Transperitoneal Anterior Approach Research Articles

Surgical Indications and Techniques for Adrenalectomy.

Indications for adrenalectomy are malignancy suspicion or malignant tumors, non-functional tumors with the risk of malignancy and functional adrenal tumors. Regardless of the size of functional tumors, they have surgical indications. The hormone-secreting adrenal tumors in which adrenalectomy is indicated are as follows: Cushing’s syndrome, arises from hypersecretion of glucocorticoids produced in fasciculata adrenal cortex, Conn’s syndrome, arises from an hypersecretion of aldosterone produced by glomerulosa adrenal cortex, and Pheochromocytomas that arise from adrenal medulla and produce catecholamines. Sometimes, bilateral adrenalectomy may be required in Cushing’s disease due to pituitary or ectopic ACTH secretion. Adenomas arise from the reticularis layer of the adrenal cortex, which rarely releases too much adrenal androgen and estrogen, may also develop and have an indication for adrenalectomy. Adrenal surgery can be performed by laparoscopic or open technique. Today, laparoscopic adrenalectomy is the gold standard treatment in selected patients. Laparoscopic adrenalectomy can be performed transperitoneally or retroperitoneoscopically. Both approaches have their advantages and disadvantages. In the selection of the surgery type, the experience and habits of the surgeon are also important, along with the patient’s characteristics. The most common type of surgery performed in the world is laparoscopic transabdominal lateral adrenalectomy, which most surgeons are more familiar with. The laparoscopic anterior transperitoneal approach is the least preferred laparoscopic method in adrenalectomy. Retroperitoneal laparoscopic adrenalectomy can be performed with a posterior or lateral approach. In addition to conventional laparoscopy, laparoscopic surgery is robot-assisted, which can be administered by transperitoneal or retroperitoneal approach. In addition, conventional or robot-assisted laparoscopic adrenalectomy can be performed transabdominally or retroperitoneally using the single-port method. Today, partial adrenalectomy can be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multiple adrenal tumors, and solitary masses of the adrenal gland. Open surgery is indicated in the case of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated. The risk of conversion to open surgery is low (approximately 5%). The open transperitoneal anterior approach is the most common open intervention, especially in large tumors with malignancy or suspected malignancy. This procedure can be performed using a midline incision, bilateral or unilateral subcostal incision, Makuuchi or modified Makuuchi incision. Thoracoabdominal incision may be required, especially in the removal of large malignant lesions as a block. The open retroperitoneal approach can be applied posteriorly or laterally.

Management of adrenal incidentaloma by laparoscopic transperitoneal anterior and submesocolic approach

Laparoscopic adrenalectomy (LA) is becoming the main approach for incidentally discovered adrenal masses (adrenal incidentaloma (AI)). The aim of this study was to evaluate the results of LA with a transperitoneal anterior approach for right adrenal lesions and either a transperitoneal anterior or transperitoneal anterior submesocolic approach for the left-sided lesions. The study is a retrospective analysis of prospectively collected data. From January 1994 to December 2012, 393 patients underwent LA, 117 of these for an AI. Sixty-seven (57.26 %) and 50 (42.73 %) patients underwent right and left adrenalectomy, respectively. The transperitoneal anterior approach was used in all 67 patients with right lesions (57.26 %) (group A) and in 13 patients with left-sided lesions (11.11 %) (group B). The transperitoneal anterior submesocolic approach was used in the remaining 37 left-sided lesions (31.62 %) (group C). Mean operative time in groups A, B, and C was 104.6 min (range 35-255), 148.9 min (range 80-210), and 82.7 min (range 45-230), respectively. One right and one left anterior LA (1.7 %) were converted to open surgery. There were one major and one minor complications (1.7 %). The mean lesion size was 4.73 cm (range 1-10 cm). Mean hospital stay was 3.6 days. With adequate experience, LA with a transperitoneal anterior approach for AI is a safe and effective procedure. Early control of the adrenal vein with minimal gland manipulation and limited surgical dissection are its major advantages. In case of left LA, the submesocolic approach reduces the operative time significantly.

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients.

