Isolated Adrenal Metastasis: The Role of Laparoscopic Surgery

Background Solitary adrenal metastases (AM) are rare and their management unclear. Surgery, especially laparoscopic adrenalectomy (LA), is debatable in the management of AM. This retrospective study analysed the feasibility and the results of LA for AM. Methods From 1997 to 2003, 16 patients underwent LA for isolated AM. Completeness of resection, postoperative morbidity and follow-up (FU) were recorded. Results There were 10 synchronous AM and 6 metachronous AM. Primary tumours included lung cancer (n = 9), melanoma (n = 3), mesothelioma (n = 1), rhabdomyosarcoma (n = 1), colonic adenocarcinoma (n = 1) and renal cell carcinoma (n = 1). Five patients required conversion to an open procedure. Minor complications occurred in three patients. Pathology confirmed the diagnosis of AM. Mean tumour size was 60 (range: 15–110) mm. Nine patients (56%) had complete resections, 3 had positive margins and 4 had incomplete macroscopic resections. Mean observed FU was 25 (range: 1–68) months. Median overall calculated survival was 23 months. Overall 5-year survival was 33% (Kaplan–Meyer). At the end of study, 8 patients were alive with a mean FU of 35 months (3 without evidence of disease). No patient presented with local relapse or port-site metastasis. We did not identify any predictive factors. All patients with incomplete macroscopic resection died within 24 months. Conclusions LA can achieve an acceptable 5-year survival, comparable to open surgery but with better postoperative comfort. It should be considered for AM with the intention of complete resection. It offers the patient the possibility of tumour resection with the benefit of a laparoscopic approach.     

腹腔镜在肾上腺手术中的应用

目的探讨腹腔镜技术在肾上腺手术中的临床应用价值。方法2000年12月-2006年5月,对86例肾上腺占位性病变行腹腔镜肾上腺切除术,其中经腹腔途径1例,经腹膜后途径81例,经腹手助腹腔镜4例。结果86例手术全部成功,无中转开放手术,无严重并发症发生。手术时间50-175 min,平均72 min。术中出血量15-120 ml,平均54 ml。术后住院时间5-8 d,平均6.3 d。86例术后随访2-65个月,平均26.5月,影像学检查未见肿瘤复发或转移,功能性肿瘤病人的症状减轻或消失。结论腹腔镜肾上腺切除术创伤小,术中出血少,术后恢复快,是治疗大多数肾上腺占位性病变的首选术式。     

The Emerging Role of Robotics in Adrenal Surgery

Robotic surgery is being performed more frequently for a variety of urologic procedures. Since the first robotic adrenalectomy less than a decade ago, this modality has gained increased acceptance in the urologic community and has been employed with increased frequency in minimally invasive centers. This review evaluates the current literature on robotic adrenalectomy, its indications, as well as its advantages and limitations compared with other forms of surgical management of adrenal pathology.     

Adult-Type Ganglioneuroblastoma in the Adrenal Gland Treated by a Laparoscopic Resection: Report of a Case

A case of ganglioneuroblastoma in the adrenal gland of a 50-year-old man is reported. The patient was incidentally found to have a nonfunctioning tumor in the right adrenal gland. The tumor, measuring 4.5cm, was successfully removed using laparoscopy. Histologically, the tumor was diagnosed to be a ganglioneuroblastoma. Immunohistochemically, a few MIB-1-positive cells and no S-100 protein-positive cells were observed. There has been no evidence of recurrence for 2.5 years to date after the operation. Adrenal ganglioneuroblastoma is extremely rare in adults, and only seven such cases have been previously reported in the literature.     

腹腔镜胃癌根治术联合术中腹腔温热化疗预防肿瘤复发的研究

目的:研究腹腔镜胃癌根治术联合术中腹腔内温热化疗对预防术后肿瘤复发,提高胃癌术后生存率的临床效果。方法:腹腔镜胃癌根治术46例,随机分为两组,其中23例胃癌根治术中施行腹腔内温热化疗,23例术中常规用生理盐水冲洗腹腔,观察术后并发症、毒副反应和近期随访结果。结果:两组术后并发症和毒副反应基本相同(P>0.05),随访2年,治疗组死亡6例(26.1%),明显低于对照组死亡的13例(34.8%),其中2例肿瘤复发,明显少于对照组的8例(P<0.05)。结论:腹腔镜胃癌根治术联合术中腹腔内温热化疗可在术中杀死腹腔内游离癌细胞,对预防术后肿瘤复发,提高术后生存率有一定的效果。     

Is Preservation of the Adrenal Vein Mandatory in Laparoscopic Adrenal-Sparing Surgery?

