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 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.     

Experience with laparoscopic adrenalectomy in children

Purpose

The aim of this study was to review the authors’ experience with laparoscopic adrenalectomy in the pediatric age group.

Methods

This is a retrospective analysis of laparoscopic adrenalectomies performed in children at King Faisal Specialist Hospital & Research Centre, between June 1997 and March 2003. Ten children had laparoscopic adrenalectomies during this period. They were between 3 weeks to 12 years of age and there was an equal number of boys and girls. Case selection was based mainly on the size of the lesion and its localized nature as seen on the imaging studies. The transperitoneal approach was used in all cases.

Results

Eleven laparoscopic adrenalectomies were performed in 10 children (1 was bilateral adrenalectomy). Presenting features were virilization (n = 3), Cushing’s syndrome (n = 1), antenatally detected adrenal cyst (n = 1), hypertension (n = 1), hepatomegaly (n = 1), loin pain with hematuria (n = 1) and an incidental adrenal mass (n = 1). One was a child with stage IV adrenal neuroblastoma postchemotherapy for resection of the residual tumor. On imaging studies, the tumors were between 2.8 and 7 cm in their largest dimension. Operating time ranged from 118 to 180 minutes in the unilateral resections, whereas the bilateral laparoscopic adrenalectomy required 330 minutes. Two had to be converted to open procedures. Postoperative hospital stay was between 2 and 15 days. Pathologic diagnoses were as follows: adrenal cortical adenoma (n = 3), adrenal medullary hyperplasia (n = 2), adrenal cortical carcinoma (n = 1), ganglioneuroma (n = 1), and neuroblastoma (n = 3). There were no complications. Follow-up ranged from 3 months to 6 years. The only mortality in our study group was in the child with stage IV neuroblastoma who died of disseminated disease 9 months later. In the rest, there has been no local recurrence or metastases, and the biochemical and hormonal parameters have remained normal in the functional tumors.

Conclusions

We believe that in a select group of pediatric adrenal lesions, laparoscopic adrenalectomy is a safe and effective procedure with the potential benefits of minimally invasive procedures.     

Laparoscopic Resection of Giant Adrenal Cavernous Hemangioma

Background:

Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy.

Methods:

Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass.

Results:

The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland.

Conclusion:

The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.     

Laparoscopic Radical Nephrectomy for Renal Masses 7 Centimeters or Larger

Objective:

To report our operative experience and oncologic outcomes for the laparoscopic management of large renal tumors.

Methods:

All laparoscopic and hand-assisted laparoscopic radical nephrectomies performed at our institution were reviewed. Thirty patients with tumors ≥7cm and a pathologic diagnosis of renal cell carcinoma were included.

Results:

Mean operative time was 175.7±24.5 minutes, and mean estimated blood loss was 275.5±165.8 mL. No case required conversion to open radical nephrectomy. The mean hospital stay was 2.4±1.6 days. Four patients (13%) had minor complications. Of the 30 tumors, 18 were pathologic stage T2, 9 were stage T3a, 2 were stage T3b, and one was stage T4. At a mean follow-up of 30 months (range, 10 to 70), 22 patients (73%) were alive without evidence of recurrence, and 5 patients (17%) were alive with disease. One patient (3%) died of complications related to renal cell carcinoma, and 2 patients (7%) died from other causes. Overall survival was 90%, cancer-specific survival was 97%, and recurrence-free survival was 80%.

Conclusion:

Laparoscopic radical nephrectomy for large tumors is a technically challenging operation. However, in experienced hands, it is a reasonable therapeutic option for the management of larger RCC neoplasms.     

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.     

Differences in Left and Right Laparoscopic Adrenalectomy

Background and Objectives:

The classic belief is that right-sided laparoscopic adrenalectomy is technically more difficult to perform than left-sided. The purpose of this study was to determine whether objective outcomes are different for the right- versus left- sided operation.

Methods:

A retrospective review of 163 laparoscopic adrenalectomies was performed to compare outcomes. Variables extracted included age, demographics, body mass index (BMI), laterality, indication, operative time, estimated blood loss (EBL), gland size, complications, open conversion rates, and length of stay.

Results:

Of the adrenalectomies performed, 109 were on the left and 54 on the right. Age, BMI, and indication were similar for each group. The mean EBL on the left side was 113mL (range, 2 to 3000) and 84mL (range, 10 to 700) for the right (P=0.85). The mean operative time on the left side was 187 minutes (range, 62 to 475) and on the right was 156 minutes (range, 50 to 365) (P=0.02). There was no difference in complication or conversion rate.

Conclusions:

There was no difference in complication or conversion rates between each side, and we observed a trend toward lower blood loss for the right side. Although we report generally similar outcomes, the mean operative time for a right-sided laparoscopic adrenalectomy was significantly less (31 minutes) than the left side.     

