Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy

Objectives:

Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients.

Methods:

A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m² was considered obese.

Results:

Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity.

Conclusions:

A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.     

Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study

Background

There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients.

Methods

BC patients at our institution undergoing various surgical procedures were identified from the 2007–2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes.

Results

One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71–4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22–8.05).

Conclusions

Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.     

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study

Background

We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission.

Methods

Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality.

Results

From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs 32.6%; P = .02), time to oral intake shorter (3 vs 6 days; P < .01), and LOS shorter (5 vs 8 days; P = .05) for LCR.

Conclusions

In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.     

Feeding jejunostomy during Whipple is associated with increased morbidity

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

Conclusion

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.     

Resident participation and postoperative outcomes in adrenal surgery

Background

The changing paradigm of surgical residency training has raised concerns about the effects on the quality of training. The purpose of this study is to identify if resident participation in laparoscopic adrenalectomy (LA) and open adrenalectomy (OA) cases is associated with deleterious outcomes.

Materials and methods

This is a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. Data from patients undergoing LA and OA from 2005 to 2010 were queried. Preoperative variables as well as intra- and post-operative outcomes for each procedure were evaluated. Multivariate logistic regression was used to analyze if resident participation was associated with significant differences in outcomes, compared with no resident participation. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into junior (Post Graduate Year [PGY]1–3), senior (PGY4–5), or fellow (≥PGY6) levels.

Results

A total of 3219 adrenalectomies were performed. Of these, 735 (22.8%) were OAs and 2484 (77.2%) were LAs. Residents were involved in 2582 (80.2%) surgeries, which comprised 1985 (76.9%) LAs and 597 (23.1%) OAs. Senior residents or fellows performed majority of the cases (85.2%). Mean operative time was significantly higher with resident participation in LA (P < 0.0001) and OA group (P < 0.0001). On multivariate analysis, resident participation was not associated with significant differences in the operative outcomes of 30-d mortality or postoperative complications after laparoscopic or OA.

Conclusions

Although resident participation does increase operative time in LA and OA, this does not appear to be clinically significant and does not result in adverse patient outcomes.     

Gallstone ileus: revisiting surgical outcomes using National Surgical Quality Improvement Program data

Background

Although surgical management remains the mainstay of therapy for gallstone ileus, the optimal approach—enterolithotomy alone or combined with biliary-enteric fistula disruption—is controversial because of the reliance on small single-center series to describe outcomes. Using the American College of Surgeons' National Surgical Quality Improvement Program database, we sought to (1) review the outcomes of patients undergoing surgical management of gallstone ileus and (2) determine if cholecystectomy in addition to enterolithotomy increased morbidity or mortality rate.

Methods

We analyzed the demographics, comorbidities, acuity, operative time, postoperative hospitalization length, and 30-d morbidity and mortality rates of 127 patients from 2005 to 2010 who underwent a procedure for the relief of gallstone ileus. We identified a subset of 14 patients who underwent simultaneous cholecystectomy. We compared the “no cholecystectomy” and “cholecystectomy” groups using standard statistical methods.

Results

The overall 30-d postoperative morbidity and mortality rate was 35.4% and 5.5%, respectively. Superficial surgical site infection and urinary tract infection were the most common complications. There was no significant difference in mortality rate between the no cholecystectomy and the cholecystectomy groups (5.3% versus 7.1%, respectively; P = 0.78), but the latter group did experience more minor complications, longer operations, and longer postoperative hospitalization.

Conclusions

Other recent studies on this topic have collected data or reviewed literature across several decades, making this study in particular one of the largest truly modern series. Perhaps reflecting changes in perioperative management, surgical treatment of gallstone ileus is less morbid than previously described, but there is still insufficient evidence to favor concurrent cholecystectomy.     

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.     

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines

Background

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS.

Methods

A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed.

Results

ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes.

Conclusion

ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

     

Risk of anastomotic leak after laparoscopic versus open colectomy

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4 % developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8 % (n = 425) and open surgery, 4.5 % (n = 378, p < 0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs. 0.6 %, p < 0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p < 0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95 % CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

     

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

Objective

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

Methods

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

Results

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7–41.4 kg/m². Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28–420 min and 0–350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1–11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

Conclusions

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.     

