Retroperitoneal Endoscopic Adrenalectomy Research Articles

Role of Mediastinal Nodal Status in the Selection of Patients with Non-small Cell Lung Cancer and Isolated Adrenal Metastases for Radical Surgical Treatment

The treatment of patients with isolated adrenal metastases remains controversial. Metastases from NSCLC suggest that these patients could have improved survival. The role of N2 status as independent predictor of poor survival is still unclear and under discussion. The aim of this study was to evaluate the role of mediastinal nodal status in patients with isolated adrenal metastases form Non Small Cell Lung Cancer (NSCLC) treated with surgery. A total of eight patients with NSCLC and isolated adrenal lesions were operated on for a period of ten years. They were divided into two groups depending on the morphology of the adrenal lesion. Group I includes 4 patients with adrenal metastases which underwent lobectomy and Retroperitoneal Endoscopic Adrenalectomy (REA). The loco regional stage was pI in 3 patients and pIIA in one. The mean size of the metastases was 24.5 mm, without capsular invasion and all of them were metachronous. The other four patients were proven to be with adenomas of the adrenal gland. All of the patients underwent lobectomy with locoregional stage pIIIA (3) and pIIA. One stage operation was performed in two cases – left lower lobectomy and adrenalectomy via frenotomy. REA was performed in two of the patients. No major postoperative complications were observed. The median survival is 34.75 months in Group I and 18.6 months in Group II. Two of the patients from Group I are still alive at the end of the study – 57 and 34 months after the initial surgery. The mediastinal nodal status is significant and independent prognostic factor for survival in surgical patients with NSCLC and isolated adrenal metastasis.

Application of Accelerated Activation in Retroperitoneal Video Endoscopic Adrenalectomy for Cushing Syndrome

Purpose.To improve the immediate results of surgical treatment of endogenous hypercorticism throughoptimizing the perioperative management of patients using accelerated rehabilitation protocols.Materials and methods.A randomized prospective study of 53 patients with a body mass index 35 kg/m2 was carried out. In the control group (n=27), TIVA based on propofol was used with postoperative analgesia by systemic administration of opioids. In the accelerated rehabilitation protocol group (n=26), we used anesthesia based on low-flow inhalation of desflurane with sympatholytic mixture infusion in intra- and postoperative periods, multimodal postoperative analgesia, and use of accelerated rehabilitation protocol in the perioperative period. The time of patients' achievement of BIS90 index, time of extubation, time of achievement of 10 points by the Aldrete scale and 0 points by the Bidway test, duration of stay in the in-patient hospital, number of postoperative complications were assessed. Effectiveness of analgesia was evaluated by the time of the first analgesia requirement, consumption of narcotic analgesic, VAS and Verbal Descriptor scale.Results.The study revealed that the time of awakening and reaching 10 points by the Aldrete scale in patients of group 2 was significantly shorter than in group 1: 3 (2; 6) and 6.5 (3.5; 9) min respectively (P=0.046). They had fewer postoperative complications, shorter hospitalization time — 58 (39; 71) hours compared to the control group with 74.5 (58.5; 87) hours (P=0.032).Conclusion.Perioperative management of obese patients after retroperitoneal video endoscopic adrenalectomy with the use of accelerated rehabilitation protocols contributed to earlier mobilization, reduction of the number of complications in the early postoperative period, reduction of the duration of stay in the in-patient hospital, which together facilitates improving the immediate results of surgical treatment of endogenous hypercorticism.

Endoscopic retroperitoneal adrenalectomy for adrenal metastases.

