Posterior Retroperitoneoscopic Adrenalectomy Research Articles

Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model.

The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.

Bilateral pheochromocytoma after kidney transplantation in neurofibromatosis type 1.

SummaryWe present the case of a 25-year-old male with a history of neurofibromatosis type 1 and bilateral pheochromocytoma 4 years after kidney transplantation that was successfully treated with simultaneous bilateral posterior retroperitoneoscopic adrenalectomy.Learning points:Hypertensive patients with NF1 should always be screened for pheochromocytoma.Pheochromocytoma is rarely associated with transplantation, but it must be ruled out in patients with genetic susceptibility.Posterior retroperitoneoscopic adrenalectomy (PRA) allows more direct access to the adrenal glands, especially in patients with previous abdominal surgeries.

Posterior retroperitoneoscopic adrenalectomy for pediatric adrenal tumors

Background/aimsPosterior retroperitoneoscoic adrenalectomy has been reported as an option for adrenal tumor resection but is not commonly performed in children owing to the extreme semikneeling position advocated to flatten the lumbar lordosis in order to achieve adequate retroperitoneal space. As children have smaller lordosis angles, flattening of the lordosis and creation of optimal retroperitoneal space may be achieved with less hip flexion. We used pediatric lumbar lordosis measurements to develop a modified prone jackknife position and report our experiences with this setup for posterior retroperitoneoscopic adrenalectomy for adrenal tumors. MethodsLordosis angles were measured on sagittal computed tomography (CT) and magnetic resonance imaging (MRI) studies of patients with adrenal tumors and compared to normal references. The data were used to develop our modified prone jackknife position. Selected patients with adrenal tumors underwent posterior retroperitoneoscopic adrenalectomy in this position. Patient demographics, diagnoses, operative times, complications, postop analgesia requirements, and length of hospitalization were analyzed. ResultsCT and MRI studies were analyzed for 20 patients with adrenal tumors diagnosed in our institution from 2012 to 2017; median lordosis angle was 27.84° (range: 15.50°–36.48°) — less than reference lordosis angles of respective age groups, and flexion angles of common operating tables. Five patients underwent retroperitoneoscopic adrenalectomy between June 2016 and June 2018. Histological diagnoses were neuroblastoma, adrenal hyperplasia, pheochromocytoma, and adrenal angiomatoid fibrous histiocytoma. Median age was 4 years [range: 1–11]. Median operating time was 137 min [range 111–181 min]. No conversions to open surgery were required. One patient had intraoperative bleeding from the adrenal vein. Only 1 patient required postoperative opioids for analgesia. Median length of hospitalization after surgery was 2 days (range: 2–3 days). ConclusionsPediatric patients can achieve flattening of lumbar lordosis with less extreme positioning. Posterior retroperitoneoscopic adrenalectomy in a modified prone jackknife position is a feasible operation for pediatric patients with small adrenal masses. Type of studyClinical research paper. Level of evidenceLevel III.

Surgical outcomes of laparoscopic adrenalectomy for primary hyperaldosteronism: 20 years of experience in a single institution.

PurposeRecently, posterior retroperitoneoscopic adrenalectomy (PRA) has been reported to have some advantages over laparoscopic transperitoneal adrenalectomy (LTA). The objectives of this study were to report our experience over 12 years with laparoscopic adrenalectomy for primary hyperaldosteronism (PHA) and to examine surgical outcomes of PRA compared with LTA in patients with PHA.MethodsThe medical records of 527 patients who underwent minimally invasive adrenalectomy, including LTA or PRA, from January 2006 until May 2017 were reviewed at Severance Hospital (Seoul, Korea). Clinicopathologic characteristics and surgical outcomes of 146 patients with PHA who underwent LTA (19 patients) or PRA (127 patients) were analyzed retrospectively by complete chart review.ResultsThe overall rates of biochemical and clinical cure were 91.1% and 93.1%, respectively. The mean operation time of the PRA group was significantly shorter than that of the LTA group (72.3 ± 24.1 minutes vs. 115.7 ± 69.7 minutes, P = 0.015). The length of hospital stay in the PRA group was significantly shorter than in the LTA group (3.5 ± 1.3 days vs. 4.2 ± 1.6 days, P = 0.029), and the first meal after surgery came earlier in the PRA group (0.3 ± 0.5 days vs. 0.6 ± 0.5 days, P = 0.049). The number of pain-killers used was also significantly smaller in the PRA group (2.3 ± 2.1 vs. 4.3 ± 2.3, P < 0.001).ConclusionPRA offers an alternative or likely superior method for treatment of small adrenal diseases such as PHA, with improved surgical outcomes.

