Laparoscopic adrenal surgery

Laparoscopic adrenalectomy (LA) was performed in 6 patients (4 right and 2 left). A transperitoneal approach in a lateral position was used. Pheochromocystoma was present in two patients and Conn's syndrome, with a solitary functioning adenoma, was the diagnosis in four. Early vascular control was obtained in the two patients with pheochromocytoma, resulting in very stable intraoperative blood pressure. Operative time for LA was 152±26 min and was associated with a short length of stay (2.0±0.6 days) and minimal intraoperative blood loss (82±30 ml). There were no conversions to laparotomy and one complication was noted. LA is a safe and effective operation for patients requiring adrenalectomy for hormone-secreting tumors.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, USA, 18–19 April 1994     

Laparoscopic adrenalectomy for isolated adrenal metastasis.

BACKGROUND: Laparoscopic adrenalectomy is accepted by many as the standard of care for the majority of adrenal masses less than 8 cm. The question exists whether laparoscopic removal of metastatic lesions to the adrenal is more difficult than laparoscopic removal of primary adrenal lesions. METHODS: We performed a retrospective analysis of all laparoscopic adrenalectomies performed at a single institution from 1998 to 2001, comparing laparoscopic adrenalectomies for primary lesions of the adrenal gland versus isolated metastatic lesions to the adrenal gland. RESULTS: Fourteen laparoscopic adrenalectomies were attempted, 10 for primary disease and 4 for metastatic disease. All 10 laparoscopic procedures were completed successfully for primary disease (average operative time=218 minutes, average tumor size=4 cm, median hospital stay=2 days). Only one of the 4 laparoscopic adrenalectomies for metastatic disease was completed successfully (average operative time=332 minutes, average tumor size=7.3 cm, median hospital stay=2 days). No major complications occurred in either group. CONCLUSIONS: We feel laparoscopic adrenalectomy is the preferred approach for primary adrenal masses less than 8 cm. Based on our experience and a review of the literature, isolated metastatic lesions to the adrenal gland appear less amenable to laparoscopic removal than do primary lesions of the same size.     

巨大肾上腺肿瘤的腹腔镜手术(附29例报告)

目的:探讨分析巨大(直径≥6cm)肾上腺肿瘤行腹腔镜手术的有效性和安全性。方法:回顾分析为29例巨大肾上腺肿瘤患者行腹腔镜手术的临床资料。结果:29例均顺利施行腹腔镜肾上腺肿瘤切除术,经腹腔途径17例,经腹膜后途径12例。肿瘤直径6.0～9.5cm,平均(6.7±2.5)cm,手术时间85～180min,平均(98±35)min,术中出血90～1200ml,平均(225±87)ml,术后胃肠功能恢复时间24～70h,平均(38±25)h,术后2～3d拔除引流管,术后住院6～10d,平均(5.7±2.3)d。随访12～36个月,平均20.5个月,27例患者临床症状消失,2例皮质腺癌复发。结论:螺旋CT及三维重建可为巨大肾上腺肿瘤患者的进一步治疗提供指导。随着技术的不断进步,巨大肾上腺肿瘤不再是腹腔镜手术的绝对禁忌证,腹腔镜手术安全、有效,已成为巨大肾上腺肿瘤患者可选择的有效术式。     

经腹、经后腹腔途径腹腔镜肾上腺肿瘤切除术(附56例报告)

目的 总结经腹腔、经后腹腔途径腹腔镜肾上腺肿瘤切除术的临床经验. 方法 2001年12月～2004年12月,我院施行腹腔镜肾上腺切除术56例.采用经腹腔途径肾上腺肿瘤切除术10例,腹部取3个trocar 穿刺入路,切开侧腹膜和肾周筋膜,在肾上极内上方分离肾上腺或瘤体,结扎速结合超声刀将肿瘤切除.经后腹腔途径切除肾上腺肿瘤46例,腰部取3个trocar 穿刺入路,用自制的气囊扩张后腹腔,切开肾周筋膜,在肾上极内上方分离肾上腺或瘤体,结扎速结合超声刀将肿瘤切除. 结果 10例经腹腔途径中3例因腹腔广泛粘连中转开放手术,46例经后腹腔途径中1例因下腔静脉损伤大出血中转开放手术.余52例术中出血量20～200 ml,平均70 ml,均未输血.手术时间40～200 min,平均110 min.术后住院3～8 d,平均5.4 d.52例随访6～36个月,平均8个月,未见肿瘤复发和转移. 结论 腹腔镜肾上腺切除术效果确切,损伤小,术后恢复快,住院时间短,是肾上腺手术的首选术式.     

Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases

Objective

To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5 cm.

Methods

Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5 cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods.

Results

All 112 operations were completed without any mortality or reoperation. Mean operative time was 151 min and mean blood loss was 30 ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147 ± 5.1 min, mean ± standard error of mean) was significantly shorter than that of the initial 12 cases (183 ± 8.8 min, p = 0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushing's adenomas, 12 pheochromocytomas, and 20 incidentalomas).

Conclusion

The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5 cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.     

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma

Background:

Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature.

Case Report:

We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively.

Conclusion:

Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.     

Laparoscopic right and left adrenalectomies

Background: Laparoscopic approach for adrenalectomy was recently described and the operative technique is not yet well defined. Methods: Twenty-seven laparoscopic adrenalectomies were performed between 1992 and 1995. There were 18 women and nine men ranging in age from 31 to 70 years (mean, 50.8 years). The surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one. Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, nonfunctional adenoma in four patients, Cushing adenoma in two, and an adrenal cyst in one. Median adrenal gland size was 2.0 cm (range 0.5–8 cm). Results: Five patients were converted to laparotomy (18%)—for dissection problems in four and for an unrecognized gland in one. The median anesthesia time was 200 min and the median surgical time was 140 min. Operative morbidity was one adrenal vein injury sectioned close to the vena cava. The hemorrhage was controlled by laparoscopic suturing without conversion. This patient required a three-unit blood transfusion. No mortality occurred and postoperative morbidity was one minor chest infection. The median postoperative in-hospital stay was 4.6 days (range 2–8) for nonconverted patients. Conclusions: Laparoscopic adrenal gland removal is safe and offers fast recovery and short in-hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.     

"瓷化"样胆囊的腹腔镜切除技术探讨

目的:探讨“瓷化”样胆囊的腹腔镜切除技术。方法:37例根据术中胆囊三角的疤痕化程度,采用常规腹腔镜胆囊切除或胆囊横断法(缝合、明胶海绵加生物蛋白胶填塞、圈套器套扎闭合胆囊管)2种手术方式。结果:无中转开腹,常规法切除21例,横断法切除16例。平均手术时间分别为41m in、82m in。平均术中出血量为87m l、170m l。平均术后住院时间为2.8d、5.2d。仅1例发生术后胆漏,3d后自行停止。结论:采用适当的手术技术可以安全地完成“瓷化”样胆囊的腹腔镜切除。     

腹腔镜胆囊切除术术中处理冰冻样三角的手术技巧

目的:总结腹腔镜胆囊切除术术中"冰冻样"Calot三角的处理经验。方法:回顾分析我院为21例患者根据其术中胆囊三角疤痕化程度,分离三角结构后行胆囊大部切除或全切除术的临床资料。结果:行腹腔镜胆囊切除术5例,腹腔镜胆囊大部切除术16例,无中转开腹。平均手术时间87min,术中平均出血160ml,术后平均住院5.2d。仅1例术后发生胆漏,3d后自愈。结论:采用适当的手术技巧,可为Calot三角"冰冻样"改变的患者安全完成腹腔镜胆囊切除术。     

Complications of operative gynecological laparoscopy.

OBJECTIVE: To assess the incidence and type of laparoscopic complications. METHODS: A series of 2140 operative laparoscopies were reviewed in a retrospective study of patient records. The setting was a tertiary-care university hospital. Operative laparoscopy included minor procedures (minimal adhesiolysis, destruction of minimal endometriosis foci, ovarian biopsy, ovarian puncture, tubal sterilization), major laparoscopic surgery (extended adhesiolysis, tuboplasties, uterine suspension, treatment for ectopic pregnancy, salpingitis, ovarian cyst, moderate and severe endometriosis), and advanced laparoscopic surgery (hysterectomy, myomectomy, bladder neck suspension). RESULTS: Two major vascular complications, 3 intestinal injuries, 1 anesthesiological complication, and 4 urinary tract injuries occurred. Two minor and 5 postoperative complications were noted. The overall complication rate was 17/2140 (0.79%). The major complication rate was 10/2140 (0.46%). CONCLUSIONS: This review is useful for helping surgeons reduce the risk of injuries and to inform patients about potential complications. These rates are similar to those that have been previously reported.     

