Initial Experiences with a New Technique for Adrenal Surgery: Single-Port Adrenalectomy Retroperitoneoscopically (SPAR)

Abstract

Introduction: Since the introduction of transperitoneal laparoscopic adrenalectomy,1 several retroperitoneal techniques have emerged. Retroperitoneoscopy can be performed with the patient in lateral or prone position.2,3 Standard three trocars are being used, but single-access retroperitoneal adrenalectomy is a new technique of which, few reports exist.4 The use of straight instruments for this procedure was reported only once.5 In our center, single-port adrenalectomy retroperitoneoscopically (SPAR) was started in 2011. Based on the literature, this retroperitoneoscopic technique was performed only in patients with small benign tumors (≤6 cm) and low body mass index (BMI) (<30).6 To our knowledge, this is the first video in urological literature showing this technique (duration 8.49 minutes). The results after seven procedures were evaluated. Materials and Methods: From May 2011 until February 2013, seven patients with either benign adrenal tumors or treatment-refractory Cushing underwent unilateral (n=5) or bilateral (n=2) SPAR, respectively, by one experienced laparoscopist. The single incision laparoscopic surgery (SILS) port (Covidien) was introduced through a 2.5–3 cm skin incision at the tip of the 12th rib with the patient in a prone position. Pneumoretroperitoneum was at constant pressure of 20 mm Hg. A 30° 5-mm laparoscope and standard instruments consisting of bipolar forceps and a Ligasure or Harmonic scalpel were used. The adrenal vein was clipped with 10-mm titanium clips. Patient characteristics, indications for surgery, perioperative outcomes, and complications were analyzed from a prospectively collected database by descriptive statistics (SPSS 20). Results: Mean age (six women and one man) was 47±5.8 years and BMI 24±1.0. In five patients, unilateral SPAR was performed for primary aldosteronism (mean tumor diameter: 1.5±0.14 cm). The mean operating time was 68±9.3 minutes and blood loss 7±1.2 mL. The mean hospital stay was 3.4±0.5 days. No conversions were indicated. One complication, that is, ureter injury (Clavien-Dindo grade IIIb), has occurred during a procedure in which the isolation cap of the Ligasure dislocated several times during introduction into the trocar opening with probable current leakage. During secondary open reconstruction, a clear thermal injury was identified at the proximal ureter. No late sequelae occurred. In the bilateral procedures, the operating times were 117 and 137 minutes, blood loss 5 mL each, and hospital stay 3 and 9 days, respectively. Depletion of excessive perioperative fluid challenge caused the extended hospital stay in one patient. Conclusions: In this video, SPAR is shown to be technically feasible for small benign adrenal tumors. Considering anatomical restrictions, retroperitoneoscopic surgery of malignant adrenal tumors is contraindicated. Initial results are encouraging with short operating times and minimal blood loss. The hospital stay is slightly longer compared to some reports in literature, but this seems a regional phenomenon in which endocrinologic reasons play a role. From a surgical point of view, most patients are able to go home on day 1 or 2 postoperatively. The serious complication that occurred indicates that close monitoring of technical problems during surgery is important. Future research should focus on the safety and advantages for cosmesis and postoperative pain. No competing financial interests exist. Runtime of video: 8 mins 49 secs