Operation duration and adrenal gland size, but not BMI, are correlated with complication rate for posterior retroperitoneoscopic adrenalectomy for benign diseases

BackgroundWe sought to determine whether obesity is correlated with complications after posterior retroperitoneoscopic adrenalectomy for benign diseases and to develop surrogate markers of abdominal fat in preoperative computed tomography. MethodsWe conducted a retrospective chart review of all patients who had undergone posterior retroperitoneoscopic adrenalectomy and preoperative computed tomography between January 1, 2008 and December 31, 2015. The cross-sectional components of fat assessed by computed tomography included total fat area, subcutaneous fat area, retroperitoneal fat area, and peritoneal fat area. The patients were grouped into 2 categories according to the absence or presence of a postoperative complication (the no-complications group and the complications group, respectively). ResultsOf 116 study patients, 20 patients (17%) had a postoperative complication. Operations of greater duration and smaller adrenal gland size were significantly correlated with complications both in univariate and multivariate analyses. Body mass index, total fat area, subcutaneous fat area, retroperitoneal fat area, peritoneal fat area, and distance of skin to muscle (in axial and sagittal images) correlated with complications in univariate analysis but not in multivariate analysis. In the no-complications group, the removed adrenal gland was larger than that removed in the complications group (6 vs 4 cm, respectively, P = .001), whereas the complications group had a greater operative duration (139 vs 104 min, respectively, P = .001) and a greater duration of hospital stay (3 days vs 1 day, respectively, P = .001). ConclusionIn this study, operations of greater duration and smaller adrenal gland size were better predictors of complications after posterior retroperitoneoscopic adrenalectomy for benign disease than measures of obesity, including body mass index.

Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy.

Posterior retroperitoneoscopic adrenalectomy has gained international popularity in the past decade. Despite major advantages, including shorter duration of operation, minimal blood loss and decreased postoperative pain, many surgeons still prefer laparoscopic transperitoneal adrenalectomy. It is likely that the unfamiliar anatomical environment, smaller working space and long learning curve impede implementation. The present study assessed the number of procedures required to fulfil the surgical learning curve for posterior retroperitoneoscopic adrenalectomy. The first consecutive posterior retroperitoneoscopic adrenalectomies performed by four surgical teams from university centres in three different countries were analysed. The primary outcome measure was duration of operation. Secondary outcomes were conversion to an open or laparoscopic transperitoneal approach, complications and recovery time. The learning curve cumulative sum (LC-CUSUM) was used to assess the learning curves for each surgical team. A total of 181 surgical procedures performed by four surgical teams were analysed. The median age of the patients was 57 (range 15-84) years and 61·3 per cent were female. Median tumour size was 25 (range 4-85) mm. There were no significant differences in patient characteristics and tumour size between the teams. The median duration of operation was 89 (range 29-265) min. There were 35 perioperative and postoperative complications among the 181 patients (18·8 per cent); 17 of 27 postoperative complications were grade 1. A total of nine conversions to open procedures (5·0 per cent) were observed. The LC-CUSUM analysis showed that competency was achieved after a range of 24-42 procedures. In specialized endocrine surgical centres between 24 and 42 procedures are required to fulfil the entire surgical learning curve for the posterior retroperitoneoscopic adrenalectomy.

