007). CONCLUSIONS: Laparoscopic adrenalectomy, when performed by experienced laparoscopic surgeons, is preferable to open adrenalectomy for the majority of pheochromocytomas, and as long as there is no evidence of invasion of surrounding structures, tumor size does not appear to have a profound effect on surgical outcome.     

Laparoscopic adrenalectomy (LA): keys to success: correct surgical indications, adequate preoperative preparation, surgical team experience

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the surgical procedure of choice for the treatment of most adrenal lesions. Controversy still remains about the treatment for primary and secondary malignant lesions and for pheochromocytoma. MATERIALS AND METHODS: From September 1997 to December 2005, 77 patients were operated on for adrenal tumors in a single center. Three patients had bilateral lesion for a total of 80 adrenalectomies. Selection criteria for laparoscopic treatment included benign characteristics of the lesions regardless of size and absence of virilization syndrome. A multidisciplinary approach was used for adequate preparation of patients with functional lesions. Fifty-five patients were eligible for LA and 22 for open surgery. RESULTS: Mean operative time was 142 minutes (range 45 to 240) in the laparoscopic group (53 patients) and 161 minutes (range 90 to 300) for the open group (24 patients). In 2 patients (4%) conversion to open procedure was necessary for intraoperative bleeding. Laparoscopic surgery in patients with pheochromocytoma was associated with a better intraoperative hemodynamic stability. CONCLUSIONS: LA is the treatment of choice for benign adrenal tumors regardless of size. Appropriate selection of patients, adequate preoperative preparation of patients with functional lesions and expertise in adrenal surgery and advanced laparoscopic skills are necessary to allow reduction of perioperative morbidity and early recovery.     

Technique and results of laparoscopic adrenalectomy

The aim of this report is to evaluate the benefits of laparoscopic adrenalectomy in terms of perioperative morbidity, complications and patients recuperation. We reviewed our experience with laparoscopic adrenalectomy in 47 consecutive patients who underwent adrenalectomy over a 4-year period. We used the lateral transperitoneal approach in all cases. The indications for adrenalectomy were Conn's adenoma in 24 patients, pheochromocytoma in 11, Cushing's syndrome in 3 and incidental adrenal tumour in 9. The average duration of surgery was 130 min (range, 60-300 min) and average adrenal gland size was 3.4 cm (range, 1.2-8 cm). Conversion from laparoscopy to laparotomy was necessary in three patients (6.4%), and postoperative complications occurred in two patients. There was no mortality. Laparoscopic adrenalectomy can be considered the method of choice for managing almost all adrenal masses, because of its low morbidity and short postoperative recovery. The main difficulty is to identify the adrenal gland, so several technical procedures are suggested.     

Laparoscopic Resection of Large Adrenal Tumors

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.