Laparoscopic adrenalectomy using the lateral retroperitoneal approach: Is it a safe and feasible treatment option for pheochromocytomas larger than 6 cm?

Objectives

To evaluate the surgical feasibility of laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of large pheochromocytomas, and to identify the preoperative risk factors for intraoperative hypertension.

Methods

We retrospectively reviewed 51 patients who underwent laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of pheochromocytomas. Patient characteristics and perioperative outcomes were analyzed and compared between the two study groups based on tumor size: group A (n = 27, ≤6 cm) and group B (n = 24, ?6 cm).

Results

There was no significant difference in preoperative characteristics between the two groups except for tumor size (P = 0.001) and urinary metanephrine (P = 0.011). Group B patients required longer operating time (P = 0.008), had a greater estimated blood loss (P = 0.001) and hemoglobin change (P = 0.002). However, no significant differences were observed in perioperative complications and mortality. Multivariate analysis showed that symptomatic pheochromocytomas (P = 0.004) and tumor size (P = 0.007) were significant risk factors for intraoperative hypertension.

Conclusions

Laparoscopic adrenalectomy using the lateral retroperitoneal approach for pheochromocytomas can be regarded as a treatment option, even for tumors measuring >6 cm. Symptomatic pheochromocytomas and large tumor size seem to represent risk factors for intraoperative hypertension.

     

Laparoscopic radical prostatectomy: transperitoneal versus retroperitoneal approach: is there an advantage for the patient?

PURPOSE OF REVIEW: Radical prostatectomy is the standard treatment for localized prostate cancer; its translation to a laparoscopic approach is considered today not only as feasible and reproducible but also as a valid and teachable alternative to its open counterpart. Beyond the "classical" transperitoneal antegrade route codified by the Montsouris group, several extraperitoneal approaches were developed, claiming clinical equivalence and reduced risks of morbidity and operative times. This article summarizes various aspects of different approaches and their outcome. RECENT FINDINGS: Complications reported about transperitoneal procedures definitely further the discovery or learning curves of the pioneering teams; the groups who developed extraperitoneal alternatives established their "new approaches" on a solid base of technical skills, acquired transperitoneally. Beyond the unsurpassed qualities of visual and working spaces belonging to the transperitoneal route, which should be taken into account with respect to teaching, transperitoneal antegrade approach to the prostate enables the surgeon with early hemostatic control and essential tactical choices to achieve negative surgical margins. SUMMARY: So far, as oncological and functional results of both approaches seem equivalent, both approaches should be further developed and remain available for teaching purposes. The true benefit for patients lies more in global quality control of surgery than in an obsessional search for alternatives to established techniques that have already stood the proof of time.     

Large sphenocavernous meningiomas: Is there still a role for the intradural approach via the pterional-transsylvian route?

Summary.  Background: Large-sized sphenocavernous meningiomas represent a surgical challenge. Although the role of skull base techniques with combined extra- and intradural steps has been recently emphasized, pure intradural resection tactics via the pterional route constitute the traditional microsurgical approach for resection of such tumours.  Method: We report the application of the pterional-transsylvian approach in 13 patients with sphenocavernous meningiomas. This series is unique because it includes only patients with tumours exceeding 5 cm in their greatest dimension.  Findings: A gross total resection was accomplished in 10 patients (77%). Eight patients had a good outcome, one had a persistent mild hemiparesis, and one died. No recurrences occurred in this group. Three patients (23%) had subtotal resections owing to invasion of the cavernous sinus in one instance and encasement of the middle cerebral artery in the others. Two had a good outcome and one died. In these patients minimal asymptomatic tumour progression was seen 3 and 6 years after surgery. The overall surgical outcome was good in 10 patients (77%), fair in one, and death in two.  Interpretation: In our experience, large sphenocavernous meningiomas may be operated on adopting pure intradural resection tactics via the pterional-transsylvian route with rates of gross total removal and surgical complications related to brain retraction or vascular manipulation comparable to those of extensive skull base approaches. The traditional intradural pterional transsylvian approach continues to have a place in the treatment of these lesions. Published online April 28, 2003 RID="*" ID="*"  This paper was supported in part by Grant “Piano B008 – P.R. 2” from M.U.R.S.T. and European Community.  Correspondence: Domenico d'Avella, M.D., Neurosurgical Clinic, Department of Neuroscience, Psychiatric and Anesthesiolgical Sciences, Policlinico Universitario, via Consolare Valeria 1, 98122 Messina, Italy.     