Objectives. To evaluate whether retroperitoneal approach for adrenalectomy is a safe and effective treatment for adrenal metastases (AM). Methods. From June 2004 to January 2014, nine consecutive patients with AM were treated with endoscopic retroperitoneal adrenalectomy (ERA). A retrospective study was conducted, and clinical data, tumor characteristics, and oncologic outcomes were acquired and analyzed. Results. Renal cancer was the primary site of malignancy in 44.4% of cases. The mean operative time was 132 ± 10.4 min. There were 5 synchronous and 4 metachronous AM. One patient required conversion to transperitoneal laparoscopic procedure. No mortality or perioperative complications were observed. The median overall survival was 11 months (range: 2–42 months). Survival rates of 50% and 25% were identified at 1 and 3 years, respectively. At the end of the study, 4 patients were alive with a mean observed follow-up of 20 months. No patients presented with local tumor relapse or port-site metastases. Conclusions. This study shows that ERA is a safe and effective procedure for resection of AM and advances the surgical treatment of adrenal disease. The use of the retroperitoneal approach for adrenal tumors less than 6 cm can provide very favorable surgical outcomes.

Surgical treatment options for aldosteronomas.

IntroductionSingle access retroperitoneoscopic adrenalectomy (SARA) is the most feasible approach for removing aldosteronomas.AimTo analyse the advantages and disadvantages of surgical approaches to treating small adrenal tumours.Material and methodsIn the period 2002-2011, 31 patients were operated on at Vilnius University Hospital Santariskiu Clinics for aldosteronomas. Adrenalectomies were performed in the lateral laparoscopic (group A, n = 6), the endoscopic retroperitoneal (group B, n = 20), and the single incision laparoscopic surgery (SILS) and SARA (group C, n = 5) approaches. Seventy five percent of patients were operated on by the same surgeon. The duration of adrenalectomies, and intraoperative and postoperative complications were compared. The possibility of minimally invasive adrenalectomies was evaluated.ResultsAccording to the patients’ age, body mass index and tumour size, the groups were equal. The average duration of surgery in group A was shorter than in groups B and C (91 ±23 min vs. 118 ±57 min vs. 144 ±88 min). Right laparoscopic adrenalectomy was longer than the left (105 ±26 min vs. 77 ±6 min), whereas right endoscopic retroperitoneal adrenalectomy was shorter than the left (109 ±50 min vs. 126 ±57 min). The best cosmetic view was in group C. The SARA method was converted into the endoscopic retroperitoneal approach and then into the laparoscopic for one patient. There were no intraoperative or postoperative complications.ConclusionsEvaluating the minimal invasion of the method, its abilities and simplicity of conversion into another type of endoscopic surgical way, the SARA approach should be the first option for removing aldosteronomas.

Bilateral Simultaneous Laparoscopic Adrenalectomy in Cushing's Syndrome: Safe, Effective, and Curative

Surgical morbidity and mortality rates are high in patients with Cushing's syndrome. Nevertheless, simultaneous bilateral laparoscopic adrenalectomy (LA) is feasible in these patients with less morbidity and good long-term results. Consecutive 22 patients who underwent LA for Cushing's syndrome between 2003 and 2010 in our institute were retrospectively studied. Ninteen patients underwent bilateral simultaneous and three underwent unilateral LA. Seven patients had Cushing's syndrome after failed pituitary surgery and five each had ectopic adrenocorticotrophic hormone dependent syndrome and bilateral macronodular hyperplasia respectively. LA was bilaterally done by lateral transabdominal adrenalectomy in 15 patients and retroperitoneal endoscopic adrenalectomy in 4 on the right side. Mean operative time for simultaneous bilateral cases was 199.45±72.43 minutes with mean blood loss of 72.72±48.6 mL. Patients were fit for discharge by the fifth postoperative day from the surgical aspect. Surgical complication rate was 26% that included wound infections in two, port site hernia, pleural effusion, and atelectasis in one each. One patient died of sepsis (5% mortality). Satisfactory metabolic control was achieved in all observable patients in the long term although Addisonian crisis and Nelson syndrome were seen in 26% and 15% respectively. LA has all advantages of minimal access surgery in patients with Cushing's syndrome who are immunocompromised and at high risk of delayed wound healing and infections. Magnification decreases the risk of retained adrenal remnants. Despite advances in minimal access surgery, perioperative morbidity continues to be significant for the procedure.

