Lateral Transperitoneal Approach Research Articles

Which surgical approach is more favorable for pheochromocytoma of different sizes (< 6 cm vs. ≥ 6 cm)? A single retrospective center experience

BackgroundTo compare the surgical effects of lateral transperitoneal approach (LTA) and posterior retroperitoneal approach (PRA) for pheochromocytoma of different sizes.MethodsData on patients with pheochromocytoma from 2014 to 2023 were collected from our hospital. According to different surgical approaches and tumor size, all patients were divided into four groups: tumor size < 6 cm for LTA and PRA and tumor size ≥ 6 cm for LTA and PRA. We compared these two surgical methods for pheochromocytoma of different sizes.ResultsA total of 118 patients with pheochromocytoma underwent successful laparoscopic surgery, including PRA group (n = 80) and LTA group (n = 38). In tumor size < 6 cm, the outcomes were no significant difference in LTA and PRA. In tumor size ≥ 6 cm, there was a significant difference in operation time (214.7 ± 18.9 vs. 154.3 ± 8.2, P = 0.007) and intraoperative blood loss (616.4 ± 181.3 vs. 201.4 ± 45.8, P = 0.037) between LTA and PRA.ConclusionLTA and PRA were performed safely with similar operative outcomes in patients with pheochromocytoma size < 6 cm. While both LTA and PRA were executed with a commendable safety profile and comparable operative results in patients afflicted by pheochromocytomas < 6 cm, the PRA technique distinctly showcased advantages when addressing large-scale pheochromocytomas (≥ 6 cm). Notably, this manifested in reduced operative time, diminished intraoperative blood loss, decreased hospitalization expenses, and a paucity of procedural complications.

Laparoscopic Bilateral Adrenalectomy with the Transabdominal Lateral Approach

Background: Laparoscopic adrenalectomy (LA) is a widely accepted method for most adrenal lesions. However, bilateral LA is performed less often than unilateral adrenalectomy. The most common indication for bilateral LA is adrenocorticotropin hormone (ACTH)-dependent Cushing’s syndrome, including persistent Cushing’s disease following unsuccessful transsphenoidal surgery and ectopic ACTH syndrome. Objectives: This retrospective study was conducted to assess the indications, safety, efficacy, and outcomes for bilateral LA with the transabdominal lateral approach. Methods: This retrospective study was conducted between January 2004 and February 2022. During the study period, transperitoneal LA was performed on 279 patients, among whom, 258 cases were unilateral LA. Therefore, our analysis included 21 consecutive patients who underwent laparoscopic bilateral LA with the transabdominal lateral approach. The surgery indication, tumor side and weight, operation time, conversion to open surgery, need for an additional trocar, complications, hospital stay, and follow-up information were analyzed. Results: Indications of bilateral LA were refractory Cushing’s disease (n=14), occult ectopic primary bilateral macronodular adrenal hyperplasia (n=5), ACTH secretion (n=1), and bilateral pheochromocytoma (n=1). The mean operative time was 207.8±21.3 min, including repositioning time. Intraoperative and postoperative complications were seen in 3 (14%) and 4 (19%) patients, respectively. No conversion to open surgery was observed. Median hospital stay was 7 (range, 5-10) days and median follow-up was 81 (range, 55-94.5) months. Three patients died at 62, 64, and 88 months after adrenalectomy due to heart failure, renal failure, and myocardial infarction, respectively. No adrenal insufficiency or signs of recurrent hypercortisolism was observed. Conclusion: Our results demonstrated that laparoscopic bilateral LA was safe and effective, allowing acceptable morbidity and hospital stay. The most common surgical indication was ACTH-dependent Cushing's syndrome, followed by ACTH-independent Cushing's syndrome. The lateral transperitoneal approach obtains an excellent anatomical view. In our series, operative time and conversion to open surgery rate were in line with the literature.

Comparison of lateral transperitoneal versus retroperitoneal laparoscopic adrenalectomy for pheochromocytoma: a single-centre retrospective study.