Laparoscopic Resection of Solitary Adrenal Metastasis from Lung Carcinoma: A Case Report

Background and Objectives:

Patients with adrenal metastases from bronchogenic carcinoma are considered incurable and any surgical treatment is usually excluded. A review of the few cases of adrenalectomy for metastases from lung cancer that have been reported in the literature shows that good results can be achieved in selected patients. We propose a laparoscopic approach to perform the adrenalectomy in these patients.

Methods:

A right laparoscopic adrenalectomy for metastasis from lung adenocarcinoma was performed. The right adrenal was resected using the anterior transperitoneal laparoscopic approach.

Results:

The tumor was resected in total. The operating time was two hours. One year after surgery the patient remains well.

Conclusions:

The current indications for laparoscopic adrenalectomy can include the removal of small metastatic adrenal lesions in selected cases.     

Adrenal incidentalomas in the laparoscopic era and the role of correct surgical indications: observations from 255 consecutive adrenalectomies in an Italian series

Background

The purpose of our study was to evaluate the impact of laparoscopic adrenalectomy on patients with incidentalomas. We analyzed the results of a multi-centre trial that was performed to evaluate the effectiveness of imaging (computed tomography and magnetic resonance imaging) to obtain a correct preoperative diagnosis.

Methods

We obtained our data from the results of a questionnaire that was distributed by mail or email in May 2005 to several surgical units operating in the Campania Region, Italy. Lap Club, a collaborative laparoscopic surgery study group founded in Naples in 1995, distributed the questionnaire. Thirteen centres participated in the audit. In all, we analyzed 255 adrenalectomies performed on 250 patients. We performed statistical analysis using SPSS software.

Results

The distribution of pathologic findings demonstrates that the number of lesions caused by cancer discovered from a preoperative indication of incidentaloma has been even smaller (1/114, 0.8%) than the previous numbers reported in the literature. Moreover, whereas most patients with adrenal cancer had lesions larger than 6 cm (7/8, 87.5%), the majority of patients with adrenal metastases had lesions 6 cm or smaller (10/12, 83.3%). Different indications for adrenalectomy emerged on comparison of endocrine surgery units with general surgery units. This difference appears to be significant (p < 0.001), especially on evaluation of the number of nonfunctioning adenomas and the number of endocrine lesions that were observed and treated.

Conclusion

Laparoscopy remains the gold standard method for adrenalectomy, but its availability must not obligate physicians to treat with surgery when an incidentaloma is detected through imaging. Adrenal malignancies when metastatic are often 6 cm or smaller. If they are single and they originated from a non–small lung cancer, they must be removed. The endocrine surgery unit remains the best setting to evaluate and treat adrenal gland surgical pathology.     

Adrenalectomy by Retroperitoneal Laparoendoscopic Single Site Surgery

Background:

Laparoscopic adrenalectomy is the current standard for treatment of benign adrenal disease. To reduce the invasiveness of surgery, new techniques have been recently proposed, such as mini-laparoscopy, natural orifice transluminal endoscopic surgery, and laparoendoscopic single site surgery (LESS). Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports.

Case Report:

A 52-year-old female patient with an incidental finding of a 3-cm mass in the left adrenal was referred to us. Preoperative blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid were normal. She underwent an adrenalectomy by retroperitoneal LESS using conventional instruments and ports. Operative time and estimated blood loss were 82 minutes and <50cc, respectively. She was discharged 12 hours after surgery. No intra- or postoperative complications occurred. Pathological analysis of the specimen identified an adrenal cortical adenoma.

Conclusion:

Adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments is feasible. Further studies must be performed to evaluate safety, indications and benefits of this approach.     

Single-port transumbilical laparoscopic-assisted adnexal surgery

Objectives:

To evaluate the efficiency and feasibility of single-port access transumbilical laparoscopic-assisted surgery in patients with large (>8cm) adnexal tumors and to present our initial experience.

Methods:

Twenty-two patients with presumably benign adnexal tumors who have undergone single-port access transumbilical laparoscopic-assisted surgery were enrolled. The procedure was performed using the method of exteriorization and extracorporeal surgery of adnexal tumors outside the abdominal cavity under laparoscopic guidance with preservation of as much ovarian tissue as possible. In each case, a homemade single-port device was inserted into the abdomen through a 2-cm umbilical incision. The clinical characteristics and operative outcomes of these patients were reviewed.

Results:

Twenty of 22 cases were completed successfully. The one failed case required an additional trocar for adequate adhesiolysis, and the other case needed intraperitoneal drainage. The median operating time was 50 minutes (range, 35 to 120), and the estimated blood loss was 38mL (range, 10 to 300). Cyst rupture occurred in 2 cases, but there were no major postoperative complications.

