THE CASE FOR LAPAROSCOPIC ADRENALECTOMY

PURPOSE: The current status of laparoscopic adrenal surgery was assessed. MATERIALS AND METHODS: A current MEDLINE search revealed 308 articles pertaining to laparoscopic surgery of the adrenal gland. Based on this literature review laparoscopic surgical anatomy, current indications and contraindications, and laparoscopic techniques were identified. The role of laparoscopic surgery for various adrenal disorders, including aldosteroma, pheochromocytoma, Cushing's syndrome, incidentaloma and adrenal cancer, were evaluated. Studies specifically comparing open versus laparoscopic adrenalectomy and the financial implications of laparoscopy were evaluated. Furthermore, newer advances in the minimally invasive management of surgical adrenal disease were identified. RESULTS: Available data from multiple institutions imply that laparoscopic adrenal surgery is safe and efficacious for aldosteroma, pheochromocytoma, Cushing's disease and incidentaloma. Compared to open surgery laparoscopy provides equally effective treatment, while minimizing patient morbidity. Laparoscopic adrenalectomy is financially superior to open adrenalectomy. For adrenal cancer open surgery currently remains the treatment of choice. CONCLUSIONS: In the majority of patients with surgical adrenal disease except those with adrenal cancer laparoscopy may now be considered an established treatment modality.     

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.     

腹腔镜手术切除巨大肾上腺肿瘤的临床探讨

目的：探讨腹腔镜手术切除巨大（直径≥8cm）肾上腺肿瘤的可行性。方法：采用经腹途径腹腔镜切除术治疗巨大肾上腺肿瘤患者6例,左侧4例,右侧2例,肿瘤最大径8．5～12cm。结果：6例腹腔镜手术均获得成功,无中转开放手术。手术时间平均120min（90～185min）,术中出血量平均150ml（50～400m1）。术后胃肠功能恢复时间1～2天,术后2～3天拔除引流管,术后住院6～lO天。随访4～24个月,未发现异常。病理检查报告肾上腺嗜铬细胞瘤2例,神经节细胞瘤1例,神经鞘瘤1例,髓性脂肪瘤2例。结论：肿瘤大小并不是选择腹腔镜手术的决定性因素。在技术娴熟的条件下,腹腔镜治疗巨大肾上腺肿瘤是安全、可行的。     

Laparoscopic radical adrenalectomy for cancer: long-term outcomes

PURPOSE OF REVIEW: Laparoscopic adrenalectomy for malignant adrenal masses has been controversial because of initial reports of high rates of local recurrence and carcinomatosis. With additional experience, improved outcomes have been reported. We evaluate the contemporary role of laparoscopy in treating adrenal malignancies. RECENT FINDINGS: Several contemporary reports now demonstrate that laparoscopic adrenalectomy for primary adrenal malignancy can provide oncologic outcomes equivalent to open surgery without an increased risk of carcinomatosis or port site recurrence. Although long-term survival of 47 months with no recurrence has been reported, the underlying aggressiveness of this tumor has contributed to a 39.6% rate of recurrence for the 48 contemporary cases reviewed in this article. This compares favorably to open series that report a similar or higher recurrence rate. When utilized for the treatment of solitary metastases to the adrenal gland, laparoscopic adrenalectomy provides equivalent oncologic outcomes to open adrenalectomy. SUMMARY: Laparoscopic adrenalectomy for malignancy can be performed in appropriately selected cases with equal oncologic outcomes to open approaches while providing advantages in patient morbidity. Caution must be taken to avoid tumor entry or spillage because of the potential for local recurrence, port site recurrence, and carcinomatosis that can occur with these aggressive tumors.     

Laparoscopic adrenalectomy for adrenal malignancy: a preliminary report comparing the short-term outcomes with open adrenalectomy

BACKGROUND: The laparoscopic approach to adrenal malignancy remains a topic of debate. METHODS: A retrospective analysis of patients who had an open or laparoscopic adrenalectomy for malignancy at a tertiary care center from 1995 to 2005 were included in this study. RESULTS: Twenty-six cases were identified: 19 women and 7 men with a median age of 48 years (range, 20-81) underwent 12 open (8 adrenocortical carcinoma [ACC] and 4 metastases) and 14 laparoscopic adrenalectomies (5 ACC, 8 metastases, and 1 lymphoma). Conversion to open surgery was required in 1 laparoscopic case (7%). Cases with obvious invasion to adjacent organs were not approached laparoscopically. There was no difference in age, sex, American Society of Anesthesiologists status or diagnosis between the two groups, but patients in the laparoscopic group had a higher body mass index. Two patients required splenectomies for splenic tears in the open group. There was no difference in operative time between the two groups, but estimated blood loss (200 vs. 550 mL; P = 0.01) and hospital stay (2 vs. 7 days; P = 0.005) were less in the laparoscopic group. The size of tumors removed by open surgery was larger than by laparoscopy (8 vs. 4 cm; P = 0.003). No locoregional recurrences are reported so far in the laparoscopic group. CONCLUSIONS: Laparoscopic adrenalectomy is both feasible and safe for some malignant tumors of the adrenal gland in experienced hands. However, it cannot be applied to all cases. Careful selection, preoperative staging, and respect for oncologic principles are important considerations in choosing laparoscopic surgery for primary and secondary adrenal malignancy. Short-term outcomes are better when the laparoscopic approach is possible. Confirmation and long-term results with further studies are required.     