BACKGROUND AND OBJECTIVE: Adrenal tissue-sparing or partial adrenalectomy evolved initially for patients with bilateral synchronous adrenal surgical pathology to preserve vital adrenal volume. In the laparoscopic era, the exact criteria for performing such procedures laparoscopically have yet to be defined. Controversy exists regarding the importance of preserving the adrenal vein, main or accessory. The aim of this retrospective study was to present our short series of laparoscopic tissue-sparing adrenalectomies with vein preservation. Our main goal is not to support partial adrenalectomy as an alternative to total (this is already advocated by many surgeons) but to emphasize the vein-preserving technique. METHODS: Seven patients with peripherally located either aldosterone-producing adenomas (4 cases) or myelolipomas (4 cases) underwent laparoscopic lateral partial adrenalectomy. One patient harbored an aldosterone-producing adenoma and a myelolipoma as well. The main adrenal vein was identified and preserved in 6 patients and the accessory vein in one. RESULTS: No conversion to open adrenalectomy was necessary, and no perioperative morbidity or mortality occurred. Three adenoma patients are normotensive 44, 23, and 20 months postoperatively, while the fourth one's pressure is refractory. CONCLUSIONS: Surprisingly, total adrenalectomies preceded the partial ones, which is controversial compared with other procedures. Laparoscopic lateral partial adrenalectomy is a technically challenging tissue-sparing operation. Meticulous dissection allows preservation of the middle artery and main or accessory vein resulting in a functioning adrenal stump.     

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.     

腹腔镜下肾切除术26例临床报告

目的评价腹腔镜下肾切除术的临床应用价值. 方法应用腹腔镜行肾切除术26例,其中经腹腔途径19例,经腹膜后途径7例.包括肾癌根治术8例,肾输尿管全切术7例(其中肾盂癌2例,输尿管癌5例),无功能和萎缩肾6例,活体供肾取肾术5例. 结果手术均获成功,手术时间120～250 min,平均190 min,出血量50～200 ml,平均130 ml,均未输血,无手术并发症.肾肿瘤8例平均随访16个月,肾输尿管全切7例平均随访20个月,其中1例输尿管肿瘤局部复发,余均无肿瘤局部复发和远处转移. 结论腹腔镜下行肾切除术可行,创伤小,术中出血少,术后恢复快.     

从腹腔镜到机器人辅助肾部分切除术的过渡:一个资深腹腔镜外科医生的学习曲线

背景腹腔镜肾部分切除术的高难度和挑战性使许多腹腔镜外科医生采用机器人辅助肾部分切除术治疗肾脏小肿瘤。从腹腔镜肾部分切除术到机器人辅助肾部分切除术的过渡期我们评估一个资深腹腔镜外科医生的学习曲线。方法我们比较同一外科医生施行的早期20例机器人辅助肾部分切除术和最近18例腹腔镜肾部分切除术的围术期结果。所有手术是在2005年4月～2009年7月间完成的。既往该医生成功施行100余例腹腔镜肾部分切除术和100余例机器人辅助手术。2组手术步骤相同,在镜下充分游离肾动静脉后,完整游离肿瘤表面,利用术中超声来界定肿瘤边界,哈巴狗血管阻断钳控制肾动脉,在热缺血状态下切除肿瘤,2-0可吸收线连续缝合肾实质,如果集合系统切开后也予以缝合。学习曲线的定义指能熟练地在较短的手术时间和热缺血时间内完成机器人辅助肾部分切除术的例数。利用散点图显示机器人辅助肾部分切除术的学习曲线,用以比较2种术式的手术时间和热缺血时间。结果 2组患者术前临床资料和肿瘤病理学结果的比较无统计学差异。2组均无切缘阳性病例。2组手术并发症也无统计学差异。在机器人辅助肾部分切除术的学习曲线(图1)中,手术时间和热缺血时间均呈下降趋势。经过早期5例手术后,机器人辅助肾部分切除术的平均手术时间即可接近最近18例腹腔镜肾部分切除术的平均手术时间。前5例机器人辅助肾部分切除术的平均手术时间是242.8 min,远远长于后15例机器人辅助肾部分切除术平均手术时间171.3 min(P=0.011)。结论 一个资深腹腔镜外科医生从腹腔镜到机器人辅助肾部分切除术过渡是一个非常迅速的过程。2组热缺血时间、术中估计出血量和住院时间均无统计学差异。经过前5例机器人辅助肾部分切除术后,一个资深腔镜外科医生行机器人辅助和腹腔镜肾部分切除术的手术时间大致相同。     

