Lateral Transperitoneal Adrenalectomy Research Articles

A 1:1 matched comparison of posterior retroperitoneal and lateral transabdominal adrenalectomy using a robotic platform

BackgroundPosterior retroperitoneal adrenalectomy is considered less invasive compared with lateral transperitoneal counterpart. There is controversy in the literature about how the two approaches compare regarding perioperative outcomes. Moreover, no studies have compared both approaches while incorporating the use of a robotic platform. The aim of this study was to compare the outcomes of robotic posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy using a 1:1 matched propensity analysis. MethodsPatients who underwent robotic posterior retroperitoneal adrenalectomy were matched 1:1 to patients who underwent robotic lateral transperitoneal adrenalectomy between 2008 and 2022 at a single center. Matching factors included diagnosis, tumor size, Gerota’s fascia-to-skin distance, and perinephric fat thickness. Perioperative outcomes were compared between groups using the χ2 analysis and Wilcoxon Rank Sum test. ResultsA total of 511 robotic adrenalectomies were performed during the study period, of which 77 patients in each group were matched. There was no difference between posterior retroperitoneal adrenalectomy and lateral transperitoneal adrenalectomy groups, respectively, in terms of operative time (134 vs 128 min, P = .64), conversion to open (0% vs 0%, P = .99), pain level on a postoperative day 1 (visual analog scale 5 vs 6, P = .14), morphine milligram equivalents used (18 vs 20 morphine milligram equivalents /day, P = .72), length of stay (1 vs 1 day, P = .48), and 90-day complications (2.6% vs 3.9%, P = .65). Estimated blood loss for posterior retroperitoneal adrenalectomy was statistically lower (5 vs 10 mL, P = .001) but not considered to be clinically significant. ConclusionPerioperative outcomes of lateral transperitoneal adrenalectomy, including those related to recovery, were similar to those of posterior retroperitoneal adrenalectomy when matched for tumor and patient anthropometric parameters.

PHEOCHROMOCYTOMA AS A RARE CAUSE OF MYOCARDIAL INFARCTION

Objective: A 41-year-old man was admitted to the cardiac care unit with acute chest pain radiating to his left arm. For the previous 20 years, he had episodes of high blood pressure accompanied by shivering, sweating, anxiety, and headaches. Electrocardiography revealed ST elevation in the II, III, and aVF leads, as well as reciprocal ST depression in the I and aVL leads. Echocardiography showed hypokinesis of the mid inferior and basal inferior segments. Troponin level increased from 0.005 to 0.177 ng/ml. Aneurysms in the coronary arteries were discovered during an urgent coronary angiography. The patient was prescribed aspirin, angiotensin-converting enzyme inhibitor, and calcium channel blocker and discharged from the hospital. Design and method: Further testing included computed tomography (CT) of the aorta and coronary arteries. The aorta had no pathological findings, but the right coronary artery was dilated in the middle segment. A CT scan of the abdomen revealed a mass in the left adrenal gland, and later abdominal and retroperitoneal magnetic resonance imaging revealed a lipid-poor left adrenal mass. Biomarkers of adrenal gland function were evaluated and blood adrenalin (150 pg/ml normal range ‹125pg/ml) and noradrenalin (680pg/ml normal range ‹600pg/ml) levels were mildly elevated. The 24-hour urinary vanillylmandelic acid level was elevated (76,6umol vs. the normal range of 68umol). Cortisol and aldosterone levels in the blood were within normal ranges. Lateral transperitoneal adrenalectomy was eventually performed successfully. Results: Histological examination of the mass revealed a pheochromocytoma. The patient's blood pressure returned to normal after the left adrenalectomy, and episodes of sweating and anxiety accompanied by an acute increase in blood pressure disappeared. Conclusions: Pheochromocytoma is a rare neuroendocrine tumor that can cause life-threatening cardiovascular complications such as myocardial infarction and cardiac arrhythmias. Unfortunately, the clinical pattern of pheochromocytoma frequently remains without typical manifestations and needs detailed laboratory and radiological confirmation. This case emphasizes the importance of a comprehensive assessment of the patient with arterial hypertension, even in the presence of subclinical sympathetic overactivity.

Prevention of conversion in posterior retroperitoneal adrenalectomy by measuring pre-operative anatomical conditions on cross-sectional imaging (computerised tomography or magnetic resonance imaging).