Aim was to evaluate the results in 62 patients undergoing laparoscopic adrenalectomy (LA) for the treatment of pheochromocytoma (PHE), with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left-sided lesions. Sixty-two patients underwent LA for the treatment of PHE at two centers in Rome and Ancona (Italy). Two patients had bilateral lesions, for a total of 64 adrenalectomies. Sporadic PHE occurred in 57 patients (91.9%) and in 5 (8.0%) it was familiar. Thirty-six patients (58.0%) underwent right adrenalectomy, 24 (38.7%) left adrenalectomy, and in 2 cases (3.2%) LA was bilateral. In 38 cases of right adrenalectomy (59.3%) and in 5 cases of left adrenalectomy (7.8%), the approach was a transperitoneal anterior one. A transperitoneal anterior submesocolic approach was used in 21 left adrenalectomy cases (32.8%). Mean operative time for right and left transperitoneal anterior LA was 101min (range 50-240) and 163min (range 50-190), respectively. Mean operative time for left transperitoneal anterior submesocolic LA was 92min (range 50-195). For bilateral adrenalectomy, mean operative time was 210min (range 200-220). Conversion to open surgery occurred in 2 cases (3.22%) due to extensive adhesions (1) and hemorrhage (1). One major and three minor complications were observed. Mobilization occurred on the first postoperative day. Hospitalization was 4.8days (range 2-19). The lesions had a mean diameter of 4.5cm (range 0.5-10). Early identification with no gland manipulation prior to closure of the adrenal vein is the main advantages of the transperitoneal anterior approach. PHE may be treated safely and effectively by a laparoscopic transperitoneal anterior approach for right-sided lesions and with a transperitoneal anterior submesocolic approach for left-sided ones.

Primary retroperitoneal germ cell tumours: excision via a thoracoabdominal extraperitoneal approach.

Primary retroperitoneal germ cell tumours usually present as a large abdominal mass in young men. The testes are normal on examination and ultrasonography but there are usually raised serum levels of human chorionic gonadotrophin and/or alpha-fetoprotein. Fourteen men (median age 33 years) with primary retroperitoneal germ cell tumours were treated by chemotherapy followed by surgical resection of the primary tumour and metastases via a thoracoabdominal extraperitoneal approach. There was minimal morbidity. The survival rate was 13 of 14 and the disease-free survival rate was 11 of 14 after a median follow-up of 15 months. The thoracoabdominal extraperitoneal approach for the removal of retroperitoneal germ cell tumours and their metastases after chemotherapy improves tumour clearance, morbidity and recovery time compared with the transperitoneal anterior approach.

Laparoscopic adrenalectomy in pheochromocytomas

The aim of this study was to evaluate 17 patients undergoing laparoscopic adrenalectomy for the treatment of pheochromocytoma by transperitoneal anterior approach. Seventeen patients underwent laparoscopic adrenalectomy for pheochromocytoma between January 1994 and May 2002. Ten females (58.8%) and 7 males (41.2%) were operated on; 14 patients (82.3%) had sporadic pheochromocytoma and 3 (17.7%) were familiar cases. Mean age was 42 yr (range 25-72 yr). All patients were treated pre-operatively with alpha-blockers. Seven patients (41.2%) underwent right adrenalectomy; 9 (52.9%) underwent left adrenalectomy and 1 (5.9%) bilateral adrenalectomy. No conversion to open surgery occurred and no mortality was observed. The right-side adrenalectomy required a mean operative time of 86 min (range 45-120), the left-side procedure a mean operative time of 116 min (range 80-140) and the bilateral one 219 min. In two patients (11.8%), a laparoscopic cholecystectomy and ovariectomy, respectively, were performed without changing the position of the patient on the operating table. Only 1 patient (5.9%) presented significant intraoperative hypertension, and arrhythmia resolved by medical therapy. No other intraoperative and post-operative complications were reported. Mean hospital stay was 3 days (range 2-8 days). At mean follow-up of 48 months (range 6-96 months), regression of symptoms and control of blood pressure were obtained without additional treatment in all patients. No recurrences were reported. In our experience, adrenal pheochromocytoma can be treated safely and effectively by laparoscopic transperitoneal anterior approach.

Hand-Assisted Laparoscopic Nephrectomy Versus Transperitoneal Anterior Approach in Living Donors for Renal Transplantation

The objective of this study was to compare two surgical approaches for living donor nephrectomy: transperitoneal anterior approach and the hand-assisted laparoscopic nephrectomy. Between January 2001 and October 2003 we performed 63 kidney transplantations from living donors. The transperitoneal anterior approach was used in 36 cases and the hand-assisted laparoscopic nephrectomy in 27. Outcomes were compared in terms of hospital stay, postoperative analgesia, and graft quality. Mean hospital stay was 4.7 days in the transperitoneal anterior approach group and 3.7 days in the hand-assisted laparoscopic group ( P < .005). Postoperative analgesia dosage was significantly lower in the hand-assisted laparoscopic group ( P < .001). Surgical complications and graft quality were similar. We concluded that hand-assisted laparoscopic nephrectomy patients had shorter hospital stays and less pain in the postoperative period, with better cosmetic results and equivalent graft quality compared to transperitoneal anterior approach patients.