腹腔镜肝左外叶切除11例报告

目的：探讨腹腔镜下肝左外叶切除术的可行性。方法：直径小于10cm,位于肝左外叶的5例原发性肝癌，4例肝海绵状血管瘤，2例肝局限性增生结节患者，在全气腹状态，气腹结合免气腹或腹腔镜加下切口下，采用微波固化，超声刀，钳夹电凝，旋转刮吸和切割缝合器等多种断肝方法行腹腔镜肝切除术。结果：腹腔镜肝左外叶切除11例均获得成功，手术时间1．5－6h，术中出血50－500ml，术后恢复顺利，住院时间为5－15d，结论：直径小于10cm，无周围脏器浸润的肝左外叶肿瘤行腹腔镜肝切除术是安全可行的。     

Laparoscopic Colorectal Surgery: Summary of the Current Evidence

INTRODUCTION

Laparoscopic colectomy has not been accepted as quickly as laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomised controlled trials (RCTs) and initial reports on port-site recurrence after curative resection. The aim of this review is to summarise current evidence on laparoscopic colorectal surgery.

PATIENTS AND METHODS

Review of literature following Medline search using key words ‘laparoscopic’, ‘colorectal’ and ‘surgery’.

CONCLUSIONS

Laparoscopic colorectal surgery proved to be safe, cost-effective and with improved short-term outcomes. However, further studies are needed to assess the role of laparoscopic rectal cancer surgery and the value of enhanced recovery protocols in patients undergoing laparoscopic colorectal resections.     

Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system

Background and Objectives:

To compare postoperative complications in patients undergoing laparoscopic and open partial nephrectomy using a standardized complication-reporting system and a standardized tumor-scoring system.

Methods:

We conducted a retrospective analysis of 189 consecutive patients with nephrometry scores available who underwent elective partial nephrectomy for renal masses. Demographic, perioperative, and complication data were recorded. By using the modified Clavien scale, we graded 30- and 90-day complication rates.

Results:

107 patients underwent laparoscopic partial nephrectomy and 82 underwent open partial nephrectomy (N=189). Open partial nephrectomy patients had higher nephrometry scores than laparoscopic patients had (7.1±2.4 vs. 5.6±1.8, P<.001). Surgical and hospitalization times were shorter, and estimated blood loss was lower in the laparoscopic group (P<.001). At 30 days, there were more overall complications in the open group, but more major complications in the laparoscopic group (P>.05). After multivariable logistic regression analysis, only higher body mass index and higher estimated blood loss were predictors of more overall complications.

Conclusions:

Laparoscopic partial nephrectomy has the advantages of decreased operative time, lower blood loss, and shorter hospital stay. The complication rate in the laparoscopic group is similar to that in the open group, despite favorable tumor characteristics in the laparoscopic group.     

单孔后腹腔镜手术在肾及肾上腺疾病中的应用（附33例报告）

目的探讨利用自制单孔多通道装置及常规腹腔镜器械完成单孔后腹腔镜肾及肾上腺手术的可行性。方法2011年8月～2012年3月,采用切151保护器＋橡胶手套自制单孔多通道装置,利用常规腹腔镜器械完成33例单孔后腹腔镜手术,其中肾上腺肿瘤切除10例,肾癌根治性肾切除6例,肾囊肿去顶减压术12例,肾蒂淋巴管结扎术4例,肾盂成形术1例。结果33例手术均顺利完成,其中1例肾盂成形术因术中缝合困难另增加-5mm通道完成手术,无中转开放手术。住院时间4～9d,平均6d。术中术后未出现明显并发症。结论自制单孔多通道后腹腔镜手术在治疗肾及肾上腺疾病方面安全可行,具有创伤小、切口美观等优点。自制单孔多通道装置制作使用方便,价格低廉。     

Medullary Thyroid Carcinoma Metastasis to the Breast and Axillary Lymph Nodes

Breast metastases of medullary thyroid carcinoma (MTC) are extremely rare, and only a few cases have been reported in the literature so far. Here, we report a case of metastatic MTC to the breast and axillary lymph nodes (LN). The case illustrates that (1) metastatic MTC of the breast could be clinically and pathologically misdiagnosed as primary breast cancer, such as invasive lobular carcinoma with axillary LN involvement; (2) unlike other metastatic breast cancer patients, who have very poor prognoses, our patient survived for more than 5 years after the breast and axillary surgery; and (3) metastasis of MTC to the breast is accompanied by axillary LN metastasis, which requires thorough axillary LN dissection, as in most primary breast cancers.     