In addition to the common laparoscopic lateral transperitoneal adrenalectomy (LTA), the posterior retroperitoneal adrenalectomy (PRA) is becoming increasingly important. Both techniques overlap in their indication, resulting in uncertainty about the preferred approach in some patients. We hypothesise that by determining anatomical characteristics on cross-sectional imaging computerised tomography or magnetic resonance imaging, we can show the limitations of the PRA and prevent patients from being converted to LTA. This retrospective study includes 14 patients who underwent PRA (n = 15) at a single institution between 2016 and 2018. Previously described parameters such as the retroperitoneal fat mass (RPF) were measured on pre-operative imaging. We compared data from one patient who had a conversion with those from 13 patients without conversion. Furthermore, we explored the influence of these parameters on the operative time. Conversion to LTA was necessary during 1 PRA procedure. Fourteen PRAs in 13 patients were successfully completed. The mean body mass index was 30 kg/m2 and the mean operation time was 98 min. One patient who underwent a conversion had a substantially higher RPF (25 mm) compared to the patients with successfully completed PRA (median: 5.5 mm [P = 0.001]). Furthermore, the operation time strongly correlated with the RPF (P = 0.004, r = 0.713). Surgeons can use pre-operative imaging to assess the anatomical features to determine whether a PRA can be performed. Patients with an RPF under 14.3 mm can be safely treated with PRA. In contrast, LTA access should be considered for patients with a higher RPF (>25 mm).

Oncocytic adrenocortic tumor of the adrenal (clinical case)

A clinical case of treatment of a 32-year-old patient with an adrenocortical tumor of the right adrenal gland is described. When applying to the clinic, the patient was complaining about moderate pain in the right lumbar region, the general condition of the patient was estimated as satisfactory. The patient was of normosthenic constitution, had no bad habits, preoperative general and biochemical blood counts, including the levels of adrenocorticotropic hormone, cortisol, aldosterone, direct renin, metanephrine, normetanephrine were within normal parameters. The patient underwent laparoscopic lateral transperitoneal adrenalectomy on the right in the position on the left side using 4 trocars. The condition of the patient was satisfactory, he was released from the hospital on the 3rd day after surgery.

Hemodynamic stability during adrenalectomy for pheochromocytoma: A case control study of posterior retroperitoneal vs lateral transperitoneal approaches.

Hemodynamic stability is one of the most critical aspects of adrenal surgery for pheochromocytoma. Few articles have evaluated the hemodynamic status of patients undergoing posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. The aim of this study is to compare the intraoperative hemodynamic parameters between lateral transperitoneal adrenalectomy (TPA) and PRA in this groups of patients.This report describes a retrospective study of 53 pheochromocytoma patients who underwent endoscopic adrenalectomy via transperitoneal (22 patients) or posterior retroperitoneal (31 patients) approaches from January 2008 to March 2015. Data from these patients were compared to investigate the differences in hemodynamic parameters between the 2 approaches.Clinical parameters at presentation were similar between the 2 groups, except for tumor size, which was larger in the TPA group. The PRA group is associated with reduced operative time, blood loss, and length of hospital stay compared to TPA even after adjusting for the tumor size. There was greater BP fluctuations and higher maximum systolic and diastolic blood pressure (BP) within the TPA group compared to PRA during univariate analysis. This was however not significant after adjusting for tumor size. There was no difference in the intraoperative inotropic support requirement between the 2 groups.PRA is associated with stable intraoperative hemodynamic status, as well as favorable perioperative outcomes compared to TPA in patients with small pheochromocytomas.

Laparoscopic transperitoneal adrenalectomy v.s. posterior retroperitoneal adrenalectomy in the aspect of complete blood count