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.     

Indications for laparoscopic adrenalectomy for non-functional adrenal tumor with hypertension: Usefulness of adrenocortical scintigraphy

AIM: Laparoscopic adrenalectomy is currently indicated for biochemically and clinically functional adrenal tumors and potentially malignant tumors of the adrenal glands. Non-functional adenomas greater than 5 cm in diameter of the adrenal gland are generally considered to represent potentially malignant tumors. The present study shows indications of laparoscopic adrenalectomy for non-functional adrenal tumors with hypertension in a retrospective fashion. METHODS: Between 1994 and 2004, 110 laparoscopic adrenalectomies were performed at Tokushima University Hospital. All 110 patients underwent detailed endocrinological examination before surgery. Medical and operative records of these 110 patients (57 men, 53 women), including operative parameters, histopathological findings and pre- and postoperative hypertension, were reviewed. Forty-five patients underwent laparoscopic adrenalectomy for non-functional adrenal tumors, and [(131)I]6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol (NP-59) scintigraphy was performed for patients with preoperative hypertension. RESULTS: Mean patient age was 55.0 years (range, 22-77 years). Mean maximum tumor diameter was 42 mm (range, 20-105 mm). All adrenal tumors were removed successfully by laparoscopic surgery. Hypertension was postoperatively improved in seven of the 11 patients with preoperative hypertension, without subclinical Cushing syndrome. Importantly, all patients who improved hypertension after adrenalectomy displayed strong accumulation in adrenal tumors with visualization of the contralateral gland on NP-59 scintigraphy. Conversely, blood pressure did not improve in four patients for whom scintigraphy yielded negative results. CONCLUSIONS: The indication of laparoscopic adrenalectomy for non-functional adrenal tumors is generally considered for lesions more than 5 cm diameter. However, the present study suggests that laparoscopic surgery should be considered even in patients with tumors less than 5 cm in diameter, if both hypertension and accumulation in tumors on NP-59 scintigraphy are present.     

ADRENAL SPARING SURGERY DURING RADICAL NEPHRECTOMY IN PATIENTS WITH RENAL CELL CANCER: A NEW ALGORITHM

PURPOSE: Ipsilateral adrenalectomy is usually performed during radical nephrectomy because of renal cell cancer. Because renal tumors are detected more often in the earlier stages due to widespread use of ultrasound and computerized tomography, we define a subset of patients who would be eligible for adrenal sparing surgery. In a retrospective analysis we evaluated whether parameters obtained preoperatively are able to predict adrenal metastasis. MATERIALS AND METHODS: A total of 866 consecutive patients who underwent nephrectomy and ipsilateral adrenalectomy from 1983 to 1999 were evaluated. Preoperative parameters, including tumor size, location, clinical stage, number of tumors, and patient age and sex, were retrospectively compared with the histological results. Univariate and multivariate analyses were performed. RESULTS: A total of 27 (3.1%) adrenal metastases were noted in the 866 patients, and 63% were on the left side and 37% on the right side. Mean tumor size was 10 cm. with versus 6 cm. without adrenal involvement. Of the 27 patients 21 had multiple metastases at diagnosis and only 6 (0.7% of all 866) presented with solitary ipsilateral adrenal metastasis. Univariate and multivariate analyses revealed tumor size and M stage as best preoperative predictors of adrenal involvement. CONCLUSIONS: Adrenal sparing surgery is possible, and we suggest a new algorithm. If maximum tumor size measured by computerized tomography is less than 8 cm. and staging examination does not show organ or lymph node metastases, adrenalectomy is not necessary because of oncological reasons. This algorithm has to be validated by a prospective analysis.     

