Laparoscopic retroperitoneal adrenalectomy

Laparoscopic adrenalectomy has largely replaced open adrenalectomy for resection of adrenal tumors, which are not adrenocortical cancer or malignant pheochromocytoma. Laparoscopic retroperitoneal adrenalectomy is a particularly useful technique in patients with tumors <7 cm and body mass index <45 kg/m2. When compared with laparoscopic transabdominal adrenalectomy, the laparoscopic retroperitoneal technique leads to reduced operating times, avoidance of intra-abdominal adhesions and irradiated fields, potentially less postoperative pain, and improved intraoperative hemostasis and visualization. The technique involves placement of 3 ports, dissecting the retroperitoneal space, identifying and ligating the adrenal vein, and removing the attachments to the adrenal gland. See the video, Supplemental Digital Content 1, http://links.lww.com/SLE/A38.     

A novel method of laparoscopy-assisted peritoneal dialysis catheter placement

Peritoneal dialysis (PD) is a widely used renal replacement therapy for end-stage renal disease patients. We compared our novel laparoscopic-assisted method with conventional procedures in the catheter survival and complications. Seventy-three patients who underwent PD catheter placement were enrolled in this study. Our laparoscopic methods were characterized with smaller incision and additional fixation in the lower abdomen. Catheter migration developed in 4 patients in the conventional group compared with none in the laparoscopic group. The catheter dysfunction-free survival was significantly longer among the patients in the laparoscopic group than that in the conventional group (P=0.001). There were no significant differences between the 2 groups in peritonitis, exit-site hematoma, or exit-site infection. Laparoscopy-assisted PD catheter insertion with an intraperitoneal loop fixation is safe and provides good maintenance of catheter function (See the video, Supplemental Digital Content 1, http://links.lww.com/SLE/A28).     

Robotic remote laparoscopic nephrectomy and adrenalectomy: the initial experience

PURPOSE: We evaluated the feasibility of performing laparoscopic nephrectomy and adrenalectomy exclusively by using robotic telepresent technology from a remote workstation and compared outcomes with those of conventional laparoscopy in an acute porcine model. MATERIALS AND METHODS: Five pigs underwent bilateral laparoscopic nephrectomy (robotic in 5 and conventional in 4) and adrenalectomy (robotic in 4 and conventional in 3). In the 9 robotic laparoscopic procedures all intraoperative manipulations were completely performed telerobotically from a remote workstation without any conventional laparoscopic assistance on site. Animals were sacrificed acutely. RESULTS: Robotic laparoscopic nephrectomy required significantly longer total operative (85.2 versus 38.5 minutes, p = 0.0009) and actual surgical (73.4 versus 27.5 minutes, p = 0.0002) time than conventional laparoscopy. However, blood loss and adequacy of surgical dissection were comparable in the 2 groups. Robotic laparoscopic adrenalectomy required longer total operative (51 versus 32.3 minutes, p = 0.13) and actual surgical (38.5 versus 18.7 minutes, p = 0.14) time than conventional laparoscopy. The solitary complication in this study was an inferior vena caval tear during robotic right adrenalectomy, which was adequately repaired by sutures telerobotically in a remote manner. CONCLUSIONS: To our knowledge we present the initial experience with remote telerobotic laparoscopic nephrectomy and adrenalectomy. Telepresent laparoscopic surgery is feasible.     

机器人辅助腹腔镜下肾上腺复杂肿瘤手术(附光盘)

目前,传统腹腔镜肾上腺切除术(laparoscopic adrenalectomy,LA)已成为治疗大部分肾上腺肿瘤的首选方法,但其在处理一些复杂性肾上腺肿瘤时仍较困难。达芬奇机器人手术系统在泌尿外科领域的广泛应用和发展是当今世界临床医学发展的里程碑。机器人辅助腹腔镜下肾上腺切除术(robot-assisted laparoscopic adrenalectomy,RALA)使得一些不适合传统腹腔镜手术的肾上腺肿瘤的微创治疗成为可能。本文就达芬奇机器人手术系统、RALA用于复杂肾上腺肿瘤治疗、RALA的手术步骤和技巧做一概述。     

Robot-assisted adrenalectomy: indications and drawbacks

Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a hormone-secreting tumor of the adrenal medulla (pheochromocytoma). Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders, although there are no prospective randomized trials comparing this technique with open adrenalectomy. However, widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Speculative advantages associated with the use of the robotic system have rarely been evaluated in clinical settings and cost increase remains an important drawback associated with robotic surgery. This review summarizes current available data regarding robotic transperitoneal adrenalectomy including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. We believe that the use of a robotic system seems to be useful especially in more difficult patients with larger tumors, truncal paragangliomas, and bilateral and/or partial adrenalectomies. Overall, we believe that overcosts due to robotic system use could be balanced by hospital stay decrease, patients’ referral increase, improved postoperative outcomes in more difficult patients and ergonomics for the surgeon. However, we also believe that the current surgical intuitive business model is counterproductive, because there are no available strong clinical data that could balance overcosts associated with the use of the robotic system.     

