Robot-assisted Posterior Retroperitoneoscopic Adrenalectomy Using Single-port Access: Technical Feasibility and Preliminary Results

Abstract

Posterior retroperitoneoscopic adrenalectomy (PRA) has several benefits compared with transperitoneal adrenalectomy in that it is safe and has a short learning curve. In addition, it provides direct short access to the target organ, prevents irritation to the intraperitoneal space, and does not require retraction of adjacent organs.1 (-) 3 We have performed several cases of robot-assisted PRA using single-port access for small adrenal tumors. This multimedia article introduces the detailed methods and preliminary results of this procedure. Five patients underwent single-port robot-assisted PRA between March 2010 and June 2011 at our institution. During the procedure, patients were placed in a prone jackknife position with their hip joints bent at a right angle (Fig.1). A 3cm transverse skin incision was made just below the lowest tip of the 12th rib (Fig.2), and the Glove port (Nelis, Kyung-gi, Korea) was placed through the skin incision while maintaining pneumoretroperitoneum (Fig.3). CO2 was then insufflated to a pressure of 18mm Hg to create an adequate working space. A 10mm robotic camera with a 30-degree up view was placed at the center of the incision through the most cephalic portion of the Glove port. A Maryland dissector or Prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA) was placed on the medial side of the incision, and Harmonic curved shears (Intuitive Surgical) were placed on the lateral side of the incision (Fig.4). Using the Maryland dissector and the harmonic curved shears, the Gerota fascia is opened, perinephric fat is dissected, and the kidney upper pole is mobilized to expose the adrenal gland (Fig.5). Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction (Fig.6). After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is ligated with a 5mm hemolock clip (Fig.7). Patient clinicopathologic data were analyzed retrospectively. The mean patient age was 56.6±8.7 (range, 47-69) years. Right and left side approaches were used in two and three patients, respectively. All cases were adrenal cortical adenoma. The mean tumor size was 1.48±0.28 (range, 1.0-1.7) cm. The mean surgery duration (skin to skin) was 159.4±57.6 (range, 103-245) minutes, and the mean estimated blood loss was 46.0±56.8 (range, 5-120) ml. The average time to oral intake and postoperative hospital stay were 0.65±0.11 (range, 0.54-0.79) days and 4.0±2.23 (range, 3-8) days, respectively. There were no conversions to open surgery or postoperative compli- cations. Some trials of minimally invasive single-access surgery of the adrenal gland have recently been performed.4 (,) 5 However, these new techniques have several limitations as a result of restrictions on instrumentation movement because of the small access ports used and relatively low-quality images produced. The recent introduction of the da Vinci S surgical robot system (Intuitive Surgical) to endoscopic surgery has improved instrumental dexterity and provided the surgeon with an ergonomically designed operating system. This system is also potentially safer and more meticulous in performing operations than endoscopic procedures as a result of a 3-D, magnified, stable operative view.6 (,) 7 The advantages of the da Vinci S surgical robot system and the numerous benefits of the posterior retroperitoneal approach motivated us to utilize single-port robot-assisted PRA. The primary selection criteria were small tumor size and a minimal amount of periadrenal fatty tissue because robot-assisted PRA using single-port access provides a small operative space, which causes manipulation problems when tumors are large. To ensure the safe application of these new techniques, we recommend that novice surgeons begin using single-port robot-assisted PRA for smaller tumors < 2cm in patients with a body mass index of < 30kg/m(2), gradually extending the size and body mass index as they accumulate experience. Although robot-assisted PRA using single-port access could not be compared with the other robotic adrenalectomy techniques in this study, the potential advantages of this approach compared to conventional robot-assisted transperitoneal adrenalectomy include a reduction in postoperative ileus, bacterial contamination, and intestinal complications because the peritoneal cavity is not opened, in addition to a reduction in postoperative pain because of its minimally invasive nature. Our initial experiences with robot-assisted PRA using single-port access assured us of its safety and feasibility for the resection of small adrenal tumors. Although single-port robot-assisted PRA appears to be safe and feasible, further experience and research is required to optimize patientselectioncriteria and verify its advantages over the traditional three-incision PRA technique.