Minimally invasive adrenalectomy and malignant adrenal tumours

Summary   Background: Minimally invasive adrenalectomy is the standard procedure for the treatment of small benign adrenal neoplasms. The question of whether this technique is also suitable for treating adrenal malignancies has recently been discussed with controversy. Methods: A literature search was performed to gather published experience and opinions concerning the role of endoscopic adrenalectomy in the treatment of primary adrenal malignancies and adrenal metastases. Results: Adrenocortical carcinomas (ACCs) have been approached laparoscopically, and this technique has even been advocated for large tumours. Several small ACCs have been successfully removed laparoscopically. Oncological catastrophes with peritoneal carcinomatosis have been reported. Reoperation after laparoscopic adrenalectomy for unsuspected ACC was usually not performed. There are no data demonstrating a survival benefit of systematic lymphadenectomy. Adrenal metastases are firm and rarely penetrate the capsule of the adrenal gland. Several reports on endoscopic adrenalectomy for metastases have been published. Conclusions: Laparoscopic adrenalectomy for ACC should be considered with great reluctance. If ACC is diagnosed postoperatively upon histological examination after laparoscopic adrenalectomy for a presumably benign tumour, reoperation is not mandatory provided oncological principles were respected during the primary operation. Adrenal metastases confined to the adrenal gland can be removed laparoscopically.      

Clipless laparoscopic adrenalectomy with needlescopic instruments.

PURPOSE: We describe our experience with clipless laparoscopic adrenalectomy using needlescopic instruments. We compared the results with those of a contemporary series of conventional laparoscopic adrenalectomy. MATERIALS AND METHODS: In 12 patients clipless laparoscopic adrenalectomy was performed with needlescopic instruments in an 8-month period. The technique included 2 or 3 subcostal 2 mm. ports and 1 umbilical 5/12 mm. port for the telescope and ultimate specimen extraction. Adrenal vessels were controlled by bipolar coagulation without endoscopic clips. Outcome data were retrospectively compared with those on 20 recent conventional laparoscopic adrenalectomies done at the same institution. The 2 types of laparoscopic adrenalectomy were performed transperitoneally. RESULTS: Patients in the clipless group had a lower mean analgesic requirement (7.5 versus 15.3 mg. morphine sulfate equivalent, p = 0.02), lower mean pain and scar scores (3.1 versus 5.3 and 1.1 versus 4.2, respectively, p <0.05) and more rapid convalescence (1.6 versus 3.3 weeks, p <0.01) but longer operative time (183 versus 136 minutes, p = 0.04). Similar blood loss, time to oral intake and hospital stay were noted in the 2 groups. No major complications, open conversions or postoperative secondary bleeding occurred in either group. A 2 mm. port was converted to a 10 mm. port in only 1 case in the clipless group due to the inability to retract a bulky liver properly with a needlescopic instrument. CONCLUSIONS: Clipless laparoscopic adrenalectomy with needlescopic instruments is feasible for most benign adrenal tumors. In addition to the benefits of conventional laparoscopic surgery, clipless needlescopic laparoscopic adrenalectomy further decreased postoperative pain, shortened convalescence and improved wound cosmesis.     

Laparoscopic adrenal surgery in children

PURPOSE: The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, more than 400 studies have been published, comprising hundreds of adults. There are few reports of laparoscopic adrenalectomy in the pediatric population. We reviewed our experience with laparoscopic adrenal surgery in children. MATERIALS AND METHODS: Laparoscopic adrenalectomy was performed in 8 girls and 5 boys 15 years or younger (mean age 6.3) between December 1994 and August 2001. The clinical diagnosis before surgery was virilizing tumor in 5 cases, nonfunctioning solid adrenal tumor in 3, Cushing's syndrome in 2, pheochromocytoma in 2 and Cushing's pituitary disease in 1. Unilateral adrenal lesions were 15 to 80 mm. at the longest axis (mean 41.4) on computerized tomography. RESULTS: Two of the 13 procedures (15.4%) were converted to open surgery. No deaths occurred. No patients presented with postoperative complications. Average operative time in unilateral nonconverted procedures was 107 minutes (range 25 to 195). Blood transfusion was required in 1 case (7.7%). Average hospital stay was 5.5 days (range 1 to 17). Average postoperative followup was 16 months (range 1 to 60). The final clinicopathological diagnosis was virilization in 4 cases, Cushing's syndrome in 2, pheochromocytoma in 2, neuroblastoma in 2, Cushing's pituitary disease in 1, teratoma in 1 and primary carcinoma in 1. CONCLUSIONS: Laparoscopic adrenalectomy is feasible and shows positive results in select pediatric patients.     

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 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.     