Conclusion:

Single-port access transumbilical laparoscopic-assisted surgery for benign and relatively large adnexal tumors is feasible and could be an alternative to convention open laparotomy or laparoscopic surgery.     

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.     

Expanding the Indications for Laparoscopic Gastric Resection for Gastrointestinal Stromal Tumors

Objective:

Laparoscopic resection of large gastric gastrointestinal stromal tumors (GIST) has been controversial. This generally has been limited to small lesions. We hypothesize that laparoscopic mobilization and resection using, in some cases, extracorporeal anastomosis of the gastrointestinal (GI) tract is an oncologically safe alternative to open surgery even when tumors are large.

Methods:

Four patients underwent a laparoscopic approach for gastric GIST tumors >2 cm at Methodist Dallas Medical Center over a 6-month period. Patient demographics, operative findings, postoperative course, and pathologic characteristics were examined.

Results:

The mean age in this patient group was 58 years (range, 36 to 77). Gastrointestinal bleeding and dyspepsia were the most common symptoms. Seventy-five percent of the patients were females. Mean tumor size was 10 cm (range, 2.5 to 20) with distribution in the stomach as follows: 75% greater curvature and 25% antrum. Tumors were removed by wedge, sleeve, and partial gastrectomies. Two of these tumors showed a high grade and the other 2 a moderate grade of differentiation. The number of mitoses was <5/50 HPF in all the tumors. No intraoperative spillage occurred in any patients, even with the largest tumor (20 cm). Importantly, all tumors were excised with a negative gross and microscopic margin. Average length of stay was 4 days. No patients required reoperation, and there were no complications postoperatively.

Conclusion:

Minimally invasive assisted approaches may be an option to treat large GIST tumors. Obeying principles of minimal touch, no spillage, and obtaining a negative margin, a safe operation with a laparoscopic approach is feasible, even in giant tumors. The large size of diagnosed GIST tumors should not preclude a minimally invasive approach.     

Laparoscopic Splenectomy Coupled with Laparoscopic Cholecystectomy

Background and Objectives:

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

Methods:

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

Results:

The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

Conclusion:

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.     

Simultaneous bilateral laparoscopic adrenalectomy for pheochromocytoma in multiple endocrine neoplasia (MEN) syndrome: Case report with review literature

INTRODUCTION

Laparoscopic adrenalectomy has gained favour as a preferred surgical approach in the multiple endocrine neoplasia (MEN) type 2 patients. Currently, there is limited literature on bilateral simultaneous laparoscopic adrenalectomy in MEN 2 syndrome. We reported two cases of bilateral pheochromocytoma associated with MEN 2 syndrome cured by simultaneous bilateral laparoscopic adrenalectomy.

PRESENTATION OF CASE

First patient presented with big lips since childhood and episodic abdominal pain. On investigations, he was diagnosed with features of MEN 2B syndrome. Second patient was hypertensive and presented with abdominal pain. On evaluation she had features of MEN 2A syndrome.

DISCUSSION

Minimally invasive approach was preferred in both cases. Bilateral simultaneous adrenalectomies were uneventfully done with acceptable operative time and blood loss with rapid perioperative recovery. These cases highlighted the feasibility of laparoscopic simultaneous bilateral adrenalectomy for pheochromocytomas in MEN 2 syndrome.

CONCLUSION

Laparoscopic simultaneous bilateral adrenalectomy is a safe feasible and preferable technique for pheochromocytomas associated with MEN 2 syndrome.     

Short- and Medium-Term Outcome of Robot-Assisted and Traditional Laparoscopic Rectal Resection

Background:

Traditional laparoscopic anterior rectal resection (TLAR) has recently been used for rectal cancer, offering good functional results compared with open anterior resection and resulting in a better postoperative early outcome. However, laparoscopic rectal resection can be technically demanding, especially when a total mesorectal excision is required. The aim of this study was to verify whether robot-assisted anterior rectal resection (RLAR) could overcome limitations of the laparoscopic approach.

Methods:

Sixty-six patients with rectal cancer were enrolled in the study. Twenty-nine patients underwent RLAR and 37 TLAR. Groups were matched for age, BMI, sex ratio, ASA status, and TNM stage, and were followed up for a mean time of 12 months.

Results:

Robot-assisted laparoscopic rectal resection results in shorter operative time when a total mesorectal excision is performed (165.9±10 vs 210±37 minutes; P<0.05). The conversion rate is significantly lower for RLAR (P<0.05). Postoperative morbidity was comparable between groups. Overall survival and disease-free survival were comparable between groups, even though a trend towards better disease-free survival in the RLAR group was observed.