Laparoscopic adrenalectomy (LA) has became the standardized treatment for pheochromocytoma. The aim of this study was to evaluate outcomes of lateral transperitoneal and retroperitoneal LA for pheochromocytoma. Between January 2011 and December 2021, 142 patients with pheochromocytoma underwent LA via lateral transperitoneal (123 patients) or retroperitoneal (19 patients) approaches. Data of these patients were assessed to investigate the differences in perioperative outcomes and intraoperative haemodynamic parameters between the two procedures. Clinical parameters at presentation were comparable between the two groups, except for tumour size, which was larger in the transperitoneal group (50 [10-115] mm vs 35 [7-110] mm, P = 0.012). There were no significant differences between the two groups in terms of operation time, estimated blood loss, intraoperative transfusion rate, incidence of complications, conversion to open surgery, postoperative analgesic requirement, time to first oral intake, or mean hospital stay. Intraoperative haemodynamic parameters of the two groups were similar. After adjusting for tumour size using propensity score matching, both perioperative outcomes and haemodynamic parameters were still comparable. Lateral transperitoneal and retroperitoneal laparoscopic adrenalectomies provide similar perioperative and haemodynamic outcomes for surgical resection of pheochromocytoma.

Comparison of lateral transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy

BackgroundThere is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy. The aim of this study is to compare lateral transperitoneal and retroperitoneal approach for left-sided and right-sided laparoscopic adrenalectomy respectively.MethodsBetween January 2014 and December 2019, 242 patients underwent left-sided and 252 patients underwent right-sided laparoscopic adrenalectomy. For left side, transperitoneal approach was used in 132 (103 with tumors < 5 cm and 29 with tumors ≥ 5 cm) and retroperitoneal approach in 110 (102 with tumors < 5 cm and 8 with tumors ≥ 5 cm). For right side, transperitoneal approach was used in 139 (121 with tumors < 5 cm and 18 with tumors ≥ 5 cm) and retroperitoneal approach in 113 (102 with tumors < 5 cm and 11 with tumors ≥ 5 cm). Patient characteristics and perioperative outcomes were recorded. For each side, both approaches were compared for tumors < 5 cm and ≥ 5 cm respectively.ResultsFor left-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time, less blood loss and longer time to oral intake. For left-sided tumors ≥ 5 cm, the peri-operative data of both approaches was comparable. For right-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time and less blood loss. For right-sided tumors ≥ 5 cm, the peri-operative data was comparable.ConclusionsLateral transperitoneal and retroperitoneal approach are both effective for laparoscopic adrenalectomy. Lateral transperitoneal approach is faster with less blood loss for tumors < 5 cm.

Nerve-sparing Robot-assisted Retroperitoneal Lymph Node Dissection: The Monoblock Technique

BackgroundRetroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage 1 or 2 testis cancer and the standard of care for men with postchemotherapy retroperitoneal residual disease. Given the morbidity of RPLND, four important surgical modifications have been proposed: minimally invasive access, nerve-sparing resection, template resection, and en-bloc resection. ObjectiveTo describe the surgical steps and perioperative outcomes of robotic nerve-sparing unilateral template RPLND with en-bloc resection (roboRPLND-NS+). Design, setting, and participantsFrom 2017 to 2019, five patients with suspicion of retroperitoneal metastatic testicular cancer on abdominopelvic computed tomography underwent roboRPLND-NS+ at a single referral center. All surgeries were carried out by a single surgeon who has performed more than 500 extended and more than 50 super-extended robot-assisted lymph node dissections. Surgical procedureA lateral transperitoneal robotic approach with a da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in six-arm configuration was used. The sympathetic chains, postganglionic sympathetic fibers, and hypogastric plexus were preserved as much as possible to ensure a nerve-sparing procedure. The template borders consisted of the renal vein cranially, the ureter laterally, the interaortocaval space medially, the common iliac artery caudally, and the psoas muscle dorsally for the right and left modified RPLND templates. Lymph nodes and the surrounding fatty tissue were progressively resected from the common iliac vessels and the abdominal aorta using the split-and-roll technique, and all of the template tissue was resected as a single specimen. Intraoperative and postoperative complications were recorded. MeasurementsLymph node yield and perioperative and postoperative oncological and functional outcomes were measured. Results and limitationsThe median patient age was 38 yr (interquartile range [IQR] 32–41) and the median operative time was 274 min (IQR 238–280). Node metastases were pathologically confirmed in three patients. The median number of lymph nodes removed was 19 (IQR 18–21), and the median number of positive lymph nodes was 2 (IQR 1–3). No patient experienced intraoperative or postoperative complications. The postoperative hospital stay was either 3 or 4 d. Maintenance of antegrade ejaculation was achieved in all patients. After median follow-up of 15 mo (IQR 14–30), all patients were alive and no recurrence was observed. Limitations include the low number of patients and the single surgeon experience. ConclusionsRoboRPLND-NS+ is a safe and feasible technique that allows removal of a high number of lymph nodes with good functional outcomes. Short-term survival outcomes were excellent, with no recurrences or deaths recorded. Patient summaryWe describe a feasible and safe robot-assisted surgical procedure for removal of lymph nodes in patients with testicular cancer. Our technique has potential to decrease the medical problems arising as side effects of the surgery while achieving good cancer control.

