经腹腔镜切除肾上腺肿瘤8例报告

目的　评价腹腔镜下肾上腺肿瘤切除的效果。　方法　经腹腔镜切除肾上腺皮质腺瘤 7例及原发性醛固酮增多症 1例 ,所有肿瘤均在右侧 ,直径均 <6cm。　结果　 8例腹腔镜手术都获得成功。平均手术时间 2 .2小时 ;术中平均出血量 70ml;术后平均禁食时间是 1.5天。　结论　经腹腔镜行肾上腺肿瘤切除具有切口小 ,创伤小 ,出血量少 ,术后恢复快的优点     

Laparoscopic adrenalectomy for malignant tumors

Objectives:   The treatment of malignant adrenal tumors using laparoscopic surgery remains controversial. We thus compared the perioperative outcome of the laparoscopic adrenalectomy for the treatment of malignant tumors with the outcome for benign tumors. We also evaluated the oncological outcome of the laparoscopic adrenalectomy for a malignancy.
Methods:   Since 1999 a total of nine laparoscopic adrenalectomies for a malignancy have been performed in nine patients. The median adrenal tumor size was 3 cm. The laparoscopic approach was transperitoneal in all cases. Seven patients had no evidence of a systemic metastatic disease, whereas two patients with a metastatic renal cell carcinoma had systemic metastatic disease at the time of the operation.
Results:   The median operation time was 165 min and the estimated blood loss was 75 mL in the laparoscopic adrenalectomy for a malignancy. There was no significant difference between laparoscopic adrenalectomy for malignant and benign tumors. Regarding the oncological outcome, seven of the nine patients, including the two palliative cases, treated with a laparoscopic adrenalectomy for a malignancy were alive at a median follow-up of 20 months. One patient died of other causes.
Conclusions:   Our results clearly indicate that a laparoscopic adrenalectomy for the treatment of a metastatic adrenal malignancy can be performed with an acceptable outcome as a minimally invasive method in carefully selected patients.     

Laparoscopic adrenalectomy in patients with large adrenal tumors

OBJECTIVES: The maximum size of adrenal tumors that should be removed by laparoscopic adrenalectomy is controversial. We conducted a retrospective comparison of the results of laparoscopic adrenalectomy between patients with adrenal tumors > or =6 cm ('large tumors') and patients with adrenal tumors <6 cm ('small tumors'). METHODS: The participants in the study were 16 patients with large tumors and 111 patients with small tumors. The patients comprised 59 men and 68 women (mean age, 49.0 years; age range, 23-79) with varying diagnoses. Of the 16 patients with large tumors, five had Cushing's syndrome, four had pheochromocytomas, six had a non-functional tumor and one had malignant lymphoma. Adrenal tumors were confirmed by hormonal assays, biochemical tests and computed tomography. Of the 16 large tumors, five tumors were on the right and 11 were on the left. RESULTS: We found no significant differences in general demographic parameters between patients with large and small tumors. The mean duration of surgery was not significantly different between two groups. (large tumors, 210 min; small tumors,175 min). The mean volume of blood loss was 212 mL for large tumors and 30 mL for small tumors (P < 0.001, significant difference). There was no significant difference in time until walking, duration of hospitalization or number of using analgesics used. The time to first oral intake of group 1 (<6 cm) was significantly shorter than group 2 (> or =6 cm). Tumor size (> or =7.5 cm) was an independent predictor of a longer operation and greater blood loss in large tumors. CONCLUSIONS: Laparoscopic adrenalectomy for large tumors was safe and minimally invasive.     

The perioperative management of children with phaeochromocytoma

The safe anaesthetic management of a child with a phaeochromocytoma requires an understanding of the pathophysiology of the disease, together with a thorough knowledge of its pharmacology, in order to avoid or minimize the potentially harmful cardiovascular changes that may occur during anaesthesia. Although there is a considerable amount of information on the management of the adult with phaeochromocytoma, much less has been written concerning children with the disease. Children differ significantly from adults in the incidence, location, presentation and management of this condition and these differences are discussed here together with some of the more controversial issues of management.     