Laparoscopic approach to pheochromocytoma: is a lower intraabdominal pressure helpful?

Laparoscopic adrenalectomy is gaining popularity because of its well-documented benefits. The aim of our study was to see if a decreased intraoperative intraabdominal pressure during laparoscopic adrenalectomy would affect the hemodynamic variables and the serum levels of catecholamines. We randomly divided 9 patients into 2 groups, maintaining either an intraabdominal pressure of 15 mm Hg (group A) or 8-10 mm Hg (group B). Norepinephrine and epinephrine blood levels were measured preoperatively, during endotracheal intubation, carboperitoneum, surgical manipulation of tumor just before the ligation of the adrenal vein, and tracheal extubation; the hemodynamic variables were recorded. The introduction of carboperitoneum resulted in an increase in heart rate and mean arterial blood pressure (MAP), although it was statistically insignificant. The norepinephrine levels showed a statistically significant increase in group A as compared with group B (P = 0.0002). Surgical manipulation of the tumor resulted in a significant increase in MAP and norepinephrine levels in group A (P = 0.007 and P = 0.0001, respectively). The epinephrine levels did not change as much because the tumor was probably predominantly norepinephrine-secreting. Norepinephrine levels continued to be high even during tracheal extubation in group A patients (P = 0.027). We conclude that a low intraabdominal pressure of 8-10 mm Hg causes less catecholamine release and fewer hemodynamic fluctuations.     

Abdominal aortic laparoscopic surgery: retroperitoneal or transperitoneal approach?

Objective: to define the respective advantages and pitfalls of the trans- or retroperitoneal approaches in laparoscopic abdominal aortic reconstruction (LAOR). DESIGN: prospective study. MATERIAL: ten patients (8 males; average age 58) underwent an aortouni- (n=2) or bifemoral bypass (n=8) to treat aortoiliac occlusive disease (n=8) or an aortic aneurysm (n=2). METHODS: a retroperitoneal approach (the "apron" technique) was used in the first 5 cases (Group I) and a transperitoneal approach in the last 5 cases (Group II). RESULTS: no early or late death occurred, and all bypasses remain patent after a mean follow-up of 5.7 months. Mean surgical and clamping times are similar in both groups (370 and 126 min in Group I; 324 and 137 min in Group II). One intraoperative conversion to open surgery and two postoperative surgical complications occurred in Group I. Four minilaparotomies of 8-10 cm were necessary in Group II. Two patients were discharged on postoperative day 6 in Group I and five in Group II. CONCLUSION: this preliminary study shows the feasibility of LAOR through both approaches. In Group II, a better exposure of the right aortic wall and of the right iliac axis was noted and division of the inferior mesenteric artery was not always necessary.     

Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach?

AIM: Mortality and morbidity of abdominal aortic aneurysm surgery have decreased significantly in time and transperitoneal approach (TPA) still preserves its popularity although retroperitoneal approach (RPA) is known to cause lower incidence and shortened duration of ileus, shorter intensive care unit (ICU) and hospital stay, earlier oral intake and less patient discomfort or pain. METHODS: One hundred and fifty patients that underwent abdominal aortic aneurysm repair at our Cardiovascular Surgery Center between January, 1990 and March, 2000 were reviewed and analyzed based on the elective/emergent nature of the surgery and the type of the incision as either TPA or RPA. RESULTS: Significantly shorter mechanical ventilation (15.2+/-3.8 vs 10.1+/-2.3 hours) and nasogastric decompression periods (40.6+/-10.7 vs 9.1+/-2.2 hours), less need for intravenous fluid supplementation and shorter ICU stay (29.5+/-14.8 vs 18.6+/-1.9 hours) were observed with the retroperitoneal approach (P<0.001). Need for allogeneic blood transfusion was, similar (1.3+/-1.4 vs0.9+/-0.4, P>0.05). Analysis of mortality and morbidity revealed bleeding as the major cause of mortality for ruptured aneurysm. A similar comparison between TPA and RPA groups, however, revealed no significant difference (P>0.05). CONCLUSIONS:| Retroperitoneal approach is a reliable technique causing less fluid-electrolyte imbalance with rapid restoration of gastrointestinal physiology. It causes less discomfort to patients with reduced need for analgesia. A shorter weaning period from mechanical ventilation is among the benefits for patients with co-morbid states.     