Randomized trial of low versus high carbon dioxide insufflation pressures in posterior retroperitoneoscopic adrenalectomy

BackgroundPosterior retroperitoneoscopic adrenalectomy has gained widespread acceptance for the removal of benign adrenal tumors. Higher insufflation pressures using carbon dioxide (CO2) are required, although the ideal starting pressure is unclear. This prospective, randomized, single-blinded, study aims to compare physiologic differences with 2 different CO2 insufflation pressures during posterior retroperitoneoscopic adrenalectomy. MethodsParticipants were randomly assigned to a starting insufflation pressure of 20 mm Hg (low pressure) or 25 mm Hg (high pressure). The primary outcome measure was partial pressure of arterial CO2 at 60 minutes. Secondary outcomes included end-tidal CO2, arterial pH, blood pressure, and peak airway pressure. Breaches of protocol to change insufflation pressure were permitted if required and were recorded. ResultsA prospective randomized trial including 31 patients (low pressure: n = 16; high pressure: n = 15) was undertaken. At 60 minutes, the high pressure group had greater mean partial pressure of arterial CO2 (64 vs 50 mm Hg, P = .003) and end-tidal CO2 (54 vs 45 mm Hg, P = .008) and a lesser pH (7.21 vs 7.29, P = .0005). There were no significant differences in base excess, peak airway pressure, operative time, or duration of hospital stay. Clinically indicated protocol breaches were more common in the low pressure than the high pressure group (8 vs 3, P = .03). ConclusionIn posterior retroperitoneoscopic adrenalectomy, greater insufflation pressures are associated with greater partial pressure of arterial CO2 and end-tidal CO2 and lesser pH at 60 minutes, be significant. Commencing with lesser CO2 insufflation pressures decreases intraoperative acidosis.

Posterior retroperitoneoscopic adrenalectomy—Case series

IntroductionPosterior retroperitoneoscopic adrenalectomy has advantages over transperitoneal technique. However many surgeons prefer the transperitoneal technique because they get a familiar and wider working space. Material and methodsA retrospective analysis of the first 10 patients submitted to posterior retroperitoneoscopic adrenalectomy was conducted. Data collected included: diagnosis, size, operation time, blood loss, conversion rate, morbidity and mortality, in-hospital length of stay. Compare our outcomes with worldwide bigger series, and take conclusions on the feasibility of the technique was the objective. ResultsWe included 2 pheochromocytomas, 1 giant cystic pheochromocytoma, 4 Conn’s, 2 Cushing’s, 1 non-functioning tumor with 4 cm. Mean operation time was 46,7 min for lesions ranging from 1,8 to 14 cm. Blood loss was negligible. One patient (10%) was converted to laparotomy because of a past clinical history of dorsal and lumbar trauma. No morbidity and no mortality. Mean hospital length of stay was 2,2 days. DiscussionMean operation time found in bigger series published in worldwide literature is 40–105,6 min. Complication rate reported ranges from 0 to 14,4%. No mortality has been ever reported. Blood loss reported in other series is 10–50 ml. The data found in our study matches other studies data. Since the same surgeon who had never performed the technique before operated all patients, makes us believe the technique is safe and feasible. ConclusionPosterior retroperitoneoscopic adrenalectomy has a small learning curve. It is technically safe and feasible. More patients will be collected to validate these results.

Useful modifications to the robotic posterior retroperitoneoscopic approach to adrenalectomy in severely obese patients

In most recent years, the laparoscopic or robotic posterior retroperitoneoscopic adren-alectomy (RPRA) has been used as an alternative to the laparoscopic transabdominal ap-proach. A 12-mm Covidien blunt balloon trocar has been used for the camera port in most previous posterior retroperitoneoscopic adrenalectomy (PRA) studies. This trocar is 100 mm in length and may not be long enough to dock the camera arm of the robot particularly in obese (BMI >35 kg/m 2 ) patients with deep and thick back walls. Here we describe a technique that uses a platform [GelPOINT mini advanced access platform (mini Gel-POINT)] for access in RPRA. A 52-year-old female with a history of multiple prior ab-dominal procedures presented with a 2 cm right adrenal mass and a BMI of 36.9 kg/m 2 . A 10–12 mm long trocar was used through the mini GelPOINT for the robotic camera. Two long robotic trocars were also utilized. A fourth 5 mm assistant port was added for retraction and to avoid additional costly robotic instrument. The total op-eration time was 95 minutes (docking and console times 20 and 75 minutes, respectively). Blood loss was minimal and there were no complications. The mini GelPOINT appears to be a feasible, safe and effective alternative for RPRA procedures in severely obese patients. It is associated with an easy setup, no balloon, and easy movement of the robotic camera trocar through the gel and appears to minimize subcutaneous emphysema.