Laparoscopic radical adrenalectomy with adrenal vein tumor thrombectomy: technical considerations

PURPOSE: We describe the technique of adrenal vein tumor thrombectomy during laparoscopic radical adrenalectomy for cancer. MATERIALS AND METHODS: During laparoscopic adrenalectomy for a heterogeneous 7 cm left adrenal mass an adrenal vein thrombus was detected intraoperatively. Laparoscopic ultrasonography was used to delineate precisely the tumor thrombus and its extension into the left main renal vein. The left renal artery and vein were transiently controlled with atraumatic vascular clamps. The renal vein was incised and the intact tumor thrombus was removed en bloc with the radical adrenalectomy specimen. The renal vein was suture repaired with 4-zero prolene and the kidney was revascularized. RESULTS: Renal warm ischemia time was 21 minutes, blood loss was 300 cc and operative time was 6.2 hours. Pathological evaluation revealed a 7.5 cm 68 gm adrenal cortical cancer with tumor thrombus. Soft tissue and adrenal vein margins were negative for cancer. CONCLUSIONS: Laparoscopic radical adrenalectomy with en bloc adrenal vein tumor thrombectomy can be exclusively performed intracorporeally, while respecting oncological principles. Essential technical steps include wide margin excision of the adrenal gland, intraoperative ultrasonography, renal vascular control, en bloc tumor thrombectomy and renal venous suture repair in a bloodless field.     

Laparoscopic simultaneous bilateral adrenalectomy: assessment of feasibility and potential indications

Objective: To report a single‐center experience with laparoscopic simultaneous bilateral adrenalectomy (LSBA) and to evaluate its safety, surgical outcomes, and potential indications of the procedure. Methods: A total of 21 patients underwent LSBA between 2000 and 2010 at our institution. Four patients had bilateral Cushing's syndrome (CS), two had bilateral pheochromocytoma, and one had a bilateral metastatic tumor. Eleven patients had unilateral or bilateral aldosterone‐producing adenoma (APA), associated with CS or subclinical CS. Three patients had unilateral APA with contralateral non‐functioning adenoma. Partial adrenalectomy was performed first by using with four ports. After the excision of one gland, the contralateral gland was removed after repositioning of the patient. Results: LSBA was completed in all 21 patients without major complications. Mean operative time was 329.7 min and the estimated blood loss was 94.1 mL. Mean tumor size was 21.8 mm. Of the 16 patients receiving an adrenal‐sparing procedure, nine of 11 discontinued glucocorticoid replacement after 2 years. The remaining five patients receiving bilateral total adrenalectomy required 0.5–0.75 mg of dexamethasone permanently. No open conversions, no deaths or no adrenal insufficiencies were encountered. Conclusions: LSBA represents a safe and viable treatment option for selected patients with bilateral adrenal disease.     

Anaesthesia for phaeochromocytoma removal in a 5-year-old boy

We describe the case of a 5-year-old boy with phaeochromocytoma of the left adrenal gland, treated surgically by removal of the tumour under general anaesthesia. Phaeochromocytoma is a particularly rare tumour in children and surgical excision is the definitive treatment. We discuss the clinical and laboratory characteristics of the case, the diagnostic approach, the preoperative and intraoperative management and the postoperative course.     

Laparoscopic adrenalectomy: a 6-year experience of 59 cases

Background: The aims of this paper were to review our experience with laparoscopic transperitoneal adrenalectomy, report on outcomes in comparison with the published literature, and demonstrate any learning curve with the technique. Methods: A review of our database and patient records was carried out for the period April 1995 to December 2000. Patient demographics, tumour characteristics, operating times, outcomes and lengths of stay were studied. Diagnostic tools, including a comparison between tumour size on computed tomography scanning and on pathological section were reviewed. A comprehensive literature review was conducted using MEDLINE. Results: Indications for surgery included 33 patients with primary hyperaldosteronism (29 adenomas, 4 hyperplasias), 12 phaeochromo­cytomas, 7 cortisol‐secreting adenomas, 4 non‐secreting adenomas, 1 medullary cyst, 1 metastasis and 1 ganglioneuroma. The tumours ranged in size from 7 to 110 mm. All tumours were localized and lateralized preoperatively using standard techniques. Throughout the review period, six open procedures were undertaken electively, for various reasons. Three cases were converted to open procedures (5.1%). Thirty‐eight left and 21 right procedures were undertaken. For all laparoscopic procedures, the average time in the operating theatre was 175.1 min. Men took 188.3 min compared with 165.7 min for women. Left‐sided lesions took 178.72 min compared with 167.63 min for right‐sided lesions. The average length of stay was 3.8 days. There was one wound infection, one blood transfusion and two readmissions: one for pain control in a patient with difficult home circumstances, and one patient suffered transient hypoadrenalism. Conclusion: The results achieved in our initial experience with this technique are comparable with the published literature. The results confirm that laparoscopic adrenalectomy is the method of choice for resection of benign adrenal pathology. The procedure has a learning curve and should be performed by a surgeon experienced in both open and laparoscopic adrenal surgery.     