Conclusion:

RLAR is a safe and feasible procedure that facilitates laparoscopic total mesorectal excision. Randomized clinical trials and longer follow-ups are needed to evaluate a possible influence of RLAR on patient survival.     

Parastomal Hernia Repair: a Single Center Experience

Background/Objectives:

Despite multiple options for operative repair of parastomal hernia, results are frequently disappointing. We review our experience with parastomal hernia repair.

Methods:

A retrospective chart review was performed on all patients with parastomal hernia who underwent LAP or open repair at our institution between 1999 and 2006. Information collected included demographics, indication for stoma creation, operative time, length of stay, postoperative complications, and recurrence.

Results:

Twenty-five patients who underwent laparoscopic or open parastomal hernia repair were identified. Laparoscopic repair was attempted on 12 patients and successfully completed on 11. Thirteen patients underwent open repair. Operative time was 172±10.0 minutes for laparoscopic and 137±19.1 minutes for open cases (P=0.14). Lengths of stay were 3.1±0.4 days (laparoscopic) and 5.1±0.8 days (open), P=0.05. Immediate postoperative complications occurred in 4 laparoscopic patients (33.3%) and 2 open patients (15.4%), P=0.38. Parastomal hernia recurred in 4 laparoscopic patients (33.3%) and 7 open patients (53.8%) after 13.9±4.5 months and 21.4±4.3 months, respectively, P=0.43.

Conclusion:

Laparoscopic modified Sugarbaker technique in the repair of parastomal hernia affords an alternative to open repair for treating parastomal hernia.     

Adrenal Schwannoma Treated With Laparoscopic Surgery

Objective:

We report a case of left adrenal schwannoma in a 62-year-old man, incidentally discovered on an abdominal computed tomography. It was successfully treated with laparoscopic adrenalectomy.

Methods:

On admission, no remarkable findings were recognized in the patient''s blood and urine examination, including adrenal function. Laparoscopic left adrenalectomy was performed with the diagnosis of a nonfunctioning adrenal tumor.

Results:

Macroscopically, the tumor (45 mm × 30 mm, 60 g) arose from the medulla of the adrenal gland with a clear border distinguishing it from surrounding tissues. Histologically, the tumor consisted uniformly of spindle cells that were positive for S-100. The cortex was compressed but showed no atrophy. The diagnosis of adrenal schwannoma was made.

Conclusion:

Although an increasing number of adrenal incidentaloma have been identified with the recent advances in imaging techniques, only a few cases of schwannoma of the adrenal gland have been reported. We reviewed the cases reported previously in an attempt to reveal the characteristic features of this rare disease.     

Laparoscopic single site adrenalectomy using a conventional laparoscope and instrumentation

Background and Objectives:

We present a case of Laparoendoscopic Single Site Surgery (LESS) left adrenalectomy performed with a conventional laparoscope and instruments.

Methods:

A 45-year-old male was diagnosed with hyperaldosteronism. Computed tomography detected a left adrenal nodule. Bilateral adrenal vein sampling was consistent with a left-sided source for hyperaldosteronism.

Results:

Total operative time for LESS left adrenalectomy was 120 minutes. The surgery was performed with conventional instruments, a standard 5-mm laparoscope, and a SILS port, with no additional incisions or trocars needed. No complications occurred, and the patient reported an uneventful recovery.

Conclusions:

LESS adrenalectomy is a feasible procedure. Although articulating instruments and laparoscopes may offer advantages, LESS adrenalectomy can be done without these.     

Combined robotic lobectomy and adrenalectomy for lung cancer and solitary adrenal metastasis

Background and Objectives:

Surgical resection of isolated adrenal metastasis in primary lung cancer is associated with improved survival. We report a combined robotic lobectomy and adrenalectomy for resection of a primary lung cancer and metastasis to the adrenal gland.

Methods:

A 69-year-old male with a significant smoking history and shortness of breath was found to have a 3-cm left upper lobe mass with an enlarged left adrenal gland measuring 1.5cm. The adrenal gland was biopsied confirming metastatic poorly differentiated carcinoma, likely lung cancer. Computed tomography, positron emission tomography, and mediastinoscopy revealed no evidence of disease outside the adrenal gland.

Results:

Following induction chemotherapy, the patient underwent combination robotic lobectomy, lymphadenectomy, and adrenalectomy while in the same lateral decubitus position. Thoracic and urologic oncology teams performed their respective portions of the operation. Overall operative time was 4 hours, and length of hospital stay was 3 days. Estimated blood loss was 150mL with no narcotic requirements beyond the first postoperative day. Final pathology revealed large cell carcinoma of the lung with metastasis to the adrenal. All surgical margins were negative.

Conclusions:

Combination robotic lobectomy and adrenalectomy is feasible and can be associated with a short convalescence, minimal pain, and an oncologically sound approach.