Comparison of Outcomes between Obese and Nonobese Patients in Laparoscopic Adrenalectomy: A Cohort Study

Introduction: Obesity is usually considered a risk factor for surgical complications. Laparoscopic adrenalectomy has replaced open adrenalectomy as the standard operation for adrenal tumors. Objective: To compare the safety of laparoscopic adrenalectomy to treat adrenal tumors in obese versus nonobese patients. Methods: This observational cohort study analyzed consecutive patients who underwent laparoscopic adrenalectomy with a lateral transperitoneal approach at a single center (2003–2020). Data and outcomes of obese (body mass index ≥30 kg/m²) and nonobese patients were compared. To analyze the association between operative time and other variables, we used simple and multivariate linear regression. Results: N = 160 (90 obese/70 nonobese) patients underwent laparoscopic adrenalectomy. Cushing syndrome and pheochromocytoma were the most frequent indications. Obese patients were older (58 vs. 52 years, p < 0.001). A greater proportion of obese patients were ASA grade III + IV (71.1 vs. 48.6%, p = 0.004). Obesity was associated with a longer operative time (72.5 vs. 60 min, p < 0.001) and greater blood loss (40 vs. 20 mL, p = 0.022). There were no differences in conversion, morbidity, or hospital stay. After adjustment for confounding factors, operative time was positively correlated with BMI ≥30 kg/m², learning curve, estimated blood loss, 2D laparoscopy, and specimen size. Conclusion: Lateral transperitoneal laparoscopic adrenalectomy is safe in patients with a BMI 30–35 kg/m², so these patients also benefit from this minimally invasive surgery.

MP04-15 LAPOROSCOPIC PARTIAL NEPHRECTOMY WITH BLUE DIODE, THULIUM FIBER AND HYBRID LASERS. IN VIVO TRIAL ON PORCINE KIDNEY

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I (MP04)1 Apr 2020MP04-15 LAPOROSCOPIC PARTIAL NEPHRECTOMY WITH BLUE DIODE, THULIUM FIBER AND HYBRID LASERS. IN VIVO TRIAL ON PORCINE KIDNEY Dmitry Enikeev*, Ekaterina Laukhtina, Mikhail Enikeev, Valeria Arkhipova, Mark Taratkin, Leonid Rapoport, and Petr Glybochko Dmitry Enikeev*Dmitry Enikeev* More articles by this author , Ekaterina LaukhtinaEkaterina Laukhtina More articles by this author , Mikhail EnikeevMikhail Enikeev More articles by this author , Valeria ArkhipovaValeria Arkhipova More articles by this author , Mark TaratkinMark Taratkin More articles by this author , Leonid RapoportLeonid Rapoport More articles by this author , and Petr GlybochkoPetr Glybochko More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000818.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Laparoscopic partial nephrectomy (LPN) is beneficial for patients with renal cell carcinoma of clinical stage T1 and T3. The main challenge of this approach is achieving of adequate hemostasis. Dissection of renal parenchyma at Z-ischemia is usually accompanied by severe blood loss, whereas vessels clamping, which is used to prevent bleeding, may result in impairment of renal function as warm ischemia time often exceeds 25-30 minutes. Therefore, a lot of effort has been made towards the development of tools, which allow resection without hilar clamping and maintaining "clean" surgical field at minimum blood loss. In this regard, laser technologies are of particular interest, because they possess optimal cutting and coagulation properties, which can be utilized simultaneously. The aim of this study was the evaluation of the efficacy and safety of a novel blue diode laser (BDL) and thulium fiber (Tm-Fiber) laser, as well as hybrid (BDL + Tm-Fiber) laser for LPN. METHODS: BDL emitting at a wavelength of 442 nm and Tm-Fiber laser emitting at the wavelength of 1942 nm (NTO IRE-Polus, Russia) were used. Both lasers were operated at continuous mode with the following settings: average power Pav = 20 W, pulse energy E = 0.7 J and Pav = 20-40 W, E = 1 - 1.5 J for BDL and Tm-Fiber lasers, respectively. In hybrid laser, the same laser parameters were used. Implementation of BDL in continuous mode should provide resection without carbonization. LPN was performed on a porcine model under Z-ischemia conditions. Laparoscopic lateral transperitoneal approach with 3 working and one optical ports was used. RESULTS: 1. Application of BDL resulted in resection without carbonization. Skin to skin operation time and the laser application time were 37 and 10 minutes, respectively. The area of the resection surface was 5 cm2. Despite the intense smoke production, resection was feasible. 2. Tm-Fiber laser induced strong smoke formation, pronounced carbonization, and slow cutting. Increasing laser power did not improve surgical outcome. The total operation time was 10 minutes, the time of laser implementation was 3 minutes then the operation was stopped. 3. Hybrid laser resulted in the successful resection. Skin to skin operation time and the laser activation time were 11 and 4 minutes, respectively. The resected area was 10 cm2. Resection surface was free of carbonization. Hemostasis was clinically acceptable. However, we were not able to prevent bleeding completely at the final stage of the operation, when the large artery (>2 mm of diameter) was affected. CONCLUSIONS: Hybrid (BDL + Tm-Fiber) laser into a single device may be advantageous for effective and safe LPN. The combination of both lasers allows fast carbonization-free cutting, whereas the coagulative properties of the Tm-Fiber laser enable adequate hemostasis. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e37-e38 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Enikeev* More articles by this author Ekaterina Laukhtina More articles by this author Mikhail Enikeev More articles by this author Valeria Arkhipova More articles by this author Mark Taratkin More articles by this author Leonid Rapoport More articles by this author Petr Glybochko More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic approaches to the retropubic space: three alternatives with anatomical considerations