Retroperitoneoscopic adrenalectomy: tips and tricks.

Posterior retroperitoneoscopic adrenalectomy has recently increased in popularity and currently adopted in about 20% of referral centers. It may provide more direct access to the adrenals, thus avoiding post-operative adhesions and the need for patient repositioning in bilateral adrenalectomy. Although it has been suggested to be feasible for large tumors, large tumor size is indicated as the main limitation of PRA, mainly because of the small space available for dissection.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: bilateral step-by-step technique.

Laparoscopic adrenalectomy is the gold standard surgical approach for small benign adrenal tumors [1]. Several surgical approaches were developed in order to overcome the difficulty to access the adrenal glands, located in the upper retroperitoneum space [2-4]. Laparoendoscopic single-site posterior retroperitoneoscopic adrenalectomy (LESS-PRA) is an emerging technique that reduced the multiple trocar-related trauma and improved cosmetic outcomes while minimizing postoperative morbidity [5-8]. The aim of this study was to describe our step-by-step technique for LESS-PRA and to compare our perioperative outcomes with the conventional 3-port lateral retroperitoneoscopic adrenalectomy (LRA). A retrospective review was carried out from February 2008 to January 2016 that included 100 patients with adrenal tumors smaller than 4cm. Study exclusion criteria were defined as tumor size greater than 4cm, patients older than 80years, and body mass index (BMI) greater than 40. A total of 20 patients underwent LESS-PRA and 80 patients underwent 3-port lateral retroperitoneoscopic laparoscopic adrenalectomy. Patient's demographic data and perioperative outcomes were compared and statistically analyzed. The cosmetic satisfaction was evaluated with a visual analog scale. Estimated blood loss was higher in LRA (100 vs. 50ml; p=0.35). Operative time was longer in LESS-PRA than LRA (100.0 vs. 60min; p<0.001). Analgesic time necessary for LRA was longer than LESS-PRA (40 vs. 24h; p<0.001). Cosmetic satisfaction score was higher in LESS-PRA (9.5 vs. 8.6; p=0.03). There were no significant differences in perioperative complications and length of hospital stay. No conversion to conventional laparoscopic or open surgery was necessary. LESS-PRA presented comparable functional and perioperative outcomes to LRA for small adrenal tumors. Although LESS-PRA was associated with longer operative time, it provided inferior estimated blood loss, analgesic time, and improved cosmetic satisfaction.

Application of posterior approach in retroperitoneoscopic adrenalectomy in the treatment of adrenal tumors

Objective To investigate the feasibility and efficacy of posterior retroperitoneoscopic adrenalectomy (PRA). Methods From September 2013 to September 2015, the clinical data of 35 patients who underwent posterior retroperitoneoscopic adrenalectomy were reviewed. There were 14 males and 21 females, aged 15-70 years, with the average of 45.8 years. Preoperative CT scan showed 19 adrenal tumors in the left side, 16 in the right side, and one case with the left adrenal adenoma combining with right renal cyst. Tumor diameter is between 10~60mm, with the average of 31mm.Twenty-two cases were diagnosed as primary aldosteronism, 4 pheochromocytoma, and 9 non-functional adrenal tumor. The posterior retroperitoneoscopic adrenalectomy were performed in all of the cases, which are under general anesthesia with tracheal intubation and prone position with hip joints and knee joints flexion of 90. Results Thirty-five operations were successfully completed via the posterior approach demonstrating clear anatomical layers. The operation time was 38-138min(mean 70 min), the drainage tube indwelling duration was 1-5d(average 2d), and the hospital stay was 2-6d(average 4d). Total costs of hospitalization were 14 789-31 992 yuan RMB, with an average of 21 239 yuan RMB. No complications occurred during the perioperative period. The average follow-up was 11 months, and no complications such as tumor recurrence occured. Conclusions Retroperitoneoscopic adrenalectomy provided clear anatomical views. It could be a safe and effective operation for the treatment of adrenal tumors. Key words: Prone position; Adrenalgland neoplasms; Posterior approach

Posterior retroperitoneoscopic approach to the adrenal arteries.