Robotic versus laparoscopic adrenalectomy: a comparative study in a high-volume center

Background

Minimally invasive surgery has become more popular in recent years. The da Vinci^® robot is one of the new technologies the use of which has gained popularity in a host of different specialties. Originally used in cardiac surgery, marked increases in utilization have been seen in urology, gynecology, and thoracic surgery. Use in general surgical procedures has now become more common. The objective benefits of the robot are unclear compared to those of laparoscopy in many procedures. The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for adrenalectomy in a high-volume center compared to routine laparoscopic techniques.

Methods

We conducted a retrospective study including consecutive patients who underwent minimally invasive adrenalectomy in a tertiary referral center at the University of Alabama Birmingham. Demographic, clinical, histopathological, and surgical variables were recorded. Patients were divided in two groups: laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA). Groups were compared using the χ² test for categorical variables and Student’s t-test for continuous variables. Significance was considered p < 0.05.

Results

Sixty patients were included, with 30 patients in each group. There were no significant differences between groups with respect to demographic variables except there were more pheochromocytoma patients in the LA group than in the RA group (13/30 vs. 5/30, respectively; p = 0.02). This study demonstrated increased operative time in the robotic group (190 ± 33 min) versus the laparoscopic group (160 ± 41 min) (p = 0.003). There was a trend for less blood loss in RA versus LA (30 ± 5 ml vs. 55 ± 74 ml; p = 0.07). There was no mortality. Morbidity and length of hospital stay were similar for both groups.

Conclusions

Robotic adrenalectomy is as safe and technically feasible as laparoscopic adrenalectomy. Subjective benefits for the surgeon with robot-assisted surgery include three-dimensional operative view, ergonomically comfortable position, and elimination of the surgeon’s tremor. The operating time is significantly longer but patient outcomes are similar to those of the laparoscopic technique.     

Laparoscopic transperitoneal adrenalectomy using a remote-controlled robotic surgical system

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors. Although laparoscopic surgery provides clear patient benefit, laparoscopic adrenalectomy using conventional instrumentation is complex. Our objective was to evaluate whether the da Vinci trade mark Surgical System, a comprehensive robotic endoscopic surgical device, could be used effectively to perform laparoscopic adrenalectomy. PATIENTS AND METHODS: Through a transperitoneal approach, three right and one left adrenal tumors were removed in four patients using this method. RESULTS: There were no complications, and the clinical results were excellent. CONCLUSION: We demonstrate the feasibility of performing laparoscopic adrenalectomy exclusively by using robotic telepresent technology from a remote workstation. The da Vinci System enables conventionally trained urologic surgeons to perform complex minimally invasive procedures with ease and precision. Therefore, we are convinced that the system helps the urologist to adapt the whole spectrum of laparoscopic procedure in this field.     

Laparoscopic hand-assisted adrenalectomy for a 20 cm benign tumor

Since its introduction in 1992, laparoscopic adrenalectomy (LA) has become the technique of choice in the surgical treatment of both secreting or non-secreting benign adrenal pathology. Although traditionally, laparoscopic approach was recommended only for tumor sizes less than 6-8 cm--as larger tumors were known to have an increased risk of malignancy--the currently growing experience and improvement of surgical techniques has allowed for an extension of the therapeutic indication, as shown by the recent case report of LA use for a benign 22 cm tumor (1). We report the case of a young patient operated in our Department for a benign 20 cm adrenal tumor for which laparoscopic "hand-assisted" adrenalectomy yielded a good postoperative outcome and minimal complications.     

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.     

介入治疗在基层医院的应用

在县级医院设备条件有限的情况下,笔者开展介入放射学工作,诊治各类患者650例,取得了满意的效果。     

Robotic Endocrine Surgery: State of the Art

Over the last decade, developments in technology have led a rapid progress in robotic endocrine surgery applications. Robotics is attractive to the surgeon because of the three-dimensional image quality, articulating instruments, and stable surgical platform. Safety and effectiveness of robotic adrenalectomy and thyroidectomy have been shown in many studies. While these robotic procedures offer better ergonomics for the surgeon, they provide similar outcomes compared to the laparoscopic approach for adrenalectomy and better cosmetic results versus the conventional option for thyroidectomy. Recently, while the robotic approach for adrenalectomy has been popularized, enthusiasm for robotic thyroidectomy has decreased. In the present review we aim to describe emerging robotic procedures and review the literature regarding outcomes.     