Introduction Many urogynecological and surgical laparoscopic interventions require access to the retropubic space, also known as the space of Retzius. Especially in patients with a history of previous surgery in this area or in general in the lower abdomen, the preparation may be complicated by adhesions and scar tissue. The necessity to combine several laparoscopic procedures in one surgical session may require consideration of the most appropriate way to approach the retropubic space. Material and methods We describe and discuss three different options to access the space of Retzius via laparoscopy: the medial transperitoneal, the extraperitoneal and the lateral transperitoneal approach. For all approaches, we used one umbilical trocar and two trocars in the lower abdomen. Results An algorithm was developed to select the most appropriate access route to the retropubic space, depending on the history of previous surgeries and accompanying interventions. Conclusion The knowledge of different access routes to the retropubic space offers the possibility of adjusting the surgical procedure to the individual constellation of the patient.

The impact of laparoscopic adrenalectomy on renal function. Results of a prospective randomised clinical trial.

Laparoscopic adrenalectomy is the gold standard management of benign adrenal masses and isolated metastases to adrenal glands. Two techniques of endoscopic adrenalectomy: lateral transperitoneal approach (LTA) and posterior retroperitoneal approach (PRA) seem to be equally safe and effective. Recent studies suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery, and lower early morbidity. However, PRA involves high insufflation pressure of CO₂ within a limited retroperitoneal space. The aim of our study was to prospectively assess the effect of LTA versus PRA laparoscopic adrenalectomies on renal function. We randomly assigned patients referred for unilateral adrenalectomy to either LTA (n = 33) or PRA (n = 44). The inclusion criteria were: hormonal activity and/or tumour diameter > 4 cm and/or suspicion of metastasis to adrenal gland. The exclusion criteria comprised: tumours > 8 cm, results of imaging studies suggesting primary invasive malignancy, and refusal to undergo randomisation. The patients were prospectively followed for a minimum of six months. Serum creatinine, cystatin C, and urinary neutrophil gelatinase-associated lipocalin (NGAL) were measured preoperatively and at postoperative days: 1, 7, and 30. We found increased concentrations of urinary NGAL at day 1 following laparoscopic adrenalectomy using PRA, as compared to LTA. Patients undergoing right-sided PRA had increased creatinine concentrations, as compared to left-sided PRA. Patients with aldosterone-producing adenoma had decreased preoperative eGFR as compared to subjects with non-functioning incidentaloma. NGAL increased significantly in this group postoperatively. All the disturbances normalised within one month postoperatively. Renal function impairment after PRA may result from compression of inferior vena cava by high retroperitoneal pressure during right-sided adrenalectomy. Despite the transient character of the observed abnormalities, we suggest that patients with high risk of acute kidney injury may benefit from an alternative technique of adrenalectomy using LTA.