Haemodynamic changes during retroperitoneoscopic adrenalectomy for phaeochromocytoma

Surgical removal of phaeochromocytoma may be accompanied byacute cardiovascular changes. We report the haemodynamic changesin seven patients with retroperitoneal laparoscopic adrenalectomyfor phaeochromocytoma. Transient hypertension (systolic pressure(SBP) >160 mm Hg) was observed in all patients during manipulationof the tumour, in two patients during pneumoretroperitoneuminsufflation, and in one patient during intubation. Small dosesof nicardipine were sufficient to control these episodes ofhypertension. Transient hypotension (SBP <100 mm Hg) wasobserved in two patients during exsufflation and in one patientduring repositioning to the lateral position. Our observationssuggest that this approach provides relative haemodynamic stability,especially during pneumoretroperitoneum insufflation. Br J Anaesth 2001; 86: 731–3     

Laparoscopic adrenalectomy for functioning and non-functioning adrenal tumors: Analysis of surgical aspects based on histological types

BACKGROUND: The aim of this study was to evaluate whether hormonal functions of the tumor influence the operative results of laparoscopic adrenalectomy, and to analyse the clinical outcomes in patients with various hormonally active adrenal tumors. METHODS: Clinical and pathological records of 68 patients were reviewed. The average age of patients was 40 years (range 20-75); 39 were women and 29 men. For the comparison, patients were divided into the non-functioning tumor group (n = 22) and the functioning tumor group (n = 46). RESULTS: All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. The median operative time and blood loss in the two groups were similar; however, in subgroup analysis, operative time for pheochromocytoma was significantly longer than that for non-functioning tumor (P = 0.044). No difference was noted in intra- and postoperative data between the groups. Of the 22 patients with aldosteronoma, 18 (81.8%) became normotensive and no longer required postoperative blood pressure medications. Adrenalectomy led to an overall reduction in the median number of antihypertensive medications (P < 0.001). All patients with Cushing adenoma had resolution or improvement of the signs and symptoms during follow-up periods. There was no evidence of biochemical or clinical recurrence in any patient with pheochromocytoma. CONCLUSION: The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as non-functioning adrenal tumors, although endocrinologic features may play a significant role.     

Laparoscopic adrenalectomy

Background Soon after its introduction, laparoscopic adrenalectomy (LA) became the procedure of choice in the surgical management of most adrenal tumors. The aim of this study was to assess the outcome and learning curve of the first 100 cases operated by the same surgical team.Methods Retrospective analysis of prospectively collected data of 100 consecutive LAs was performed. The parameters studied were indication for surgery, side and length of operation, intra- and postoperative complications, size of tumor, conversion to open surgery, final diagnosis, and length of stay.Results Between 1996 and 2002, 100 LAs were performed in 90 patients. The procedures included 45 left, 35 right, and 10 bilateral resections for pheochromocytoma (29), Cushings syndrome (27), Conns syndrome (16), nonfunctioning adenoma (13), and others (5). Mean tumor size was 4.16 cm (range, 0.3–11). Overall major morbidity occurred in eight patients (9%); there was one mortality due to cerebrovascular accident in an elderly patient. Five cases (5%) were converted to open surgery. The mean length of stay for the whole group was 4.7 days (range, 2–25). In order to assess the learning curve, procedures were divided into three, equal consecutive groups (n = 33, 33, and 34). Intraoperative complications in the intermediate and late groups were significantly less compared to those in the early group (2/33, 2/34, and 7/33, respectively; (p < 0.05). Similarly, the mean operating time was significantly reduced between the early (169 min) and both intermediate (116 min) and late (127 min) groups (p < 0.005). The conversion rate was reduced between the three groups (3/33, 2/33, and 0/34), but this was not significant (p = 0.06).Conclusions As expected, the outcome of LA is associated with a steep learning curve. According to this study, it seems that performance of approximately 30 cases by an experienced laparoscopic surgeon is required to master the procedure.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003An erratum to this article can be found at .     