Bilateral Pheochromocytoma in von Hippel-Lindau Syndrome Simultaneously Removed by Lateral Retroperitoneal Endoscopic Approach

ABSTRACT Von Hippel-Lindau (VHL) syndrome is an autosomal dominant familial neoplastic syndrome caused by mutation in VHL tumor suppressor gene localized on chromosome 3p25. The disease is characterized by abnormal vascular proliferation and increased risk of developing renal cell carcinoma, pheochromocytoma, hemangioblastoma of the central nervous system, tumors of the endolymphatic bag, cysts of the kidney, liver and pancreas, epididymal cystadenomas, neuroendocrine tumors of the pancreas, angiomas in the retina. We report a case of a bilateral pheochromocytoma, simultaneously removed by unilateral total and contralateral subtotal retroperitoneal endoscopic adrenalectomy. How to cite this article Todorov G, Grozdev K, Lukanova T, Mioljevikj-Miserliovska B, Miserliovski R. Bilateral Pheochromocytoma in von Hippel-Lindau Syndrome Simultaneously Removed by Lateral Retroperitoneal Endoscopic Approach. World J Endoc Surg 2012;4(3):102-104.

Single-port endoscopic retroperitoneal adrenalectomy: initial experience

Over the last decade, laparoendoscopic adrenalectomy has become the standard of care for adrenal removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multi-port laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We applied the SPA technique to adrenalectomy using the posterior retroperitoneal approach. Between January 2010 and July 2010, a 52-year-old female with Conn’s adenoma and two females, aged 31 and 39, both diagnosed with pheochromocytoma, underwent single port endoscopic retroperitoneal adrenalectomies. Procedures were performed using two different commercially available specific access devices and conventional laparoscopic equipment. No conversions to open or conventional retroperitoneal approach were necessary. No perioperative or postoperative complications occurred. Operating time ranged from 120 min to 240 min. All patients were discharged from the hospital 2 days after surgery. The single port access technique has been successfully applied to adrenalectomy as an available alternative to multiport laparoendoscopic adrenalectomy. Exposure, visualization, and dissection are the same as in retroperitoneal endoscopic adrenalectomy. Single port access surgery offers the patient benefits such as faster convalescence, decreased postoperative scarring and better cosmetic effect.

Retroperitoneal endoscopic adrenalectomy is safe and effective (Br J Surg 2010; 97:1667–1672)

Retroperitoneal endoscopic adrenalectomy is safe and effective (<i>Br J Surg</i> 2010; 97:1667–1672)

Retroperitoneal endoscopic adrenalectomy is safe and effective

The aim of this study was to review an experience with retroperitoneal endoscopic adrenalectomy (REA). This is the procedure of choice for adrenal tumours at this institution. Between 1997 and 2008, 112 REAs were performed in a single university centre. Data were retrieved retrospectively from a prospectively collected database, including information on patient demographics, surgical procedure, complications and hospital stay. One hundred and twelve REAs were carried out successfully in 105 patients, including seven bilateral adrenalectomies. Thirty-nine patients with unilateral adrenal disease had a phaeochromocytoma, of whom 16 had multiple endocrine neoplasia syndrome type 2, 21 patients had Cushing's disease and 20 had Conn's disease. Median body mass index was 27 (interquartile range 23-29) kg/m(2). The median duration of unilateral operations was 100 (90-130) min with a median blood loss of 5 ml. Median tumour size was 3.1 (2.0-4.4) cm. Conversion from REA to open surgery was needed in two patients. Seven patients experienced postoperative complications (2 major, 5 minor). One patient needed a reoperation. The median postoperative hospital stay was 3 days. A learning curve with a significant decrease in operating time was observed over the years. REA appears to be a safe and effective surgical technique for adrenal gland tumours up to 6 cm in diameter, with a minimal complication rate.