Introduction: Minimally invasive surgery is the gold standard for treatment of benign adrenal tumours up to 7–8 cm in diameter. Nowadays, two surgical approaches are performed routinely – lateral transperitoneal adrenalectomy (LTA) and posterior retroperitoneal adrenalectomy (PRA). Both methods are recognized as safe and beneficial for a patient, what can also prove the statistical analysis in the perioperative period. Aim: The aim of our work was to compare lateral transperitoneal adrenalectomy with posterior retroperitoneal adrenalectomy in the aspect of complete blood count. M aterial and Methods: Patients, who underwent videoscopic adrenalectomy in our Department from 02.2015 to 06.2018, were prospectively included to the study. The inclusion criteria was the tumour size smaller than 8cm in abdominal CT. Primary neoplasms were excluded from the study. All surgieres were carried out by one surgeon. Patients were randomized to PRA or LTA. The blood samples were collected - a day before the surgery, and a day, a week, and a month after the surgery. We assessed the rate of leucocytes, red blood cells, hemoglobin and platelets in the peripheral blood. Additionally, the volume of intraoperative blood loss was measured. Results: 77 videoscopic adrenalectomies were carried out, 33 (42,9%) – LTA, 44 (57,1%) – PRA. The average age of the patients constituted- LTA – 61.2± 8.3, PRA – 59.3±10.2. Tumour size in LTA – 4 cm, in PRA – 4.1 cm. Adrenal gland adenomas, basing on postoperative histopathological findings, were most commonly removed tumours in our study: LTA – 82%, PRA – 70%. Intraoperative blood loss was not significant in both groups. We found differences in red blood cells, leucocytes, hemoglobin and platelets rates in each group, without statistically siginificant difference in both groups. Conclusion: Basing on our work, both minimally invasive adrenalectomies are not only effective but also safe. There were not any significant differences in both groups in the aspect of complete blood count. Both approaches – PRA and LTA can be routinely performed as a treatment of benign adrenal lesions and the choice of the approach depends on surgeon’s experience.

Patients criteria determining difficulty of the laparoscopic lateral transperitoneal adrenalectomy. A retrospective cohort study

BackgroundIdentification of patients in whom adrenalectomy may be more difficult, can help in decision making in borderline and doubtful cases. The aim of the study was to determine patients criteria influencing difficulty of laparoscopic lateral transperitoneal adrenalectomy (LTA). Material and MethodsThe study enrolled 275 patients who underwent LTA. We analyzed the impact of gender, age, history of previous abdominal surgery, body mass index, risk of anesthesia measured as ASA scale, size, localization (left/right), and histological type of the tumor on parameters reflecting the level of difficulty of the procedure: operative time, intraoperative blood loss, conversion rate and intraoperative complications rate. ResultsMultivariate logistic regression showed that following factors were associated with longer operative time: gender, tumor size and malignant lesions. In another model it was shown that age, size of the tumor and malignancy were associated with more excessive blood loss. Moreover, it was shown, that tumor size predictive factor for conversion. Univariate analysis showed a relation with malignancy, but multivariate analysis revealed no significance. ConclusionsPatient age, gender, size and histological type of the tumor are criteria influencing parameters reflecting the level of difficulty. This criteria could be considered as predictors of the difficulty of LTA. Surgery in case of patients with combination of this risk factors should be handled by surgeon with sufficient experience to minimalize the risk of adverse events.

Posterior Retroperitonoscopic Adrenalectomy; How to Do it – Pearls and Secrets

Background: Since the early 1990s, endoscopic adrenalectomy has become the gold standard surgical approach for the adrenal gland. Also, lateral transperitoneal adrenalectomy (LTA) which is the most widely used approach accompanies that.. Posterior retroperitonoscopic adrenalectomy (PRA) is another safe and effective approach for the adrenal gland. However, it has not gained global popularity. This is largely attributed to the unfamiliarity of surgeons with the ergonomics and executional steps of the procedure, and the relevant retroperitoneal anatomy. Misconceptions held by both surgeons and anesthesiologists regarding the consequences of the high-pressure retroperitoneal insufflation required may also be a contributing factor. The aim of this article is to provide a detailed description of PRA in a manner which allows the proper acquisition of the knowledge required to perform the procedure safely and effectively. Methods: To achieve the objective of this article, it has been broadly divided into three sections including background, operative technique, and comments. The background provides an introduction to the procedure and its advantages. The section about operative technique provides a detailed description of the preoperative preparatory phase, the proper access, and the executional steps of the procedures supplemented with illustrative figures. It also provides insight into potential hazards related to the anatomy of the adrenal veins, and the means of dealing with variant anatomy. The comments’ section deals with the procedure’s learning curve, and the factors affecting it. It also describes the ideal case for the commencement of the learning curve. A clarification of the misconceptions surrounding PRA is also provided in this section. Conclusion: With thorough technical knowledge and an adequate learning curve, PRA could serve as the surgeon’s preferred surgical approach to the adrenal gland within the confines of its selection criteria.

Laparoscopic and robotic adrenal surgery: transperitoneal approach.

Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.

Comparative outcomes of lateral transperitoneal adrenalectomy versus posterior retroperitoneoscopic adrenalectomy in consecutive patients: A single surgeon's experience

Among several minimally invasive adrenalectomy techniques, lateral transperitoneal adrenalectomy (LTA) is the procedure of choice for benign adrenal tumors; however, posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative that is increasing in popularity. This study compared the outcomes of these two approaches. Since a single surgeon started adrenalectomy, LTA had been performed exclusively until PRA was adopted and became the standard treatment. Therefore, the consecutive patients were allocated into two groups according to the date of surgery: the first group received LTA and the second group received PRA. LTA was performed in 29 patients and PRA in 19 patients. There was no difference in sex, age, body mass index, clinical diagnosis, and tumor size between the LTA and the PRA group. The PRA group showed less blood loss (117.0 mL vs. 58.5 mL, p = 0.035) and tended to have a shorter operating time (92.2 minutes vs. 78.1 minutes, p = 0.054) and less pain score on postoperative Day 1 (3.8 vs. 3.0, p = 0.095) and Day 2 (3.2 vs. 2.5, p = 0.051). The mean operation time was significantly shorter for patients in the PRA group undergoing right adrenalectomy (109.2 minutes vs. 80.5 minutes, p = 0.009), but those undergoing left adrenalectomy had a similar operating time to the LTA group (83.2 minutes vs. 74.8 minutes, p = 0.380). PRA is a good alternative operative technique for an endocrine surgeon who is experienced in the transperitoneal approach.

Systematic Review of Surgical Approaches for Adrenal Tumors: Lateral Transperitoneal versus Posterior Retroperitoneal and Laparoscopic versus Robotic Adrenalectomy.

Background. Laparoscopic lateral transperitoneal adrenalectomy (LTA) has been the standard method for resecting benign adrenal gland tumors. Recently, however, laparoscopic posterior retroperitoneal adrenalectomy (PRA) has been more popular as an alternative method. This systematic review evaluates current evidence on adrenalectomy techniques, comparing laparoscopic LTA with PRA and laparoscopic adrenalectomy with robotic adrenalectomy. Methods. PubMed, Embase, and ISI Web of Knowledge databases were searched systematically for studies comparing surgical outcomes of laparoscopic LTA versus PRA and laparoscopic versus robotic adrenalectomy. The studies were evaluated according to the PRISMA statement. Results. Eight studies comparing laparoscopic PRA and LTA showed that laparoscopic PRA was superior or at least comparable to laparoscopic LTA in operation time, blood loss, pain score, hospital stay, and return to normal activity. Conversion rates and complication rates were similar. Six studies comparing robotic and laparoscopic adrenalectomy found that outcomes and complications were similar. Conclusion. Laparoscopic PRA was more effective than LTA, especially in reducing operation time and hospital stay, but there was no evidence showing that robotic adrenalectomy was superior to laparoscopic adrenalectomy. Cost reductions and further technical advances are needed for wider application of robotic adrenalectomy.

Laparoscopic adrenalectomy by the lateral transperitoneal approach in patients with a history of previous abdominal surgery.

IntroductionEven the half of patients undergoing laparoscopic adrenalectomy has history of previous abdominal surgeries. However, it is still uncertain if this fact has an impact on the operation itself as well as the postoperative course.AimTo analyze the effects of previous abdominal surgery on surgical outcomes in adrenal tumor patients subjected to laparoscopic adrenalectomy.Material and methodsThis study included 268 patients with adrenal gland tumors operated on by means of laparoscopic lateral transperitoneal adrenalectomy: 1) previously subjected to at least one abdominal surgery (group A, n = 101), or 2) with no history of previous abdominal operations (group B, n = 167).ResultsGroups A and B did not differ in terms of tumor size (p = 0.132), mean operation time (p = 0.456), mean intraoperative blood loss (p = 0.754), or perioperative complication rate (p = 0.833). Dissection of intraperitoneal adhesions was considered difficult in 32 patients from group A (31.6%) and 8 subjects from group B (4.7%, p < 0.001). Conversion was required in three subjects from group A (2.9%) and 3 patients from group B (1.8%, p = 0.529).ConclusionsPrevious abdominal surgery does not constitute a contraindication to laparoscopic transperitoneal adrenalectomy.

Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenalectomy

Laparoscopic adrenalectomies are being performed increasingly, either with transperitoneal or retroperitoneal approaches. Studies comparing the 2 approaches have not shown the superiority of either technique, but these studies are limited by small sample sizes and single-institution designs. To overcome these limitations, we performed a meta-analysis of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy. A systematic review of studies comparing lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy was conducted. Study endpoints included perioperative outcomes and measures of postoperative recovery. Meta-analysis was performed using a random effects model, pooling variables evaluated by more than 3 studies. Twenty-one studies comparing a total of 1,205 lateral transperitoneal adrenalectomies and 688 retroperitoneal adrenalectomies were suitable for meta-analysis. Patients in the 2 groups were similar in term of age, sex, body mass index, lesion size and location, and rates of malignancy. There were no statistically significant differences between lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy in terms of operative time, blood loss, hospital stay, time to oral intake, overall and major morbidity, and mortality. Both lateral transperitoneal adrenalectomy and retroperitoneal adrenalectomy are associated with very low rates of perioperative complications. According to our meta-analysis, clinical outcomes after either technique are similar. For most adrenal lesions requiring operation, minimally invasive adrenalectomy can be performed safely and effectively with either transperitoneal or the retroperitoneal approach. Additional studies may be needed to analyze if any difference in long-term results exist.

Laparoscopic Bilateral Simultaneous Adrenalectomy: Results of 11 Operations

This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy. This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin. Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96). Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.

Transperitoneal Laparoscopic Adrenalectomy: Outline of the Preoperative Management, Surgical Approach, and Outcome

The laparoscopic approach to the adrenal gland has evolved to be the gold standard for most cases of adrenal conditions requiring surgical treatment. There is general consent about the safety, efficacy, and reproducibility of laparoscopic adrenal surgery. Compared to the open surgery, significant advantages with regard to shorter hospitalization time, decreased postoperative morbidity, improved cosmetics, and quicker convalescence are evident. The anatomic location of the adrenal gland led to the development of various approaches, including lateral transperitoneal, anterior transperitoneal, lateral retroperitoneal, posterior retroperitoneal, and even transthoracic approaches. The lateral transperitoneal approach is the technique most frequently used for laparoscopic adrenalectomy. A large operative field provides good orientation and visualization of familiar landmarks known from open surgery. In particular in the early learning curve this represents an advantage of the transperitoneal laparoscopic approach. This article describes in detail the indications, contraindications, preoperative evaluation, surgical technique, management of intraoperative complications, and outcome after lateral transperitoneal adrenalectomy.

Lateral transperitoneal laparoscopic adrenalectomy.

Several laparoscopic approaches to the adrenal gland have been described. The lateral transperitoneal approach has several distinct advantages when contrasted with other techniques for laparoscopic adrenalectomy (LA). We present our technique and results obtained in 50 consecutive transperitoneal LAs. We review 50 consecutive laparoscopic adrenalectomies (28 female, 19 male) performed from 1993 to 1998 S.J. Shichman or R.E. Sosa was either the primary surgeon or the first assistant for all cases. The lateral transperitoneal approach described below was used in all cases. Indications for adrenalectomy included Cushing's syndrome (13), aldosteronoma (15), pheochromocytoma (7), nonfunctioning adenoma (11), hyperplasia (2), and 1 case each of Carney's syndrome and metastasis to the adrenal gland. We performed 5 bilateral, 22 left, and 18 right laparoscopic adrenalectomies. The average time needed for bilateral adrenalectomy was 503 min (range 298-690 min); for left adrenalectomy, 227 min (range 121-337 min); and for right LA, 210 min (range 135-355 min). We demonstrated a yearly trend in lower operative times. The largest adrenal gland removed measured 13.8 x 6.7 x 3.5 cm. Intraoperative blood loss was low. Only one patient received a blood transfusion. Conversion to open adrenalectomy was not required. Postoperative analgesic requirements were low. The average length of stay was 3.8 days for bilateral LA and 3 days for unilateral LA. Complications occurred in 5 patients (2 wound infections, 2 hematomas, and 1 pleural effusion). There was no mortality. Lateral transperitoneal adrenalectomy is a safe and efficient technique for the removal of functional and nonfunctional adrenal masses. This technique is associated with low morbidity, a minimal postoperative analgesic requirement, and a short hospital stay and, in our opinion, is more versatile than the retroperitoneal approach.