Is there a role for incomplete resection in the management of retroperitoneal liposarcomas?

Complete surgical resection is the most effective modality for the treatment of retroperitoneal sarcomas. Previous studies of all types of retroperitoneal sarcomas have not shown a survival benefit of incomplete resection over no resection. Because death often occurs as a result of local progression in retroperitoneal liposarcomas (RPLS), it is possible that incomplete resection may be beneficial in this histologic type. In this study we have sought to determine the clinical outcomes in patients with incompletely resected and unresected RPLS with the aim of defining patients who may benefit from palliative resection. From a prospective clinical database 55 patients with incompletely resected (n = 43) or unresected (n = 12) RPLS were identified between 1982 and 1999. Statistical analyses were performed using the log-rank test and Kaplan-Meier estimates with disease-specific survival as the primary end point. Variables studied included age, gender, recurrent versus primary disease, tumor grade, and tumor size. The patient population consisted of 34 men and 21 women with a mean age of 61 +/- 14 (SD) years. The median time to death was 10 months (range 1 to 83 months) with a median followup of 12 months (range 1 to 60 months) for survivors. Partial resection was an independent factor for increased survival as compared with exploration or biopsy only (median survival 26 versus 4 months, p < 0.0001). Of patients who received incomplete resections, locally recurrent presentation (n = 19) versus primary disease (n = 24) was a negative prognostic variable (median survival 17 versus 46 months, p = 0.009). Successful palliation of symptoms was achieved in 24 of 32 patients (75%) with preoperative symptoms. In select patients with unresectable RPLS, incomplete surgical resection can provide prolongation in survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumors, suggesting that surgical resection should be attempted in the majority of patients.     

Laparoscopic splenectomy in the elderly: a morbid procedure?

BACKGROUND: Laparoscopic splenectomy has emerged as the gold standard for elective splenectomy. Few reports have critically evaluated the results of laparoscopic splenectomy in elderly patients. METHODS: All laparoscopic splenectomies performed between August 19, 1998 and June 8, 2004 were reviewed retrospectively. RESULTS: Of 235 splenectomies, 188 were performed for patients younger than age 65 years (group 1), and 45 were performed for patients 65 years of age or older (group 2). The groups were demographically similar, except for the average age and the American Society of Anesthesiology (ASA) classification. Operative characteristics were similar, but the average length of hospital stay differed: 2.2 days for group 1 and 3.9 days for group 2 (p < 0.03). Complications occurred for 8.5% of group 1 and 17.8% of group 2, but the percentages were similar by ASA class. CONCLUSIONS: Elderly patients have a higher rate of complications after laparoscopic splenectomy. The complications are similar when matched for ASA class, but a larger percentage of elderly patients fall into higher ASA class ratings.     

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

Purpose

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

Methods

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

Results

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

Conclusions

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.     

Balloon-assisted endoscopic retroperitoneal gasless approach (BERG) for lumbar interbody fusion: is it a valid alternative to the laparoscopic approach?