Differently from transperitoneal adrenalectomy, with the posterior retroperitoneoscopic approach adrenal arteries are dissected first [1, 2]. Knowledge of their position is pivotal as they are covered by peri-adrenal fat [3, 4]. Four posterior retroperitoneoscopic adrenalectomies were selected, in which adrenal arteries are dissected to show their path and how they can be localized among peri-adrenal fat. A video is presented herein, which focuses on surgical anatomy of adrenal arteries when approached during a posterior retroperitoneoscopic adrenalectomy. Details about relative positions between adrenal arteries and adjacent structures are considered and shown during their dissection. The posterior retroperitoneoscopic approach offers a direct view of adrenal arteries and allows for their exposure and safe division in the early steps of adrenalectomy.

Adrenalectomia posterior retroperitoneoscópica – introdução da técnica num hospital generalista

Posterior retroperitoneoscopic adrenalectomy, a seldom performed surgical approach to the adrenal glands seems to offer several advantages when compared with the transperitoneal approach. They include, among others, lesser need for analgesia, inferior surgical time and faster global recuperation period.Its main drawback has been the fact that most general and endocrine surgeons are unfamiliar and feel unconfortable when dealing with the retroperitoneal space area.It is our main purpose with this paper to contribute to a better understanding and knowledge of this surgical procedure. The steps that led to its implementation among us are summarily described. Our first eleven patients are reported.This approach is discussed at the light of our experience and the verified outcomes, particularly in what concerns the technical and logistic conditions that are deemed mandatory to allow it to be properly and safely performed.

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.

Complications of minimally invasive adrenalectomy

Over the last decade minimally invasive adrenalectomy has become the gold standard in adrenal surgery. Laparoscopic adrenalectomy with the patient in the lateral decubitus position and posterior retroperitoneoscopic adrenalectomy have gained worldwide acceptance. In this overview the complications of minimally invasive adrenalectomy are analyzed based on the published data. Die incidence of intraoperative and postoperative complications ranges from 0 % to 15 % for unilateral adrenalectomy and rises up to 23 % for bilateral surgery. No significant differences were found between laparoscopic and retroperitoneoscopic operations. Nevertheless, splenic injuries and intra-abdominal abscesses are reported only after laparoscopic procedures, while relaxation and/or hypoesthesia of the abdominal wall are typical for posterior retroperitoneoscopic surgery. Conversion to open surgery significantly influences the rate of perioperative and postoperative complications (odds ratio 6.2); therefore, high surgeon and center case volume could improve the results of adrenal surgery.

Retroperitoneoscopic Adrenalectomy in Obese Patients: Is It Suitable?

The aim of this study was to evaluate the suitability of posterior retroperitoneoscopic adrenalectomy for patients with morbid obesity. This retrospective clinical cohort study included patients who underwent elective posterior retroperitoneoscopic adrenalectomy. Intraoperative (operative time, blood loss, intraoperative complications, conversion rate) and postoperative (hospital stay, morbidity, mortality) parameters were compared between the two study subgroups: obese (body mass index [BMI] ≥30 kg/m(2)) and non-obese patients (BMI <30 kg/m(2)). A total of 137 subsequent patients were enrolled in the study (41 obese and 96 non-obese patients). Mean tumour size was 5.2 ± 2.2 cm; aldosteronism and incidentaloma were the most frequent indications. Operative time was significantly longer (87 vs. 65 min; P = 0.0006) in obese patients. There was no difference in operative blood loss. One conversion was necessary. Overall, the 30-day postoperative morbidity was significantly higher in obese patients (26.8 vs. 11.5 %; P = 0.025). The hospital stay was significantly longer in obese patients (3.1 vs. 2.5 days; P = 0.003). Dorsal retroperitoneoscopic adrenalectomy can be safely performed in morbidly obese patients, maintaining the advantages of minimally invasive surgery. Avoiding an abdominal approach is beneficial for patients. There is a more favourable postoperative course, shorter hospital stay, better cosmetic outcome and quicker recovery with dorsal retroperitoneoscopic adrenalectomy. The prolonged operative time, longer hospital stay and higher risk of postoperative complications that occurred in obese patients were acceptable in light of the generally higher risk associated with surgeries performed in obese patients.