Laparoskopische Adrenalektomie in Seitenlage – ein Vergleich mit der konventionellen dorsalen Technik

OBJECTIVES: Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib. METHODS: Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm. RESULTS: Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection). CONCLUSION: LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.     

International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy

The aim of this study was to provide an evidence‐based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urological Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. A systematic literature search (January 2004 to January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma (ACC) and large adrenal tumours were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single‐site (LESS) and robotic adrenalectomy were reviewed. The major findings are presented in an evidence‐based fashion. Large retrospective and prospective data were analysed and a set of recommendations provided by the committee was produced. Laparoscopic surgery should be considered the first‐line therapy for benign adrenal masses requiring surgical resection and for patients with pheochromocytoma. While a laparoscopic approach may be feasible for selected cases of ACC without adjacent organ involvement, an open surgical approach remains the ‘gold standard’. Large adrenal tumours without preoperative or intra‐operative suspicion of ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy are safe. The approach should be chosen based on surgeon training and experience. LESS and robotic adrenalectomy should be considered as alternatives to laparoscopic adrenalectomy but require further study.     

Robotic Versus Laparoscopic Adrenalectomy for Pheochromocytoma

Background

Although initial reports demonstrated the safety and feasibility of robotic adrenalectomy (RA), there are scant data on the use of this approach for pheochromocytoma. The aim of this study is to compare perioperative outcomes and efficacy of RA versus laparoscopic adrenalectomy (LA) for pheochromocytoma.

Methods

Within 3 years, 25 patients underwent 26 RA procedures for pheochromocytoma. These patients were compared with 40 patients who underwent 42 LA procedures before the start of the robotic program. Data were retrospectively reviewed from a prospectively maintained, IRB-approved adrenal database.

Results

Demographic and clinical parameters at presentation were similar between the groups, except for a larger tumor size in the robotic group. In both groups, skin-to-skin operative time, estimated blood loss less, and intraoperative hemodynamic parameters were similar. The conversion to open rate was 3.9 % in the robotic and 7.5 % in the laparoscopic group (p = .532). There was no morbidity or mortality in the robotic group; morbidity was 10 % (p = .041) and mortality 2.5 % in the laparoscopic group. The pain score on postoperative day 1 was lower, and the length of hospital stay shorter in the robotic group (1.2 ± .1 vs. 1.7 ± .1 days, p = .036).

Conclusions

To our knowledge, this is the first study comparing robotic versus laparoscopic resection of pheochromocytoma. Our results show that the robotic approach is similar to the laparoscopic regarding safety and efficacy. The lower morbidity, less immediate postoperative pain, and shorter hospital stay observed in the robotic approach warrant further investigation in future larger studies.     

Advantages of using robotic Da Vinci system for unilateral adrenalectomy: early results

STUDY AIM: The goal of this study was to report the early results of unilateral transperitoneal adrenalectomy using robotic Da Vinci system, and to compare them to the results of the laparoscopic standard adrenalectomy. METHODS: Prospective study included all patients operated on for unilateral laparoscopic or robotic adrenalectomy from November 2000 to November 2002. RESULTS: Twenty-eight patients underwent unilateral adrenalectomy using either standard laparoscopy (14 patients) or robotic Da Vinci system (14 patients). Mean duration of robotic adrenalectomy seemed to be longer than standard laparoscopy (111 vs. 83 min; P = 0.057). This tendency decreased while surgeons' experience was increasing. Mean duration of operating room activity was similar for both types of surgery. Peroperative events without conversion, conversion rate (7%), drainage, morbidity (21%), duration of hospitalisation were similar for both types of surgery. Duration of standard laparoscopic adrenalectomy was positively correlated to patients body mass index. This correlation was absent in patients operated on by robotic Da Vinci system. CONCLUSION: This preliminary study found no objective data demonstrating that robotic Da Vinci system was superior to standard laparoscopic approach for unilateral adrenalectomy. However, we think that it is necessary to continue further evaluation of this system to demonstrate its possible superiority.     