肾上腺外科疾病手术方式的选择

与传统的开放手术相比,腹腔镜肾上腺切除术具有手术创伤小、出血少、术后疼痛轻、住院时间短、切口并发症少、康复快等优点。随着腹腔镜手术的普及,腹腔镜肾上腺切除术由最初的选择性手术逐步成为标准的手术,目前已经成为肾上腺外科首选的手术方法。对于较大的肾上腺肿瘤或恶性肿瘤,腹腔镜手术的作用还存在一定争议。本文就各种肾上腺疾病进行外科治疗时腹腔镜手术与开放手术的选择进行讨论。     

Laparoscopic adrenalectomy for solitary metachronous adrenal metastasis from lung cancer: Report of a case

We report herein the case of a 69-year-old man who underwent laparoscopic adrenalectomy for a solitary adrenal metastasis 10 months after a left lower lobectomy for T2N1M0 lung cancer. A 30×20 mm tumor was found in the left adrenal gland, and dissected using an ultrasonically activated scalpel. Histological examination revealed metastatic squamous cell carcinoma. The patient recovered uneventfully and his condition is now stable 18 months after the second operation, with no evidence of local recurrence or metastatic disease. Although laparoscopic resection for malignant adrenal tumors is still controversial, we consider that laparoscopic adrenalectomy may be an optional treatment for metastatic adrenal tumors, provided the tumor is solitary, small in size, and well-localized. To our knowledge, only 14 cases of laparoscopic adrenalectomy for malignant tumors have been reported to date; however, this is the first case of successful laparoscopic adrenalectomy for a metastasis from lung cancer.     

Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases

PURPOSE: To our knowledge we introduce the technique of anatomical retroperitoneoscopic adrenalectomy. MATERIALS AND METHODS: From February 2000 to October 2005 anatomical retroperitoneoscopic adrenalectomy was performed in 800 consecutive patients with adrenal lesions using a 3 port lateral retroperitoneal approach. After incising Gerota's fascia 3 relatively bloodless planes were entered consecutively to expose and separate the adrenal gland. When entering the first dissection plane between the perirenal fat and anterior renal fascia located at the superomedial side of the kidney, the adrenal could be identified at the initial stage of the operation. The following dissections proceeded in the plane between the posterior renal fascia and the lateral aspect of perirenal fat, and then in the avascular plane located on the parenchymal surface of the upper renal pole. The adrenal vein was dealt with at the final stage. Operative time was defined as the time from skin incision to skin closure. RESULTS: Mean +/- SE operative time was 45 +/- 19.1 minutes (range 25 to 230) and mean estimated blood loss was 25 +/- 10.6 ml (range 5 to 200). Average time to oral intake and ambulation were 1.2 and 1.0 day, respectively. Minor postoperative complications occurred in 12 patients (1.5%). Major complications and perioperative mortality were not observed. The procedures resulted in marked clinical improvements in patients with a hormone secreting tumor, except in 6 with idiopathic adrenal hyperplasia. CONCLUSIONS: Anatomical retroperitoneoscopic adrenalectomy is a safe, effective, technically efficient procedure for surgical adrenal diseases.     

Laparoscopic Resection of Large Adrenal Tumors

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.     

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.     

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.     

腹腔镜肾上腺切除术和开放肾上腺切除术治疗肾上腺巨大良性肿瘤的比较

目的：了解腹腔镜肾上腺切除术（1aparoscopicadrenalectomy,LA）和开放肾上腺切除术（openadre—nalectomy,OA）治疗肾上腺巨大（〉6cm）良性肿瘤的差别。方法：分析2009年1月～2011年12月手术治疗的50例肾上腺巨大良性肿瘤的l陆床特点。其中LA组26例,OA组24例。比较两组年龄、肿瘤大小、手术时间、术中出血量、住院时间、切口长度;LA组嗜铬细胞瘤切除6例,OA组嗜铬细胞瘤切除7例,比较两者术中血流动力学变化。结果：术后病理为肾上腺腺瘤2例,节细胞神经瘤10例,嗜铬细胞瘤13例,髓样脂肪瘤19例,肾上腺囊肿伴出血3例,神经鞘膜瘤2例,肾上腺巨淋巴结增生（Castleman病）1例。LA组和OA组比较,平均年龄分别为（45．3±15．6）岁和（52．2±13．2）岁（P=0．069）;肿瘤直径分别为（7．75±1．26）cm和（8．38±1．96）cm（P=0．098）;平均手术时间分别为（65．2±23．4）min和（126．9±32．5）min（P〈0．01）;出血量分别为（,54．1±19．5）m1和（205．0±49．6）ml（P〈O．01）;住院时间分别为（4．8±1．6）d和（7．6±2．1）d（P〈0．01）;切口长度分别为（7．56±2．06）cm和（18．28±3．25）cm（P〈O．01）。LA组无一例发生手术相关并发症或中转开放;（）A组冈肾血管损伤行一侧肾切除1例。LA组切除嗜铬细胞瘤术中最高收缩压和心率低于OA组（P〈O．05）。术后随访3～26个月,肿瘤无复发。结论：尽管I。A需延长切口取出肿瘤,但与OA相比,切除肾上腺巨大良性肿瘤仍具有手术时间短、出血少、创伤小、恢复快等优势。