Robot-assisted Laparoscopic Adrenalectomy: Step-by-Step Technique and Comparative Outcomes

Background

Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses.

Objective

To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA).

Design, setting, and participants

We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group.

Surgical procedure

The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure.

Outcome measurements and statistical analysis

Demographic parameters and main surgical outcomes were assessed.

Results and limitations

A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3 cm [interquartile range (IQR): 3] vs 4 cm [IQR: 3]; p = 0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50 ml [IQR: 50] vs 100 ml [IQR: 288]; p = 0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p = 0.66) and positive margin rate (p = 0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p = 0.02).

Conclusions

The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy.

Patient summary

In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.     

腹腔镜肾上腺手术22例报告

目的 :探讨腹腔镜肾上腺切除术的方法、技巧。方法 :经腹膜后腔或腹腔途径 ,实施腹腔镜肾上腺切除 2 2例。结果 :2 2例手术均获成功 ,手术时间 15 0～ 2 70min ,失血 2 0～ 2 0 0ml,术后第 1天进流质并下床活动 ,术后平均住院 4d ,术中腹膜破裂 5例 ,无其他并发症。结论 :腹腔镜肾上腺切除用食指分离建立后腹膜腔和用吸引管分离肾上腺具有省时、省力等优点     

腹腔镜在肾上腺肿瘤切除术中的应用（附8例报告）

2000年10月-2001年6月在电视腹腔镜下施行肾上腺肿瘤切除术8例，除1例因术中出血，止血困难转为开放手术外，其余均顺利完成手术，无手术后并发症。对腹腔镜下肾上腺肿瘤手术适应证、手术技巧、及并发症进行了讨论。     

基于肾上腺血管解剖的后腹腔镜肾上腺切除技术的改进及临床应用

目的:基于对肾上腺血管解剖的理解,探讨后腹腔镜肾上腺切除术的新技术。方法:2013年12月至2015年5月共收治179例肾上腺肿瘤患者,其中男92例,女87例;肿瘤位于右侧88例,左侧91例;患者12~79岁,平均(47.8±9.8)岁;肿瘤直径0.8~11.5 cm,平均(2.8±1.3)cm。根据患者病情完善术前准备后均由同一术者根据以下策略行后腹腔镜肾上腺切除术:(1)腹膜后空间建立后沿腰大肌表面游离并纵行打开肾筋膜直至膈肌脚,寻及膈下动脉并结扎切断肾上腺上动脉;(2)寻及肾动脉,紧贴肾动脉及肾上极内侧缘夹角向深面游离,结扎肾上腺中、下动脉;(3)通过肾动脉及肾脏内侧缘所形成的"中央静脉三角"寻找肾上腺中央静脉并离断;(4)在肾脏、肾上腺之间游离,到达肾前融合筋膜层面,将肾上腺与肾脏重叠部分分离;(5)离断肾上腺周围相连的结缔组织,完整切除肾上腺。结果:178例手术获得成功,1例中转开放手术;手术时间12~68 min,平均(30.2±10.3)min;出血量10~110 ml,平均(20.6±12.7)ml;术后住院1.5~3.9 d,平均(2.3±0.8)d;2例术中出现腹膜损伤,术后随访期间未见肿瘤复发及转移。结论:此操作方法更加直接的处理肾上腺血供,减少了出血的几率,游离面较少,根据肾上腺解剖关系不用刻意寻找肾上腺肿瘤,操作更加省时、简单。     

腹腔镜肾上腺嗜铬细胞瘤切除术七例报告

目的探讨腹腔镜手术治疗肾上腺嗜铬细胞瘤的可行性及安全性。方法2003年10月至2007年4月，我院行腹腔镜肾上腺嗜铬细胞瘤切除术7例，肿瘤最大径为3．0～6．5cm，平均5．0cm。6例患者术前均有不同程度的高血压。术前常规行降压、扩容处理。采用后腹腔镜入路6例，经腹入路1例，术中术后严密监测血压变化并给予相应处理。结果5例腹腔镜手术成功，2例中转开放手术。手术时间为70-360min，平均163min，术中出血50-600ml，平均300ml。7例患者术中均出现血压波动，无围手术期患者死亡。病理报告证实为嗜铬细胞瘤。随访7～49个月，5例患者术后2个月内血压恢复正常，1例仍需服用降压药物。结论腹腔镜肾上腺嗜铬细胞瘤切除术可行，疗效确切，充分的术前准备和熟练的腹腔镜操作技术是手术安全的保证。     