Laparoscopic anterior adrenalectomy for the treatment of adrenal metastases.

Aim of this study was to evaluate the results in 6 patients undergoing laparoscopic adrenalectomy for the treatment of solitary adrenal gland metastases. One hundred forty-five patients underwent laparoscopic adrenalectomy by transperitoneal anterior approach. In 6 patients the indication was the presence of a solitary adrenal gland metastasis. Primary tumors were the following: truncal melanoma, gastric cancer, renal cancer, lung cancer, and breast cancer. Mean age was 57 years (range 44-70 years). Three patients underwent right adrenalectomy and 3 patients a left adrenalectomy. No conversion to open surgery occurred. No mortality or intraoperative complications were observed. Mean operative time was 103 minutes (range 70-150) for right adrenalectomy and 170 minutes (range 90-280) for left adrenalectomy. No postoperative complications occurred. Mean diameter of the tumor was 3.5 cm (range 2-5 cm). Tumor free margins were obtained in every case. Mean hospital stay was 2 days (range 2-3 days). At follow-up, 2 patients have died of systemic dissemination of the disease, one 15 months and one 24 months after the operation. The remaining 4 patients are alive and disease free at a mean follow-up of 7 months (range 4-11 months). So far, no port site metastases or local recurrence have been observed. In our experience adrenal gland metastasis can be treated safely and effectively by the laparoscopic transperitoneal anterior approach.

Section 3. Adrenal: Laparoscopic adrenalectomy: current status with a review of Japanese literature

A decade has elapsed since laparoscopic adrenalectomy was first performed in 1992. Accumulated experiences of laparoscopic adrenalectomy have shown superior results to treat small functional benign tumors and make the indication expand to large tumors, pheochromocytomas and localized malignant tumors. Following the initially established transperitoneal approach, which includes anterior and lateral approaches, the retroperitoneal lateral flank and posterior lumber approaches have been performed. Each approach has advantages and disadvantages. The transperitoneal approach supplies a large operative field, many anatomical landmarks and easy handling. But it causes post-operative irritability and it is very difficult to perform after previous upper abdominal surgery. The retroperitoneal approach can be performed even after previous abdominal surgery and patients may be more comfortable after the operation. However, the narrow working space and the lack of anatomical landmarks may increase the rate of intra-operative complications and the rate of conversion to open surgery. Although there is no clear preference between transperitoneal and retroperitoneal approaches, the transperitoneal approach is commonly employed and the transperitoneal anterior approach seems to be the easiest one for right adrenal tumors and the transperitoneal lateral approach for left adrenal tumors. The shorter convalescence with laparoscopic adrenalectomy as compared with open adrenalectomy has been accepted and lower morbidity from laparoscopic adrenalectomy has been achieved. The operative time has been shortened to the level of open adrenalectomy. Less blood loss, less pain and better cosmesis are absolute advantages for the patients. Laparoscopic adrenalectomy is now the gold standard for the treatment of adrenal tumors.

The ideal living donor nephrectomy "mini-nephrectomy" through a posterior transcostal approach.

Cadaver kidney donation has failed to keep pace with an increase in the number of patients with end-stage renal disease. Living donor kidney transplantation is evolving as a means to partially alleviate the shortage of cadaver organs. Living donor nephrectomy is most commonly performed through a retroperitoneal approach using a flank incision. This procedure is safe and has minimal complications, but the flank incision traversing the abdominal wall musculature can be associated with major perioperative pain and discomfort. Currently, laparoscopic donor nephrectomy is the most popular minimally invasive alternative. This is performed through a transperitoneal anterior approach using three or four upper abdominal incisions to accommodate a laparoscope and working ports. In addition, a 7to 8-cm lower midline or Pfennenstiel incision is used to extract the kidney allograft. Recently, this incision has also been used as a hand port for assistance during the laparoscopic procedure. Delayed initial graft function has been reported with laparoscopic nephrectomy. This is attributed to shorter length of vessels, a prolonged period of warm ischemia, and decreased renal perfusion because of insufflation of the abdomen during laparoscopic dissection. Laparoscopy is also associated with complications of transperitoneal surgery, especially a longterm risk of adhesive intestinal obstruction. In a followup period of 5 years, 15 episodes of intestinal obstruction were noted in 4,000 laparoscopic donors (Ratner L, personal communication, June, 2001). The procedure also requires considerable training and expensive instrumentation. Despite these disadvantages, the benefits of this minimally invasive procedure have appealed to voluntary donors, increasing living donor kidney donation. The advantages of a minimally invasive technique and its appeal to donors prompted us to develop a novel procedure that is minimally invasive and that provides the safety of a retroperitoneal approach. Our hypothesis was that the smallest incision possible to extract the kidney from the donor would be sufficient to perform the mobilization of the kidney and dissection of the vessels and ureter. The key features would be the strategic placement of the incision to reduce the postoperative discomfort and appropriate instrumentation to enhance the limited exposure. We have achieved this by adopting minimally invasive techniques in an open surgical setting. We use a 6to 8-cm posterior transcostal incision instead of the standard 14to 20-cm flank incision. We refer to this novel procedure as the “mini-nephrectomy.” To date, we have successfully performed 28 donor nephrectomies using this keyhole incision. We have reported in detail the outcomes of 15 consecutive donors using this technique (unpublished data). Here, we describe the technical details of this novel surgical procedure and its successful outcomes.