Laparoscopic and robotic assisted adrenal surgery

The aim of this paper is to review the current state of laparoscopic and robotic surgery in the mannagement of benign and malignant disease of the adrenal gland. Adrenal lesions can be adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal cysts, hematomas, adrenal cortical carcinomas, metastases from other cancers, or other rare causes. Laparoscopic adrenalectomy (LA) has become the new standard of care for benign adrenal neoplasms and is being increasingly utilized for malignant disease. Robotic assistance offers unique advantages in visualizing and dissecting the adrenal gland, especially considering its challenging vasculature. Series of robotic adrenalectomy (RA) and LA show that techniques are both safe and effective compared to open. There is also growing evidence in using minimally invasive approaches in adrenal sparing-surgery. Success in these procedures depends on a firm understanding of adrenal anatomy and in careful patient selection. Both LA and RA are offer advantages to patients and are comparable in outcomes. RA offers the potential for increased visualization and faster learning curve which may allow for both faster, and more precise dissection, as well as increased utilization of minimally invasive techniques. While LA remains the standard of care, RA is an excellent option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.     

Robotic versus laparoscopic adrenalectomy in obese patients

Background

Recently, we demonstrated better perioperative outcomes with robotic versus laparoscopic adrenalectomy (LA) with the posterior retroperitoneal approach in general, and for removal of large adrenal tumors. It is unknown if robotic adrenalectomy (RA) is equivalent to LA in obese patients. The aim of this study is to compare perioperative outcomes of RA versus LA in obese patients.

Methods

Between 2003 and 2012, 99 obese (BMI ≥ 30 kg/m²) patients underwent adrenalectomy at a tertiary academic center. Of these, 42 patients had RA and 57 had LA. The perioperative outcomes of these patients were compared between the RA and LA groups. Data were collected from a prospectively maintained, institutional review board approved database. Clinical and perioperative parameters were analyzed using Student t and χ² tests. All data are expressed as mean ± standard error of the mean.

Results

The groups were similar in terms of age, gender, and tumor side. Body mass index was lower in the robotic versus laparoscopic group (35.4 ± 1.0 vs. 38.8 ± 0.8 kg/m², respectively, p = 0.01). Tumor size (4.0 ± 0.4 vs. 4.3 ± 0.3 cm, respectively, p = 0.56), skin-to-skin operative time (186.1 ± 12.1 vs. 187.3 ± 11 min, respectively, p = 0.94), estimated blood loss (50.3 ± 24.3 vs. 76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay (1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06) were similar in both groups. The conversion to open rate was zero in the robotic and 5.2 % in the laparoscopic group (p = 0.06). The 30-day morbidity was 4.8 % in the robotic and 7 % in the laparoscopic group (p = 0.63).

Conclusions

Our study did not show any difference in perioperative outcomes between RA and LA in obese patients. These results suggest that the difficulties in maintaining exposure and dissection in obese patients nullify the advantages of robotic articulating versus rigid laparoscopic instruments in adrenal surgery.     

Thirty robotic adrenalectomies

Background Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution’s series of 30 robotic adrenalectomies, and evaluates the procedure’s safety, efficacy, and cost. Methods Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period. Results Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy ($12,977) were not significantly different than charges for traditional laparoscopic ($11,599) or open adrenalectomy ($14,600). Conclusions Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.     

Robot-assisted laparoscopic partial adrenalectomy: a case report and review of the literature

Adrenal-sparing surgery has recently been reported in the literature on minimally-invasive surgery. Originally described as a conventional laparoscopic procedure, encouraging outcomes in terms of preservation of adrenal function have been reported. Since the introduction of robotic surgery, surgeons have utilized robotic assistance for adrenal surgery and have recently described adrenal-sparing surgery using this platform. Certain patients that present with adrenal masses may benefit from minimally-invasive partial adrenalectomy, including those with a solitary adrenal gland, bilateral adrenal masses, and hereditary disease predisposing them to multiple adrenal masses. Patients without these conditions may also benefit from adrenal-sparing surgery in order to preserve normal adrenal function. We present the case of a patient with a 1.5-cm adrenal mass who elected to undergo adrenal-sparing surgery. The technique of transperitoneal laparoscopic partial adrenalectomy utilizing the da Vinci™ Surgical System is described. We also review the literature on minimally-invasive partial adrenalectomy in which robotic-assistance was utilized. In conclusion, while robot-assisted laparoscopic partial adrenalectomy remains in its infancy, it can be performed safely and with satisfactory surgical and functional outcomes.     

DSA透视下逆行双J输尿管支架管置入术

双“J”输尿管支架在输尿管梗阻性疾病的治疗中应用广泛,疗效满意。我院有11例于膀胱镜下未能顺利置入输尿管支架者,在DSA下成功逆行插入,现报道如下。