Laparoscopic adrenalectomy for pheochromocytoma

Background Laparoscopic adrenalectomy is a safe and effective treatment for most surgical diseases of the adrenal gland. However it has been suggested that catecholamine effects associated with pheochromocytoma render the laparoscopic approach a more challenging and a more morbid procedure. The purpose of this study was to compare the operative characteristics and outcomes of laparoscopic adrenalectomy for pheochromocytoma to those of aldosteronoma and incidentaloma.Method Patient records and operative reports were retrospectively reviewed for demographics, diagnoses, operative management, and outcomes for patients undergoing laparoscopic adrenalectomy between June 1994 and July 2002 at two academic medical centers. A total of 74 patients were included and analyzed by diagnosis. Differences were considered statistically significant at p < 0.05.Results Twenty-eight patients with pheochromocytoma, 27 with aldosteronoma, and 19 with incidentally discovered nonfunctioning adrenal masses underwent laparascopic adrenalectomy. Patients undergoing resection for pheochromocytoma trended toward more operative blood loss (150 ml) compared to aldosteronoma (88 ml) and incidentaloma (75 ml). Eight patients were converted to an open procedure for a 10.8% conversion rate. The mean operative time was 171 min and there was a 10.8% perioperative complication rate. The mean hospital stay was 3.4 days. These results were not statistically significant between diagnostic groups.Conclusion Despite concern about increased operative times and morbidity associated with pheochromocytoma, our experience supports that laparoscopic adrenalectomy may be performed as safely as, and achieve outcomes similar to, those for other diseases.Paper presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, California, USA, March 2003     

Laparoscopic adrenalectomy for pheochromocytoma: evaluation of experience and strategy at a single institute

OBJECTIVE

To assess the utility, safety and feasibility of laparoscopic adrenalectomy (LA) for pheochromocytoma. We reviewed our experience, focusing on surgical outcomes compared with our historical open adrenalectomy (OA) and modifications in surgical procedures.

PATIENTS AND METHODS

Between 1997 and 2007, 23 patients with pheochromocytoma underwent LA at our institution. As controls, 18 patients undergoing OA were examined retrospectively. In the first cases of LA, we used an abdominal wall‐lifting device with low pneumoperitoneal pressure and initial ligation of the adrenal vein. In subsequent cases, we adopted similar methods to those we perform for other benign adrenal tumours, including a ‘regular’ pneumoperitoneal pressure, and disconnection of the adrenal vein as the last step of tumour dissection.

RESULTS

Rates of hypertension crisis (systolic blood pressure (sBP) of >200 mmHg) and sudden hypotension subsequent to ligation of the adrenal vein (sBP of <80 mmHg) were 17% and 48% in the LA group, and 44% and 72% in the OA group, respectively. Instability of blood pressure was not amplified by the modifications in surgical procedures of laparoscopy. The groups were comparable for operative duration. The intraoperative blood loss among LA patients in whom adrenalectomy was completed laparoscopically was significantly less than that among OA patients, at a median (range) of 70 (10–530) mL vs 400 (10–990) mL (P < 0.001). However, four LA patients with conversion to open surgery had severe blood loss. Regarding postoperative complications and convalescence, the LA group had more favourable outcomes.

CONCLUSION

Laparoscopic removal of pheochromocytoma can be safely and feasibly accomplished by surgical approaches similar to those used for other pathological conditions of the adrenal gland. However, conversion to open surgery should be considered in cases with unexpected difficulty in dissection, invasion or adhesion.     

Laparoscopic simultaneous bilateral partial and total adrenalectomy: a longer follow‐up

OBJECTIVE

To examine the feasibility and safety of laparoscopic simultaneous bilateral adrenal surgery (LSBAS) and to compare the results between laparoscopic total adrenalectomy (TA) and partial adrenalectomy (PA).

PATIENTS AND METHODS

Between 1999 and January 2008, 12 patients underwent LBAS in our institution, with TA used in four with Cushing’s disease refractory to pituitary surgery or radiation, in one with occult ectopic adrenocorticotropic hormone (ACTH) Cushing’s syndrome, and one with bilateral adrenal macronodular hyperplasia. Six patients (five with primary aldosteronism and one with Cushing’s syndrome) had bilateral functioning tumours had bilateral PAs.