OBJECTIVE: In the last years the use of interbody fusion devices with an anterior spinal lumbar approach has become a common procedure for the treatment of degenerative disc disease and spinal instability. We analysed our series of a simplified endoscopic approach to the anterior spine and made a review of the retroperitoneal endoscopically assisted approach to the anterior lumbar spine in the international literature. METHODS AND RESULTS: From 1999 through 2002, twenty consecutive "balloon-assisted endoscopic retroperitoneal gasless (BERG)" lumbar fusions were performed at San Filippo Neri Hospital in Rome, Italy. The surgical indications included patients with grade I or II spondylolisthesis and symptomatic degenerative disc disease with foraminal stenosis. Fourteen patients underwent a single level fusion (4 cases at L4-L5; 10 cases at L5-S1) and six patients underwent a double level fusion (L4-L5 and L5-S1). Mean operating time was 135 minutes (single level fusion), 175 minutes (double level fusion) and the mean intraoperative blood loss was 177 mL. No perioperative complications were observed and no procedure was converted to open surgical fusion. Patients were allowed to ambulate on the second postoperative day. Fusion was achieved in nineteen patients (fusion rate of 95%) 12 months after surgery. CONCLUSIONS: The BERG technique is a safe, effective, simplified, less technically demanding alternative approach when performing ALIF procedures, without the morbidity associated with laparoscopic or traditional approaches.     

Augmented versus Virtual Reality Laparoscopic Simulation: What Is the Difference?

BACKGROUND: Virtual reality (VR) is an emerging new modality for laparoscopic skills training; however, most simulators lack realistic haptic feedback. Augmented reality (AR) is a new laparoscopic simulation system offering a combination of physical objects and VR simulation. Laparoscopic instruments are used within an hybrid mannequin on tissue or objects while using video tracking. This study was designed to assess the difference in realism, haptic feedback, and didactic value between AR and VR laparoscopic simulation. METHODS: The ProMIS AR and LapSim VR simulators were used in this study. The participants performed a basic skills task and a suturing task on both simulators, after which they filled out a questionnaire about their demographics and their opinion of both simulators scored on a 5-point Likert scale. The participants were allotted to 3 groups depending on their experience: experts, intermediates and novices. Significant differences were calculated with the paired t-test. RESULTS: There was general consensus in all groups that the ProMIS AR laparoscopic simulator is more realistic than the LapSim VR laparoscopic simulator in both the basic skills task (mean 4.22 resp. 2.18, P < 0.000) as well as the suturing task (mean 4.15 resp. 1.85, P < 0.000). The ProMIS is regarded as having better haptic feedback (mean 3.92 resp. 1.92, P < 0.000) and as being more useful for training surgical residents (mean 4.51 resp. 2.94, P < 0.000). CONCLUSIONS: In comparison with the VR simulator, the AR laparoscopic simulator was regarded by all participants as a better simulator for laparoscopic skills training on all tested features.     

The pectoralis major myocutaneous flap: Is the subclavicular route safe?

BACKGROUND: The pectoralis major myocutaneous flap has a proven track record as a reconstructive tool, but excessive bulk and a limited arc of rotation can be problematic. Although this can be addressed by passing the pedicle deep to the clavicle, some authors consider that this modification may compromise the flap. This prospective study therefore sought to compare the supraclavicular and subclavicular routes with particular emphasis on potential vascular sequelae. METHODS: One-hundred patients were randomly allocation into two groups. Following flap harvest, the pedicle was passed in either a supraclavicular or subclavicular plane depending upon allocation. The survival rate and complications of each flap were assessed at 1 month. RESULTS: Total flap necrosis occurred in three (7.0%) of the subclavicular flaps and two (3.5%) of the supraclavicular flaps. This difference was not significant (p =.77). Likewise no statistical difference was noted between the rates of partial flap necrosis, fistula formation infection, or secondary hemorrhage in either group. CONCLUSIONS: The subclavicular route addresses the problem of pectoralis major myocutaneous flap bulk and may increase the arc of rotation of the flap without significantly compromising its vascular supply.     

Large-diameter heads: Is bigger better?

Instability is a major cause of failure in total hip arthroplasty. Large femoral heads have been introduced to improve stability. Although this has been effective in reducing dislocations, optimal component position is still required to maintain stability. In addition, large head articulations have introduced new potential problems, including wear, polyethylene fracture, and taper corrosion. In order to be clinically beneficial, the use of large femoral heads must be complemented with optimal component position and balanced against any potential risks.