Evaluation of Two Methods of Endoscopic Adrenalectomy

The aim of this study was to analyse the results of minimally invasive adrenalectomy and to compare the advantages and weaknesses of two methods of operation. The outcomes of 70 patients operated on between 2000 and 2006 because of lesions of the adrenal glands were analysed. The patients were allocated to two groups: 40 patients underwent laparoscopic adrenalectomy (group A), and 30 patients underwent retroperitoneal endoscopic adrenalectomy (group B) (1 patient had bilateral lesions of the adrenals). Blood loss during the operation, incidence of complications and conversions, duration of operation, size of tumour and patient's body mass index (BMI) were analysed. Median tumour size was 3.49 +/- 1.27 cm (range: 2-7 cm) in group A, and 3.9 +/- 1.38 cm -(range: 1.4-6 cm) in group B. More than half of all patients (n = 38; 54.3 %) were operated on because of a non-functional adrenal adenoma. Conversion was performed on 5 patients (12.5 %) in group A and on 1 patient (3.3 %) in group B. Operation time in group A was 122 +/- 30.42 min, and in group B 135 +/- 57.05 min. The training period for laparoscopic adrenalectomy was shorter. There were no significant differences in blood loss during operation or incidence of complications. The size of the tumour and the patient's BMI did not have a statistically significant impact on the duration of operation. Laparoscopic and retroperitoneal endoscopic adrenalectomies are of the same value in most aspects. However, the training period for laparoscopic adrenalectomy was shorter.

Retroperitoneal Endoscopic Versus Conventional Open Adrenalectomy: A Cost-Effectiveness Analysis

A retrospective cost-effectiveness analysis was carried out, comparing retroperitoneal endoscopic and conventional adrenalectomy, which is based on a large group of patients, restricted in tumor size for the purpose of ensuring comparability. Between 1990 and 2004, 61 patients underwent either an endoscopic or open adrenalectomy for tumors smaller than 6 cm. A short-term, base cost-effectiveness analysis was performed to evaluate costs per day prevented, and a sensitivity analysis was calculated. Average recovery time, postoperative stay, and resumption to oral intake were significantly shorter in the endoscopic group, whereas operative time was longer. No major complications occurred in either group. In 3 endoscopic procedures conversion was indicated. The base cost-effectiveness ratio was 15.41 per day postoperative stay prevented by the endoscopic approach. The number needed to treat with endoscopic adrenalectomy to prevent 1 week of postoperative stay is 2. Retroperitoneal endoscopic adrenalectomy may be considered a cost-effective procedure, compared to the conventional open adrenalectomy.

Retroperitoneal endoscopic adrenalectomy vs. Conventional adrenalectomy in treatment of benign adrenal lesions: Comparative analysis

Minimally invasive adrenalectomy is considered to be the standard of care for the surgical treatment of the adrenal gland' s pathology. Since the initial report of laparoscopic adrenalectomy in 1992 and of retroperitoneal endoscopic adrenalectomy in 1994, it has evolved into a feasible and safe minimally invasive procedure for benign adrenal tumors. Clinical characteristics and outcomes of 63 retroperitoneal endoscopic adrenalectomies (REAs) and 45 conventional adrenalectomies (CAs) from 1996 to 2004 were evaluated. 61 patients underwent 63 REAs. Tumor size varied from 2 to 8 cm. Median age was 48.6 years. Median operative time was 135 min (45-240), median intraoperative blood loss - 85 ml (30-550). The complication rate was 17.77%. Median postoperative hospital stay was 5 days (2-10). 44 patients underwent 45 conventional adenalectomies. Median age was 44.5 years (16-71). Intraoperative complication rate was 17.77%, postoperative -22.22 %, Median operative time was 120 min (75-240). Median postoperative hospital stay was 10 days (6-21). No statistically significant difference was established between median operative times of REA- and CA-groups (p=0.91). Conventional adrenalectomy was associated with a significantly increased complication rate (p= 0.009). Hospitalization was also longer after the open tecnique (d). Introduced in 1994 and displaying all advantages of minimal access surgery REA has become the standard of care for benign adrenal tumors.