经腹腹腔镜肾癌根治术(附70例报告)

目的探讨经腹途径腹腔镜肾癌根治切除术的技术要点及临床价值。方法采用经腹途径腹腔镜肾癌根治术,切开侧腹膜后,首先处理肾蒂血管,然后行肾癌根治术。结果70例手术全部成功,无中转开放手术,手术时间90～230min,平均130min。术中及术后均未输血。2例切口感染,4例皮下气肿。术后住院4～8d,平均6.2d。70例随访2～78个月,平均47个月,无肿瘤复发。结论经腹途径腹腔镜肾癌根治术具有创伤小,安全有效,恢复快等优点,具有良好的临床应用前景。     

Adrenal gunshot wound: Laparoscopic approach. Report of a case

INTRODUCTION

Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy.

PRESENTATION OF CASE

We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy.

DISCUSSION

We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication.

CONCLUSION

Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomies.     

Oncologic Outcome after Laparoscopic Radical Prostatectomy: 10 Years of Experience

Background

While the published short-term oncologic outcomes after laparoscopic radical prostatectomy (LRP) are encouraging, intermediate and long-term data are lacking.

Objective

We analyzed the oncologic outcome after LRP based on 10 yr of experience.

Design, setting, and participants

This retrospective analysis of data prospectively collected from 1998 to 2007 studies 1564 consecutive patients with clinically localized prostate cancer (cT1c–cT3a) who underwent LRP.

Intervention

LRP was performed by two surgeons at either L’Institut Mutualiste Montsouris (IMM) in Paris, France, or Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City, USA.

Measurements

Progression of disease was defined as a prostate-specific antigen (PSA) of ≥0.1 ng/ml with confirmatory rise or initiation of secondary therapy. Patients were stratified as low, intermediate, or high risk based on the pretreatment prostate cancer nomogram progression-free probability of >90%, 89–71%, and <70%, respectively.

Results and limitations

The overall 5-yr and 8-yr probability of freedom from progression (PFP) was 78% (95% confidence interval [CI], 74–82%) and 71% (95% CI, 63–78%), respectively. For low-, intermediate-, and high-risk cancer, the 5-yr PFP was 91% (95% CI, 85–95%), 77% (95% CI, 71–82%), and 53% (95% CI, 40–65%), respectively. Surgical margins (SMs) were positive in 13% of the cases. Nodal metastases were detected in 3% of the patients after limited pelvic lymph node dissection (PLND) and in 10% after a standard PLND (p < 0.001). The 3-yr PFP for node-positive patients was 49%. There were 22 overall deaths and 2 deaths from prostate cancer.

Conclusions

LRP provided 5- and 8-yr cancer control in 78% and 71% of patients, respectively, with clinically localized prostate cancer and in 53% of those with high-risk cancer at 5 yr. A PLND limited to the external iliac nodal group is inadequate for detecting nodal metastases.     

腹腔镜下胃癌全胃切除术79例的体会

目的 探讨腹腔镜下胃癌行全胃切除术的可行性及效果.方法 对2004年6月至2006年12月共行腹腔镜下根治性全胃切除术79例,其中行D1及D1+淋巴结清扫12例,D2/D2+淋巴结清扫67例.肿瘤位于胃近端者19例,位于胃体者41例,皮革胃2例,位于胃窦并浸润至胃小弯中上部者17例进行分析.结果 79例中77例成功进行腹腔镜手术,2例中转开腹,中转率为2.5%.平均手术时间(275.8±20.8) min,平均出血量(163.3±48.6) ml,平均每例清扫淋巴结(34.7±12.2) 枚,肿瘤近残端(3.8±1.2) cm,远残端(6.9±2.8) cm.术后肛门排气时间(3.6±0.9) d,下床活动时间(2.5±0.4) d.无术后死亡,无吻合口漏,术后发生并发症7例均经内科治疗痊愈.术后随访9～39个月,平均25.6个月,15例患者因肿瘤复发死亡,余64例仍生存.结论 腹腔镜下全胃切除联合胃癌标准根治术是安全可行的,能达到开腹手术的淋巴结清扫范围,且具有创伤小、出血少、恢复快、并发症率低等优点.