Laparoscopic live‐donor nephrectomy

that kidney transplant waiting lists lengthen each year. One of the potential solutions to this problem is to spleen. The operation begins with mobilization of the increase the use of live donors, a policy that has been colon by incising the lateral peritoneal reflection from particularly successful in Norway [1]. Although living the splenic flexure to the pelvic inlet. The kidney is kidney donation has many advantages, including the then identified by opening the overlying Gerota’s best graft survival results, these benefits carry a unique fascia. The renal vein is dissected to display its adrenal price in that an otherwise healthy individual must be and gonadal tributaries, which are divided between exposed to all the risks of major surgery for the benefit metal clips. The renal artery is then gently dissected of another person. A traditional open nephrectomy, free to demonstrate its origin from the aorta. whether performed through an extraperitoneal loin The ureter is mobilized with a generous amount of approach or a transperitoneal anterior approach, meso-ureteric tissue down to the level of the pelvic leaves a formidable wound. There is no doubt that this inlet. The ureter is clipped and divided at this point is one of the main disincentives to potential live donors and then the remaining lateral, posterior and superior who may express concerns about wound pain, poor fascial attachments of the kidney are divided to leave cosmetic results and the need for a prolonged recovery the kidney attached only by its vascular pedicle. At period. The advent of laparoscopic live-donor nephrec- this stage a 5–6 cm kidney retrieval incision is made tomy has the potential to overcome many of these either in the midline below the umbilicus or transversely disincentives but there is a need to define the place of just above the pubis. A purse-string suture is placed in this new procedure before it becomes widely adopted. the peritoneum, which is then incised to allow the

Transperitoneal anterior laparoscopic adrenalectomy: the easiest technique

Four laparoscopic methods have been developed to approach the adrenal gland: anterior or lateral transperitoneal approaches, and lateral or posterior retroperitoneal approaches. The advantages and disadvantages of these methods were reviewed during a workshop held by the Japanese Society of Endourology and ESWL in 1997. The transperitoneal anterior approach, when combined with a lateral approach for the left side, is the easiest for small adrenal tumors, and discloses the adrenal vein early in the procedure. For large tumors over 5 cm in diameter, the transperitoneal lateral approach is the most feasible bilaterally. Regardless of the methods of approach, laparoscopic adrenalectomy has already become the standard procedure for adrenal tumors, because it minimizes the operative morbidity and postoperative hospital stay.

A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy.

To compare the efficacy of retroperitoneoscopic adrenalectomy by a posterior lumbar approach (RPA) with that obtained by a transperitoneal anterior approach (TAA) or retroperitoneal lateral flank approach (RLA). Fifty-one patients underwent endoscopic adrenalectomy by three approaches, including laparoscopic adrenalectomy by TAA in 33, retroperitoneoscopic adrenalectomy by RLA in 5, and retroperitoneoscopic adrenalectomy by RPA in 13. The average adrenal tumor size was 27 mm (range 8 to 65). The average number of trocars required for RPA was 3.2 which was significantly less than that for TAA and for RLA (4.2 and 4.1, respectively). The conversion rate to open surgery was 9.1% by TAA, 0% by RLA, and 7.7% by RPA. The average operating time for TAA was 252 minutes, which was significantly shortened to 194 minutes by RLA and 142 minutes by RPA (P < 0.02). The average blood loss was 101 mL for TAA and was negligible by RLA and RPA (22 and 32 mL. respectively). RPA allowed direct access to the main adrenal vascular supply before the gland was greatly manipulated. Endoscopic adrenalectomy by TAA or even by RLA required extra ports for retraction of liver, spleen, vena cava, or adrenal gland, with higher chance of vein avulsion. RPA was technically feasible and most effective for retroperitoneoscopic adrenalectomy in regard to the simplicity of vascular control. The operating time, perioperative morbidity, and cost were reduced with this approach.