Laparoscopic adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach - prospective randomized trial.

IntroductionLaparoscopic adrenalectomy has become the gold standard of surgical treatment for benign adrenal masses. Two alternative surgical approaches are currently advocated: the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). Several randomized trials have compared LTA to PRA, but most of them included small numbers of patients or had stringent inclusion criteria.AimTo compare clinical results of LTA and PRA endoscopic adrenalectomies for tumors < 8 cm with wide inclusion criteria.Material and methodsWe randomized 77 patients to either LTA (n = 33) or PRA (n = 44). The groups were comparable in terms of age, gender proportions, body mass index, tumor size, clinical and pathological diagnosis. We analyzed duration of surgery, intraoperative blood loss, postoperative pain, length of hospital stay and postoperative morbidity.ResultsThe follow-up concerned 98.8% of patients and was on average 28 (8–47) months long. There were no conversions. We identified significantly lower intensity of pain assessed 24 h after surgery in the PRA group (3.4 ±1), as compared to LTA (4.2 ±1), with lower prevalence of shoulder pain (2.3% vs. 30.3%, respectively). Postoperative hospital stay was shorter in the PRA (1.14 ±0.4) than in the LTA (1.36 ±0.5) group. Perioperative morbidity concerned 4 patients in each group with pain requiring oral analgesia > 7 days.ConclusionsTo our knowledge this is the largest prospective randomized study comparing LTA to PRA. We demonstrated safety, efficacy and very low morbidity of both techniques. The PRA proved superior to LTA in terms of lower intensity of postoperative pain and shorter hospital stay.

Risk Assessment and Learning Curve in Laparoscopic Transperitoneal Adrenalectomy - Early and Late Experience of a Single Team.

Since its first description in 1992, laparoscopic adrenalectomy has become the standard of treatment for most benign and low grade small adrenal tumors but due to the low incidence of adrenal disease, it remains a rarely performed intervention outside referral or excellence centers. Although laparoscopic surgery had a positive impact on complications of adrenalectomy, surgical risk should be thoroughly assessed when it comes to secreting or large tumors. This is a retrospective analysis of laparoscopic adrenalectomies performed in the first 4 years of practice 2007-2010 - the early experience including the learning curve of the senior surgeon, and our late experience from 2016 to 2019. All interventions were performed by a single team led by a senior surgeon with extensive experience in advanced laparoscopic surgery, using the lateral transperitoneal approach. In total, 82 cases were included, out of 153 laparoscopic adrenalectomies performed between 2007 and 2019. Only one conversion was recorded during the early experience and two laparoscopic reinterventions were needed for hemostasis and drainage. Non-secreting adenoma was the most frequent indication for surgery (26 cases) followed by Cushing's Syndrome (22 cases) while adrenocortical carcinoma was diagnosed in 3 cases. Significant differences were found between the two periods regarding operative time and length of postoperative hospital stay (p 0.001). With growing experience in laparoscopic transperitoneal adrenalectomy, less complications and shorter operative time and postoperative hospital stay are to be expected.

AB076. The comparation of the robot-assisted partial nephrectomy with two different trocar layout methods