Safety and efficacy of endoscopic retroperitoneal adrenalectomy

Minimally invasive adrenalectomy has replaced open surgery in the treatment of benign adrenal tumours. Transperitoneal and retroperitoneal approaches have been advocated. However, long-term outcome data are rare. Over a period of 8 years, 123 patients underwent surgery for benign adrenal lesions using the endoscopic retroperitoneal approach. Data were analysed retrospectively by review of medical charts. Long-term results were obtained by sending questionnaires to patients and contacting their primary physicians. One hundred and twenty-three patients underwent 126 endoscopic retroperitoneal adrenalectomies. Mean operating time for unilateral adrenalectomy was 115 min, whereas that for bilateral adrenalectomy was 208 min. The conversion rate was 4.8 per cent. Complications occurred after 15.9 per cent of adrenalectomies. One patient died during the postoperative period. Long-term results were obtained in 80 patients (74.8 per cent). Nine patients (11 per cent) reported chronic incisional pain and six patients (8 per cent) had chronic abdominal pain. Addisonian crisis after bilateral adrenalectomy occurred in three patients. Most patients (86 per cent) were satisfied with the cosmetic results. Endoscopic retroperitoneal adrenalectomy is a safe and effective procedure. Long-term outcome is acceptable and the procedure has excellent cosmetic results.

Retroperitoneal hand-assisted laparoscopic surgery for endoscopic adrenalectomy

Although hand-assisted laparoscopic surgery (HALS) is very common in various laparoscopic procedures, it is rarely used for retroperitoneal endoscopic adrenalectomy because of the small working area. The authors evaluate HALS in endoscopic adrenalectomy with respect to its use as a rescue procedure in complicated cases. In their department, 47 patients underwent endoscopic adrenalectomies between 1998 and 2004. Mainly because of complicated anatomy, three primary aldosteronism cases were converted to retroperitoneal HALS. This involved making an additional 6 cm skin incision, into which the surgeon's left hand was inserted, with the palm used to create a sufficient visual field and working area. The fingers were used for tactile sensation and blunt resection. For these three cases, successful retroperitoneal HALS in endoscopic adrenalectomy resulted in no mortality or morbidity. These findings indicate that this procedure is a feasible technique for complicated benign adrenal tumor cases.

Initial experience with endoscopic retroperitoneal adrenalectomy.

Initial experience with endoscopic retroperitoneal adrenalectomy.

Trans- and Retroperitoneal Endoscopic Adrenalectomy: Experience in 26 Consecutive Adrenalectomies

Objective: To assess our current concept and results of transperitoneal laparoscopic adrenalectomy (TPLA) and retroperitoneal endoscopic adrenalectomy (ERA) for a variety of benign disorders of the adrenal glands. Background Data:According to the literature, minimal invasive adrenalectomy has shown to be a safe and effective surgical alternative to open adrenalectomy. Both, transperitoneal and retroperitoneal endoscopic minimal invasive access are currently used for surgical removal of benign adrenal tumors. There is still some debate about the indications and the access used for a minimal invasive approach. Patients and Methods: Treatment and clinical outcome of all patients who underwent either transperitoneal laparoscopic or endoscopic retroperitoneal adrenalectomies for benign diseases from February 1997 to August 2002 were analyzed retrospectively. Results: Twenty-six minimal invasive adrenalectomies were performed in 23 patients with a mean age of 57 years. Whereas 11 patients underwent unilateral right- sided ERA, unilateral TPLA was performed in 9 patients on the left side. Three patients had bilateral TPLA. The mean operating time for unilateral ERA and TPLA was 114 and 79 min, respectively. Bilateral TPLA was prolonged to 223 min operating time. There were only two minor postoperative complications. The mean hospital stay for unilateral TPLA, ERA and bilateral TPLA was 4.7, 5 and 6 days, respectively. There was no mortality. Conclusion: Both, ERA and TPLA are safe and clinically effective treatment modalities for benign disorders of the adrenal glands. We currently favor a transperitoneal laparoscopic approach for bilateral and left-sided adrenal tumors, whereas right-sided tumors <8 cm are removed by a retroperitoneal approach. Large right-sided tumors >8 cm are better removed by transperitoneal access.

Minimally invasive adrenal surgery.