RESULTS

All 12 operations were completed with no intraoperative complication, conversion, re‐operation or death. The mean (range) operative duration was 323 (180–560) min, and the mean estimated blood loss was 79 (20–200) mL. There was adrenal insufficiency after surgery in three patients. Patients who had a PA had significantly longer surgery than those treated with TA, with a mean (sd ) of 390 (36) vs 255 (27) min.

CONCLUSION

LSBAS is technically feasible; although surgery was longer than TA, bilateral PA in patients with bilateral functioning tumours mitigated the need for life‐long steroid replacement.     

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group

Study Type – Practice patterns (retrospective cohort) Level of Evidence 2b

OBJECTIVE

? To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold‐standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain.

PATIENTS AND METHODS

? The data of 363 patients who underwent a LA were prospectively collected in 23 centres. ? All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10–20 LAs/year) and group C (>20 LAs/year). ? In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. ? Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed.

RESULTS

? The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). ? In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. ? The mean (sd ) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. ? The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively.

CONCLUSION

? LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high‐volume centres by a surgeon performing at least >10 LAs/year.     

后腹腔镜八步法行巨大肾上腺肿瘤解剖性切除术

目的:介绍采用后腹腔镜八步法行巨大(直径≥5cm)肾上腺肿瘤解剖性切除术的手术技巧及临床效果。方法:2009年1月~2013年10月期间对34例巨大肾上腺肿瘤患者采用后腹腔镜八步法行巨大肾上腺肿瘤解剖性切除术:①清除腹膜外脂肪;②打开Gerota筋膜,游离肾脏背侧间隙;③游离肾脏腹侧间隙;④打断肾脏与肿瘤之间的连接;⑤游离肾上腺肿瘤膈面;⑥游离肾上腺肿瘤腹侧;⑦处理肾上腺肿瘤上极;⑧完整切除肿瘤。结果:34例腹腔镜手术全部完成,仅1例中转开放手术。肿瘤平均直径〔7.3±2.4(5.5~14.5)〕cm,平均手术时间〔89±44(30~185)〕min,术中平均估计出血量〔172±246(10~1000)〕ml。1例术中输血800ml,1例术后输血400ml;1例术后并发急性肺水肿,保守治疗后康复;术后平均恢复饮食时间为〔1.6±0.9(1~4)〕d,术后平均住院时间为〔6.3±2.6(3~14)〕d。结论:按照八步法行后腹腔镜巨大肾上腺肿瘤解剖性切除术,具有操作空间充分、层次清楚、视野清晰、手术成功率高、创伤小、出血少及并发症少等优点。后腹腔镜八步法巨大肾上腺肿瘤解剖性切除术安全可行。     

Laparoscopic radical adrenalectomy for malignancy in 31 patients

PURPOSE: Laparoscopic adrenalectomy for malignancy is controversial. We analyzed our experience with laparoscopic radical adrenalectomy for cancer with an emphasis on predictors of surgical outcome and oncological followup data. MATERIALS AND METHODS: Since July 1997, 31 patients have undergone a total of 33 laparoscopic adrenalectomies for malignancy. Mean adrenal tumor size was 5 cm (range 1.8 to 9). The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Data were obtained from patient charts, radiographic reports and direct telephone calls to patient families. RESULTS: Associated organ resection (radical nephrectomy) was performed in 3 patients. One case was electively converted to open surgery. There was no operative mortality. The pathological diagnoses were metastatic cancer in 26 cases and primary adrenal malignancy in 7. Current median followup, available on 30 patients, was 26 months (range 1 to 69). Overall 15 patients (48%) died and 16 (52%) were alive, of whom 13 (42%) showed no evidence of disease. Cancer specific survival at a median followup of 42 months was 53% and 5-year actuarial survival was 40%. Local recurrence was noted in 7 patients (23%). There were no port site metastases. Survival was similar in patients with tumors less than 5 cm vs 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients with local recurrence (p = 0.016). CONCLUSIONS: Laparoscopic radical adrenalectomy can be performed with acceptable outcomes in the carefully selected patient with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. To our knowledge the largest series in the literature to date is presented.