BackgroundTo analyze the effect of two different trocar layout methods, which include the midline and lateral transperitoneal approach, on the robotic-assisted partial nephrectomy (RAPN).MethodsTransperitoneal approach was used in all the cases. In the midline layout group, 12-mm camera port was placed 2 cm to navel, besides the rectus abdominis. An 8-mm robotic trocar was placed on the lateral margin of the rectus abdominis, 3 cm from the costal margin approximately. Another 8-mm robotic arm trocar was placed to the point that 5 cm away from anterior superior iliac spine. Insert the 12-mm assistant trocar next to the rectus abdominis and on the right side, 5-mm assistant trocar was planted in the central line of the lower abdomen. For the lateral transperitoneal approach, place the 12-mm Trocar located in the midpoint between the nephroid projection and navel. The 8-mm robot Trocar is placed on the side of the lens hole, with the distance greater than 3 cm. The other 8-mm robot trocar was suggested to be put in the place greater than 3 cm from the iliac crest. The 12-mm auxiliary Trocar is placed above the navel. A 5-mm auxiliary Trocar was placed in the midline of the xiphoid process.ResultsIn the midline layout group, 50 cases were included, among which, the mean operation duration was 254.8 min (140–380 min), blood loss was 164.8 mL (30–1,000 mL), warm ischemic time was 27.2 min (7–50 min). In these cases, the conversion to open surgery was required in one case because of the limited operation view and 2,400 mL blood was transfused to that patient. In the lateral transperitoneal approach group, 8 cases were included and the mean operation duration was 239 min (160–310 min), blood loss during the surgery was 140 mL (100–200 mL), warm ischemic time is 28.5 min (12–46 min). In the midline layout cases, the operative field of vision is much closer to that of an ordinary laparoscopic view and the scope is relatively far from the kidney. No open surgery was conversed and no blood transfusion happened. In these cases, the field of view was larger and the robot arm had a wider range of motion. In the side layout group, the speculum was relatively closer to the kidney with the small operation view. The robot arm had a small range of motion, but it had a more complete field of vision for the upper pole of the dorsal kidney.ConclusionsBoth surgical methods are suitable for RAPN. The midline layout method is closer to the traditional laparoscopic view, which can be used more widely. The lateral layout is more suitable for kidney tumors located on the dorsal upper pole of the kidney.

Incidental giant adrenal lymphangioma presenting as nonfunctional cystic mass.

Surrenal masses can be encountered with many different clinical manifestations and a diverse spectrum of etiologies in clinical practice. Recent advances in imaging and laboratory studies as well as their increasingly widespread use and easy accessibility have currently made it possible to diagnose a greater number of surrenal masses than ever. The basic approach principles vary for incidentally detected masses, benign/malignant masses, and hormonoactive masses. Lymphangiomas are benign congenital malformations of lymphatic channels that primarily affect the neck and head region. They are typically found in children younger than 2 years of age, they are uncommon in adults, and they rarely involve surrenal glands. In this paper, we present a woman with a hormonally inactive right giant surrenal mass showing recent rapid growth, which was diagnosed to be a lymphangioma with an atypical localization in the histopathological examination. The patient was operated with right surrenalectomy and total mass excision via laparoscopic lateral transperitoneal approach.

Laparoscopic adrenalectomy for large adrenal pheochromocytoma: a case report and discussion

A 40-year-old patient who presented hypertension and hyperglyemia, on CECT showing 7x6.2x5 cm sized retroperitoneal mass lesion in left para-aortic region extending to suprarenal region, diagnosed as pheochromocytoma. Patients BP monitored hourly, started antihypertensive and insulin. After adequate control of blood pressure and blood sugar patient planned for laparoscopic adrenalectomy by lateral transperitoneal approach. GA and combined epidural spinal anesthesia given. The patient was placed in the right-lateral decubitus position with the left side up. The surgeon and assistant stand on the right side of the table. and 4 trocars were inserted. The first port is situated 2 cm below the costal margin at the midclavicular line. The lateral port is placed under direct visualization at the anterior axillary line. The remaining port was placed between the two port. Adrenal Vein bluntly dissected, the vein is carefully doubly ligated with hemlock clips and transacted between clips. The adrenal gland was retracted in a superolateral direction and the harmonic scalpel was used to continue dissection laterally. The specimen was retrieved via a small, 4 cm incision on lateral costal margin. Histopathology of tumor specimen confirmed diagnosis as pheochromocytoma. Laparoscopy offers a better anatomical exposure, shorter length of stay, a decrease in postoperative pain, faster return to preoperative activity level, improved cosmesis, and reduced blood loss, early to resumption of oral feeding.

Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery

BackgroundLaparoscopic adrenalectomy is an effective method for benign adrenal tumor removal. In the literature, both lateral transperitoneal (TLA) and posterior retroperitoneoscopic (RPA) approaches are described. Since 2007, the number of patients increased significantly in our center. Therefore, RPA was introduced in 2011 because of its potential advantages in operating and recovery times. The learning curve of RPA is now evaluated.MethodsAll data of patients undergoing laparoscopic adrenalectomy from 2007 until 2014 were prospectively collected. Patients were eligible for RPA with a tumor <7 cm, with BMI < 35 kg/m2, and with low suspicion of malignancy. The learning curve of RPA was measured by operating time. Furthermore, blood loss, preoperative complications and hospital stay were analyzed. Descriptive statistics were performed using SPSS 20.0.ResultsIn the study period, 290 patients underwent surgery, of whom 113 underwent RPA. After starting with RPA, operating times decreased significantly (median 100 min in the first 20 patients to 60 min after 40 patients, p < 0.05). There was a significant difference in operating times (median 108 vs. 62 min, p < 0.05) and hospital stay (median 4 vs. 3 days, p < 0.05) in unilateral surgery in favor of RPA, compared to TLA. Also in bilateral surgery, operating times were significantly shorter (median 236 vs. 117 min, p < 0.05). In both groups, few major complications occurred.ConclusionAfter the introduction of RPA, a short learning curve was seen for a single surgeon with extensive experience in laparoscopic adrenal surgery. Compared to TLA, RPA has significant advantages in operating times and hospital stay. Therefore, RPA may be the preferred approach for patients with BMI < 35 kg/m2 and small benign adrenal tumors (<7 cm).

Subcostal Port Placement for Lateral Transperitoneoscopic Adrenalectomy: Assessment of Surgical Efficacy.

The purpose of this study was to evaluate the safety and efficacy of the modified lateral transperitoneal (MLTP) approach in comparison with the traditional lateral transperitoneal (LTP) and lateral retroperitoneal (LRP) approach. From January 2008 to December 2012, 287 patients underwent laparoscopic adrenalectomy, and the MLTP, LTP and LRP approaches were used in 93, 96 and 98 patients. The patients' demographics and surgical outcomes from the three approaches were reviewed and compared. There were no significant differences in the general demographic or postoperative recovery variables among the three groups. However, the average volume of blood lost was lower for the MLTP group than for the other two groups. Additionally, the average operative time was significantly shorter in the MLTP group than in the LTP group and slightly shorter than in the LRP group, but the differences were not statistically significant. This study shows that the MLTP approach is a safe and effective procedure which is associated with shorter operative time and lower volumes of blood loss.

Laparoscopic Management of a Complex Adrenal Cyst

Adrenal cysts are rare, and their clinical management remains controversial. We report a case involving an adrenal cyst with a complicated appearance on radiological studies. Unenhanced computed tomography revealed a unilocular, noncalcified, hypoattenuating mass with a thin wall in the left adrenal gland. The lesion gradually increased in size from 10 to 50 mm at two-year follow-up. On contrast-enhanced magnetic resonance imaging, a mural nodule with contrast enhancement was observed. The entire adrenal gland was excised en bloc via a lateral transperitoneal laparoscopic approach without violating the principles of surgical oncology. The pathological diagnosis was an adrenal pseudocyst. Laparoscopic adrenalectomy is a safe option for the treatment of complex adrenal cysts, while maintaining the benefits of minimal invasiveness.

V4-13 LEFT-SIDED LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA

You have accessJournal of UrologyAdrenal/Robotics1 Apr 2014V4-13 LEFT-SIDED LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA Omer Demir, Ozan Bozkurt, Tevfik Demir, Canan Altay, Mustafa Secil, and Adil Esen Omer DemirOmer Demir More articles by this author , Ozan BozkurtOzan Bozkurt More articles by this author , Tevfik DemirTevfik Demir More articles by this author , Canan AltayCanan Altay More articles by this author , Mustafa SecilMustafa Secil More articles by this author , and Adil EsenAdil Esen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1546AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Laparoscopic partial adrenalectomy or adrenal sparing surgery originated from the aim of preserving functioning gland in order to obviate the need for hormonal replacement and undesired side effects. A case of left-sided laparoscopic partial adrenalectomy for phechromocytoma and technical aspects are presented in this video. Methods A 54 year old female patient was referred to our hospital with a 4 cm left adrenal mass in ultrasonographic examination. She has been on medication for HT for 2 years and she was complaining of flushing and palpitation. Endocrinologic work-up consisted of plasma thyroid hormone levels, plasma catecholamine and basal cortisol levels, ACTH supression test, 24-hour urinary measurement of cortizol and catecholamines. She underwent PET-CT imaging for radiologic diagnosis. She was prescribed alpha-blocker therapy 1-month before surgery and left-sided laparoscopic partial adrenalectomy with lateral transperitoneal approach using 3 entry ports was performed. Intraoperative laparoscopic color doppler ultrasonography confirmed the viability and vascular supply of the remaining adrenal gland. Results Thyroid hormone levels and plasma catecholamine and basal cortisol levels were in normal ranges and ACTH suppression test was negative. 24-hour urinary measurement of homovanillic acid (HVA) level was slightly higher than normal levels with 10.73 mg/24h (Reference ranges: 0.5-6.2 mg/24h) whereas vanillylmandelic acide (VMA), metanephrine and normetanephrine levels were in normal ranges. PET-CT imaging supported the diagnosis of pheochromocytoma. Operation was performed under general anesthesia and the operation time was 45 minutes. No peroperative or postoperative complication was encountered and the patient was discharged one day after the surgery. Pathologic examination revealed pheochromocytoma. Conclusions Laparoscopic partial adrenalectomy might be attempted for excision of pheochromocytoma whenever feasible. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e554 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Omer Demir More articles by this author Ozan Bozkurt More articles by this author Tevfik Demir More articles by this author Canan Altay More articles by this author Mustafa Secil More articles by this author Adil Esen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Videoscopic adrenalectomy - when does retroperitoneal seem better?