Comparison of Outcomes After Laparoscopic Versus Posterior Retroperitoneoscopic Adrenalectomy

Posterior retroperitoneoscopic adrenalectomy (PRA) was popularized by Walz and colleagues as an alternative approach to minimally invasive adrenalectomy, offering less postoperative pain and faster return to normal activity compared with laparoscopic transperitoneal adrenalectomy (LA). The authors have recently changed from LA to PRA in suitable patients and audited their outcomes. Data were prospectively collected for 10 patients who underwent PRA, and a chart review and telephone interviews were conducted with 13 consecutive patients who underwent LA by the same surgeon. Patient demographics, tumor characteristics, analgesia use, operative and anesthetic time, length of stay, and complications were recorded. Data were collected for 13 LAs and 10 PRAs. Patients' baseline characteristics, including age, BMI, and tumor size, were similar between the 2 groups. There were no conversions to open surgery, transfusions, or deaths. Operative time was similar between the 2 groups. PRA patients required less, inpatient postoperative opioid analgesia compared with LA patients (median 1.25 vs. 23 mg of intravenous morphine equivalent, P=0.003), and had a shorter length of stay (median 1 vs. 2 d, P<0.001). The median total days on opioids were lower for PRA patients compared with LA patients (0.5 vs. 9 d, P<0.001). Our initial results supports previously published findings that PRA is a safe procedure, with a relatively short learning curve, resulting in reduced postoperative analgesia use, and reduced length of hospital stay when compared with the laparoscopic transperitoneal approach.

Posterior retroperitoneoscopic adrenalectomy: outcomes and lessons learned from initial 50 cases

Posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative approach to minimally invasive adrenalectomy, potentially offering less pain and faster recovery compared with laparoscopic transperitoneal adrenalectomy (LA). The authors have recently changed from LA to PRA in suitable patients and audited their first 50 cases. Data were prospectively collected for 50 consecutive PRAs performed by the same surgeon. Patient demographics, tumour characteristics, analgesia use, operative and preparation time, length of stay, and complications were recorded. Fifty adrenalectomies were performed in 49 patients. The median (range) age was 58.5 years (30-83) and the majority of patients were female (n = 33, 66.0%). The median (interquartile range (IQR)) preparation time was 35.5 (28.5-50.0) and median operation time was 70.5 (54-85) min, which decreased during the study period. After a learning curve of 15 cases, median operative time reached 61 min. PRA patients required minimal post-operative analgesia, with a median (IQR) of 0 (0-5) mg of intravenous morphine equivalent used. The median (IQR) length of stay was 1 (1-1) day, with 8 (16.0%) same-day discharges. There were four complications: one blood pressure lability from a phaeochromocytoma, one reintubation, one self-limited bleed and one temporary subcostal neuropraxia. There were no conversions to open surgery or deaths. Our results support previously published findings that PRA is a safe procedure, with a relatively short learning curve, resulting in minimal post-operative analgesia use and short length of hospital stay.

Telementoring: A Multi-institutional Experience with the Introduction of a Novel Surgical Approach for Adrenalectomy

Telementoring is a video-conferencing tool which can deliver expert opinion to physicians and their patients in remote locations. We report our experience with the use of telementoring as a technique to instruct in the performance of posterior retroperitoneoscopic adrenalectomy (PRA). Issues regarding utility, regulation, and future directions of telementoring are addressed. Two consecutive PRAs conducted at Yale New Haven Hospital, New Haven, Connecticut, with telementored guidance from MD Anderson Cancer Center, Houston, Texas, are presented. Practical points in implementing cross-institutional telementoring are presented. A review of the current literature was done to discuss medicolegal issues, regulations and a proposal for future implementation of this technique. The PRAs were performed after careful preparation of appropriate issues regarding cross-institutional telementoring. The procedures were performed quickly and safely. Loss of transmission occurred once, but was reestablished within seconds and was not disruptive to the surgical procedure. Patients were discharged within 48 hours and without complications. In our experience, telementoring was convenient and effective in helping with the execution of a new surgical technique. Telementoring is a technical application with utility in remotely helping and guiding another surgeon through the execution of a novel surgical approach. The cyberspace consultation is safe and enhances patient care through a real-time collaborative approach which extends beyond the confines of one institution and one surgeon. Aspects concerning improvement in both implementation and regulation of telementoring mandate further research and creation of nationwide guidelines.