Short-term outcomes of laparoscopically assisted surgery for rectal cancer following neoadjuvant chemoradiotherapy: a single-center experience

Objective

The efficacy of laparoscopic treatment of rectal cancer remains unclear, and little is known about its effect on sphincter preservation. We compared short-term outcomes of laparoscopically assisted and open surgeries following neoadjuvant chemoradiotherapy (CRT) for mid and low rectal cancer.

Methods

This study enrolled 137 patients with mid-low rectal cancer who underwent curative resection, 51 by laparoscopically assisted (Lap group) and 86 by conventional open (Open group) surgeries, following neoadjuvant CRT from July 2007 to July 2012. The clinical and surgical findings of the two groups of patients were prospectively collected and analyzed.

Results

Three patients (5.9%) in the Lap group were converted to an open procedure. The mean operating times were similar in both groups. The Lap group had a significantly higher rate of sphincter preservation (62.7% versus 41.9%, P = 0.018) and significantly lower mean blood loss than the Open group. Mean times to first flatus, start of a normal diet, and overall postoperative hospitalization were longer for open surgery. The complication rate (11.8% versus 31.4%, P = 0.009) was significantly lower in the Lap group. Mean distal resection margin, involvement of the circumferential resection margin (2.0% versus 3.5%, P = 1.000), and mean lymph nodes harvested (12 versus 11; P = 0.242) were equivalent in the two groups.

Conclusions

Laparoscopically assisted surgery following neoadjuvant CRT is safe for patients with rectal cancer and provides favorable short-term benefits but without compromising oncologic outcomes. This sphincter-preserving procedure may be a treatment of choice for patients with lower rectal cancer.     

Closing the gap between the laparoscopic and open approaches to abdominal wall hernia repair: a trend and outcomes analysis of the ACS-NSQIP database

Objective

To assess trends in utilization and perioperative outcomes of laparoscopic and open abdominal wall hernia repair.

Methods

Using the ACS-NSQIP database between 2009 and 2012, patients were identified as having an ICD-9 diagnosis of an umbilical, ventral, or incisional hernia as well as a CPT code for a laparoscopic or open abdominal wall hernia repair. A coarsened exact matching procedure was utilized to create a matched cohort to mitigate selection bias. Thirty-day outcomes analysis was done for the aggregate and matched cohorts. Subcategory analysis was performed for inpatient/outpatient status, strangulated/incarcerated hernias, initial/recurrent repairs, and hernia type (umbilical, ventral, incisional). Chi-square analysis was performed to determine the statistical significance of each comparison.

Results

In total, 112,074 qualifying patients were identified, 86,566 (77.24 %) open and 25,508 (22.76 %) laparoscopic. Patients undergoing laparoscopic repair were more likely to have preexisting comorbidities, but less likely to experience any postoperative morbidity (11.74 vs. 7.25 %, P < 0.0001), serious morbidity (4.55 vs. 3.02 %, P < 0.0001), or mortality (0.36 vs. 0.24 %, P = 0.0030). Creation of the matched cohort produced 17,394 patients in both the laparoscopic and open groups and resulted in a loss of advantage for the laparoscopic approach in terms of morbidity associated with umbilical hernia repairs (P = 0.0082 vs. P = 0.3172). Patients undergoing laparoscopic repair were still less likely to experience any postoperative (9.57 vs. 4.92 %, P < 0.0001) or serious morbidity (3.37 vs. 1.70 %, P < 0.0001). Hospital length of stay in the matched cohort supported initial primary repairs done by an open approach.

Conclusion

The laparoscopic approach is used in a minority of abdominal wall hernia repairs, though utilization increased by 40 % from 2009 to 2012. The laparoscopic approach continues to be safer on many fronts, but not all, and is arguably not better for umbilical or primary hernia repairs on the basis of overall morbidity and length of stay.

     

Does ventral hernia defect length,width, or area predict postoperative quality of life? Answers from a prospective,international study

Background

The goal of this study was to determine if ventral hernia defect length, width, or area predict postoperative pain and quality of life following ventral hernia repair (VHR).

Methods

The International Hernia Mesh Registry, a prospective database from 40 institutions worldwide, was queried for patients undergoing VHR from October 2007 to June 2012. Laparoscopic and open VHR were evaluated separately. Width and length were stratified into large, ≥10 cm and small, <10 cm, along with area as large, ≥100 cm² and small, <100 cm².