IntroductionVideoscopic adrenalectomy is the gold standard for the surgical treatment of benign adrenal tumours. The two most common approaches are the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). So far it has not been established which is the preferable one. The choice depends primarily on the surgeon's preference and contraindications for a particular approach in individual cases.AimTo compare the two most common approaches for videoscopic adrenalectomy, LTA and PRA, based on a literature review and our own experience.Material and methodsWe reviewed the literature (PubMed and Cochrane 1990 – current) and analysed retrospectively our own patients who underwent videoscopic adrenalectomy between 2009 and 2013. The analysis covered patient features, tumour characteristics, reasons for qualification for each approach, operative time and postoperative complications.ResultsOut of 71 videoscopic adrenalectomies, 50 were performed using PRA and 21 using LTA. Patients in the PRA group on average were older, but had smaller tumours. There was no significant difference in perioperative morbidity between PRA and LTA. Mean blood loss and total operative time were smaller/shorter for the PRA group in comparison to the LTA group. Time to first oral intake and the average postoperative hospital stay were shorter for PRA than LTA.ConclusionsVideoscopic adrenalectomy is a safe and efficient technique performed using both LTA and PRA approaches. The choice of technique should be guided, most of all, by surgeon experience, patient characteristics, tumour size and location. Our preferable approach is PRA, especially for small (< 6 cm) benign tumours. We find LTA advantageous for tumours of larger size, with suspected malignant character (either primary or secondary), in ectopic position, as well as in patients lacking an ipsilateral kidney or when a simultaneous abdominal operation is planned.

Comparison of robotic adrenalectomy with traditional laparoscopic adrenalectomy with a lateral transperitoneal approach: a single‐surgeon experience

Although several recent studies have demonstrated the feasibility and safety of robotic adrenalectomy, it is unknown whether this procedure has advantages over the traditional laparoscopic approach. This study compared our initial experience using the da Vinci-S® robotic surgical system during laparoscopic adrenalectomy with our experience with traditional laparoscopic adrenalectomy. From October 2009 to May 2012, 23 consecutive patients (13 women, 10 men) underwent laparoscopic adrenalectomy by the same surgeon at Anam Hospital, Korea University Medical Center. Fifteen patients (9 women, 6 men) underwent robot-assisted adrenalectomy (right-sided, 4 patients; left-sided, 11 patients). Eight patients (4 women, 4 men) underwent traditional laparoscopic adrenalectomy (right-sided, 5 patients; left-sided, 3 patients). The lateral transperitoneal approach was used for all patients. There were no cases of conversion to traditional laparoscopic or open surgery. The mean operative time was longer in the robotic group (208.2 minutes, range 120-320) than the laparoscopic group (181.13 minutes, range 75-270). There were no cases of intraoperative complications or mortality. The mean hospital stay did not differ significantly between groups (robotic group, 5.86 days (SD 1.16); laparoscopic group, 6.71 days (SD 1.38)). With its magnified stereoscopic three-dimensional vision, elimination of tremor, and ability to articulate and rotate surgical instruments, the da Vinci-S® robotic system may be an ideal surgical tool for the operation of adrenal lesions. Robotic adrenalectomy appears to be a safe and effective alternative to traditional laparoscopic adrenalectomy.