腹腔镜下切除无症状、生化正常的肾上腺嗜铬细胞瘤12例报告

目的:探讨无症状、生化检查正常的肾上腺嗜铬细胞瘤的诊治原则。方法:回顾分析12例无症状、生化检查正常的肾上腺嗜铬细胞瘤患者的临床资料,术前口服酚苄明1～2周,充分扩容,行腹腔镜肾上腺肿瘤切除术,其中经腰2例,经腹10例。结果:12例患者术中挤压肿瘤时血压均波动明显,手术一期完成,未发生大出血、心脑血管意外等严重并发症,无一例中转开放手术。术后病理均诊断为肾上腺嗜铬细胞瘤。随访6～36个月,血压正常,无复发。结论:无症状、生化检查正常的肾上腺肿瘤临床多见,术前按嗜铬细胞瘤进行准备,充分扩容后行腹腔镜手术是安全、有效的。     

基层医院后腹腔镜肾上腺肿瘤切除术的体会和疗效

目的 探讨基层医院开展后腹腔镜肾上腺肿瘤切除术的疗效和经验.方法 回顾性分析我院2003 年1 月至2011 年2 月完成的10 例后腹腔镜肾上腺肿瘤切除术,分析手术疗效,总结手术经验.结果 所有手术均成功,无一例中转开放手术,无手术并发症.术后病理报告均为肾上腺皮质腺瘤.肿瘤平均直径大小2.8依2.3 cm.随访3~24 个月,所有患者临床症状均消失,CT 复查未见肿瘤复发.结论 基层医院根据自身情况开展后腹腔镜肾上腺肿瘤切除术安全可靠,疗效确切,但要严格把握适应症、充分术前准备、循序渐进.     

Laparoscopic telementored adrenalectomy: The Italian experience

Background: Laparoscopy is widely accepted as the gold standard for adrenalectomy. Telementoring has been developed to reduce the complications associated with surgeon inexperience. We report our preliminary experience with laparoscopic telementored adrenalectomy.Methods: From July 2002 to May 2003, eight laparoscopic telementored adrenalectomies were performed between two separate operating sites 430 km apart. Six of these procedures were monolateral laparoscopic adrenalectomies, and one was bilateral. All cases were performed by an expert open surgeon who was skilled in laparoscopic procedure but who had no experience in laparascopic adrenalectomyResults: All the procedures were successfully performed in a telementored fashion. The mean operative times, blood loss, and postoperative morbidity results were comparable to those for standard laparoscopic adrenalectomies reported in the literature.Conclusions: This preliminary experience has demonstrated the feasibility of national telementoring. It is a viable method that can potentially add to surgical education and decrease the likelihood of complications due to inexperience with new techniques.     

Laparoscopic Cortical-Sparing Adrenalectomy for Bilateral Pheochromocytoma

A 32-year-old female with asthma was hospitalized for pneumonia in 2/06. She underwent a CT scan of the chest which revealed an incidental finding of bilateral adrenal masses. On further questioning, she admitted to palpitations and flushing. She was normotensive. Biochemical workup was significant for elevated urinary norepinephrine and normetanephrines, and plasma catecholamine level. MIBG scan showed positive uptake in the left adrenal gland consistent with pheochromocytoma. T2 weighted MRI showed bilateral adrenal masses, left greater than right. After adequate alpha blockade with phenoxybenzamine, the patient underwent a laparoscopic left adrenalectomy. Pathology revealed a 3.5 cm pheochromocytoma. The patient then underwent a right cortical-sparing adrenalectomy to avoid complete adrenal insufficiency and Addisonian crisis. The choice of operation was made realizing the potential for increased bleeding, which was further complicated by the patient’s Jehovah’s Witness beliefs, which prohibit transfusion of any blood products. At surgery, a small, well-circumscribed mass of the inferior right adrenal gland was found, and excised in its entirety. A postoperative ACTH-stimulation test showed appropriate cortisol response. Pathology revealed a 1.5 cm pheochromocytoma, and the patient recovered uneventfully. Cortical-sparing adrenalectomy has been reported with success rates of 65–100% in avoiding exogenous steroid dependence.^1,2 Bilateral pheochromocytoma remains the most common indication. Risks for both recurrence and malignancy require lifelong follow-up in these patients. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.