Results

In total, 865 International Hernia Mesh Registry patients underwent VHR. Large defect width, length, and area had no association with hernia recurrence or reoperation in both open and laparoscopic VHR. There was a significant increase in operating room time and length of stay for large compared with small width, length, and area for open and laparoscopic VHR patients (P < 0.05). Large area was associated with increased seroma and ileus in open and laparoscopic VHR (P < 0.05). There was greater pain and activity limitation at 1 mo for large versus small width and area whether repaired laparoscopically or open (P < 0.05). When comparing large to small length, there was no difference in pain for all follow-up time points when repaired laparoscopically, but there is significantly increased odds of pain and activity limitation at 1, 6, and 12 mo when repaired open (P < 0.05).

Conclusions

Patients undergoing laparoscopic or open VHR with large defect widths and total area have a greater chance of pain and activity limitation at 1-mo follow-up, but not long term. Large defect lengths are associated with increased early and chronic discomfort in open VHR only.     

Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis

Background

Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME.

Materials and methods

Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated.

Results

Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME.

Conclusions

RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.     

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.     

A Comparison of Postoperative Complications in Open versus Robotic Cystectomy

Background

Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated.

Objective

To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC).

Design, setting, and participants

A prospective cohort study of 187 consecutive patients undergoing RC at our institution—104 open RC, 83 robotic RC.

Intervention

Open or robotic RC with urinary diversion.

Measurements

Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using χ² and multivariate logistic regression analyses.

Results and limitations

At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p = 0.04) as well as more major complications (30% vs 10%; p = 0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p = 0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p = 0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3–4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion.

Conclusions

Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational.     

Transperitoneal Laparoscopic Adrenalectomy in Children

Purpose:

The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults. The aim of our study was to describe the safety and feasibility of minimally invasive adrenalectomy in children on the basis of surgical skills and results.

Materials and Methods:

This was a retrospective study of 4 pediatric laparoscopic adrenalectomies performed at our center between 2009 and 2012. All patients underwent transperitoneal lateral laparoscopic adrenalectomies (2 right and 2 left adrenalectomies).

Results:

Four laparoscopic adrenalectomies were performed. Indications for surgery were neuroblastoma in 2 patients, secernent adrenocortical tumor in 1 patient, and adrenocortical nodular hyperplasia in 1 patient. Patients had a mean age of 87 months (range, 17–156 months) at diagnosis, and the average lesion size was 3.23 cm (range, 0.7–6.4 cm). All laparoscopic adrenalectomies were successful, no conversions to open surgery were required, and no postoperative complications or deaths occurred. The average operating time was 105 minutes (range, 80–130 minutes), blood loss during surgery was minimal, and the mean postoperative hospital stay was 3.75 days (range, 3–5 days). None of the patients showed signs of recurring disease at 15-month follow-up.

Conclusions:

Laparoscopic adrenalectomy is a safe, feasible, and reproducible technique offering numerous advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications. It also provides good visibility and easy access to other organs.     

Laparoscopic Living-Donor Nephrectomy: Analysis of the Existing Literature

Context

Laparoscopic living-donor nephrectomy (LLDN) has achieved a permanent place in renal transplantation and in some centers has replaced open donor nephrectomy as the standard technique.

Objective

To evaluate the published literature regarding the relative results and complications of open LLDN and the hybrid technique of hand-assisted LLDN.

Evidence acquisition

A systematic review of the literature was performed, searching PubMed and Web of Science. A “free text” protocol using the term living-donor nephrectomy was applied. Six hundred twenty-nine records were retrieved from the PubMed database and 686 records were retrieved from the Web of Science database.

Evidence synthesis

Fifty-seven comparative studies were identified in the literature search. The three techniques of open, laparoscopic, and hand-assisted laparoscopic donor nephrectomy were compared in terms of reported outcomes. With regard to the perioperative outcome parameters, laparoscopy was better than open surgery in terms of blood loss, analgesic requirements, and duration of hospital stay and convalescence. Postoperative graft function was not significantly different between the different forms of donor nephrectomy, although longer warm ischemia times are reported for laparoscopy.

Conclusions

All three techniques of live-donor nephrectomy are standard of care. The laparoscopic techniques result in less postoperative pain and estimated blood loss with shorter hospital stay, while postoperative graft function is not inferior to that after open live-donor nephrectomy.     

Complications of Laparoscopic Surgery for Renal Masses: Prevention,Management, and Comparison with the Open Experience

Context

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

Objective

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

Evidence acquisition

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

Evidence synthesis

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

Conclusions

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.