The adrenals can be approached endoscopically using either transperitoneal or retroperitoneal access, most surgeons favouring the transperitoneal flank approach with the patient in the lateral decubitus position. Endoscopic retroperitoneal adrenalectomy can be performed via either a posterior or a lateral approach. The main advantage of the retroperitoneal approach in the prone position is that it allows bilateral adrenalectomy without repositioning the patient. Although technically more demanding, endoscopic adrenalectomy provides clear advantages over open procedures for tumours less than 5-6 cm in diameter. The small working space provided by the retroperitoneal approach is a contra-indication for the dissection of tumours over 5-6 cm in diameter. Peritoneal adhesions caused by previous abdominal surgery or a large right lobe of the liver may contra-indicate transperitoneal access. For small benign tumours, the transperitoneal and retroperitoneal routes are safe and effective, and there is no clear advantage of one procedure over the other. Invasive adrenal carcinoma is an absolute contra-indication for endoscopic adrenalectomy. Whether large (>5-6 cm) and potentially malignant tumours should be removed laparoscopically remains debatable.

Endoscopic retroperitoneal adrenalectomy

Background: Open adrenalectomy requires a large incision of the abdominal wall or lumbar region which is associated with considerable morbidity. The endoscopic approach to adrenal surgery has the potential to reduce patient discomfort. Methods: The retroperitoneal space is created by balloon dissection with the patient in lateral decubitus position. Incision of the lateroconal fascia and dissection of the upper renal pole allow access to the adrenal gland and its removal. All adrenal pathology less than 6 cm in diameter is suitable for the endoscopic retroperitoneal approach. Results: Endoscopic retroperitoneal adrenalectomy has proven safe and effective in adrenal pathology except for adrenal tumors greater than 6 cm in diameter or for patients who have had earlier retroperitoneal surgery on the affected side. Conclusions: Endoscopic retroperitoneal adrenalectomy appears preferable because the adrenal tumor can be approached in its proper anatomical plane. Therefore, dissection or retraction of surrounding organs is unnecessary which renders the adrenalectomy more facile.

Comparison of three techniques for adrenalectomy

Conventional open adrenal surgery requires relatively large incisions and is associated with postoperative wound pain, intercostal neuralgia and pulmonary complications. Introduction of laparoscopic techniques has enabled development of minimally invasive adrenalectomy. A case-control study of nine open, nine transperitoneal laparoscopic and 12 retroperitoneal endoscopic adrenalectomies was done in patients who were matched for Quetelet index, adrenal disorder and size of adrenal lesion; all tumours were less than 6 cm in diameter. Conversion to open adrenalectomy was necessary in two patients having transperitoneal laparoscopic adrenalectomy and in one having retroperitoneal endoscopic adrenalectomy. Operative time was longest in transperitoneal laparoscopic adrenalectomy (P = 0.004 and P = 0.005 versus open and retroperitoneal endoscopic adrenalectomy respectively). Blood loss was least in retroperitoneal endoscopic adrenalectomy (P = 0.01 versus both other groups). End-tidal carbon dioxide increase was greater in transperitoneal laparoscopic and retroperitoneal endoscopic than in open adrenalectomy (P = 0.014 and P = 0.01 respectively). After retroperitoneal endoscopic adrenalectomy, use of analgesia was least (P = 0.0003 versus other groups). Postoperative hospital stay was shortest after retroperitoneal endoscopic adrenalectomy (P = 0.024 and P = 0.027 versus open and transperitoneal laparoscopic procedures respectively). Retroperitoneal endoscopic adrenalectomy was optimal in patients with small adrenal tumours.

Ergebnisse der endoskopischen, retroperitonealen Adrenalektomie unter besonderer Berücksichtigung des intraoperativen Verlaufs

In 20 patients the hemodynamic and ventilatory data during endoscopic retroperitoneal adrenalectomy were checked retrospectively to analyze the hemodynamic and ventilatory effects of a pneumoretroperitoneum. After insufflation of CO2 into the retroperitoneal space we observed an increase in systolic blood pressure [median 180 mm Hg ([130-200)]. Analyzing the ventilatory parameters we noted that the minute ventilation had to be increased by a median value of 4.25 I (0.4-13) to reduce the increased carbon dioxide levels during CO2 insufflation. After insufflation of CO2 into the retroperitoneal space we observed no major complications. We therefore believe that retroperitoneal endoscopic adrenalectomy is also indicated in patients with cardiac or pulmonary diseases.