Transperitoneal Laparoscopic Surgery Research Articles

PD03-08 SURGICAL AND FUNCTIONAL OUTCOMES OF BILATERAL SYNCHRONOUS ADRENALECTOMY FOR FUNCTIONAL TUMORS: A COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023PD03-08 SURGICAL AND FUNCTIONAL OUTCOMES OF BILATERAL SYNCHRONOUS ADRENALECTOMY FOR FUNCTIONAL TUMORS: A COHORT STUDY Keshav Agarwal, Rashmi Ramachandran, Nikhil Tandon, and Rajeev Kumar Keshav AgarwalKeshav Agarwal More articles by this author , Rashmi RamachandranRashmi Ramachandran More articles by this author , Nikhil TandonNikhil Tandon More articles by this author , and Rajeev KumarRajeev Kumar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bilateral synchronous adrenalectomy has the potential for significant surgical and functional morbidity. We reviewed our 15-year experience with bilateral synchronous adrenalectomy to assess safety, surgical outcomes, morbidity and impact on health-related quality of life. METHODS: In an IRB approved study, we reviewed our prospective database of patients who underwent bilateral synchronous adrenalectomy for functional tumours between April 2008 and August 2022. Demographic profile, metabolic and radiological parameters, operative details and complications were recorded. Follow-up was obtained either in-person or telephonically and analysed for resolution of symptoms, quality of life using the WHO-QoL BREF questionnaire and complications of chronic steroid intake. RESULTS: During the study period, 337 adrenalectomies were performed which were bilateral in 51 patients, 48 undergoing both surgeries synchronously. 33 of these 48 patients had bilateral pheochromocytomas and 15 had Cushing’s syndrome. Among patients with Cushing’s syndrome, three had life-threatening symptoms requiring urgent bilateral surgery. Clinical details are given in Table 1. 40 patients had transperitoneal laparoscopic surgery and 8 underwent open surgery (Table 2). There were two intraoperative and 7 post-operative complications. 43 patients were available for follow-up. All had resolution of symptoms, BMI changes, and only two patients continued to receive one antihypertensive medication. Episodes of steroid deficiency occurred in 7 patients while steroid excess occurred in 3 patients. Quality of life was satisfactory in all patients in all domains. CONCLUSIONS: Bilateral synchronous adrenalectomy is safe and feasible in patients with functional adrenal tumors. It leads to symptom resolution with amelioration of hypertension and BMI changes with satisfactory overall quality of life. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e77 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Keshav Agarwal More articles by this author Rashmi Ramachandran More articles by this author Nikhil Tandon More articles by this author Rajeev Kumar More articles by this author Expand All Advertisement PDF downloadLoading ...

Lateral transperitoneal laparoscopic management for paragangliomas in para-aortic position: Surgical experience from case reports of three patients

Paragangliomas are a type of neuroendocrine tumour with catecholamine secretion outside of the adrenal medulla. These tumours are frequently found in the para-aortic region, which makes them difficult to manage laparoscopically. We herein present a case report of three patients with paragangliomas in a difficult superior para-aortic position. All cases had symptoms of catecholamine release with uncontrolled episodic hypertension and had their tumours successfully removed by transperitoneal laparoscopic management. We have found this method to be a suitable approach because it reveals a wide surgical field and a view over all organs, especially blood vessels around the tumour. Although blood and urine dopamine and noradrenaline levels were not measured postoperatively, all three patients were discharged without complication and they did not display any more clinical symptoms. Lateral transperitoneal laparoscopic surgery provided a wide field of view, which clearly revealed the tumour and surrounding components indicating it is one of the safest and most effective approaches, especially for paragangliomas adjacent to large blood vessels.

Effects of Retroperitoneal or Transperitoneal Pneumoperitoneum on Inferior Vena Cava Hemodynamics and Cardiopulmonary Function: A Prospective Real-Time Comparison.

Objective: To evaluate the effects of CO2 pneumoperitoneum on venous hemodynamics and cardiopulmonary function during transperitoneal or retroperitoneal laparoscopic surgery. Materials and Methods: A single-institution prospective study. Forty-three patients with renal-cell carcinoma undergoing retroperitoneal (22) or transperitoneal (21) laparoscopic partial nephrectomy were enrolled. Hemodynamic functions were monitored by minimally invasive FloTrac/Vigileo system. Transesophageal echocardiography was used to measure the diameter and blood flow of the inferior vena cava (IVC). Measured parameters were recorded at baseline, 10, 30, 60 minutes following insufflation to 14 mm Hg and 10 minutes following desufflation. Results: For hemodynamic changes in the transperitoneal laparoscopic surgery (TPL) and retroperitoneal laparoscopic surgery (RPL), transperitoneal CO2 insufflation resulted in a rapid parallel increase in central intravenous pressure (CVP), peak airway pressure (AWP), and IVC blood flow velocity after the first 30 minutes of pneumoperitoneum (p < 0.05). In contrast, CVP, AWP, and IVC blood flow velocity increased progressively in RPL. The variation of those parameters was significantly lower than that of TRL (p < 0.001; p = 0.002; p = 0.004). The mean maximum CVP in the two groups was 20 and 16 mm Hg, respectively. The IVC diameter at the cavoatrial junction was significantly reduced in TPL after 10 minutes of insufflation, but it remained unchanged in RPL throughout the surgery. For cardiopulmonary function changes, heart output decreased after a short period of pneumoperitoneum, but no statistical differences were observed between the two groups. The increments of partial pressure of arterial carbon dioxide and end-tidal carbon dioxide tension were significantly higher in RPL than TPL (p < 0.001; p < 0.001). Conclusions: Compared with retroperitoneal pneumoperitoneum, transperitoneal pneumoperitoneum has significant effects on IVC hemodynamics. Elevated intra-abdominal pressure (IAP) causes higher AWP and venous return resistance, which lead to the significant increase of CVP during transperitoneal approach. Adjusting the balance between IAP and CVP might be an effective way to control intravenous bleeding. Clinical Trial Registry: Registration number: ChiCTR2000038291.

Erratum: Comparison of Laparascopic and Open Adrenalectomy

Purpose: Laparoscopic adrenalectomy, which was performed successfully for the first time in 1992, has become the preferred method in adrenal surgery especially in adrenal diseases. In this study, our aim is to compare the demographic and operative data of laparoscopic and open adrenalectomies performed in the general surgery clinic of our hospital. Methods: The records of the patients who were operated in hospital due to a surrenal mass between August 2006 and December 2012 have been retrospectively assessed. Demographic characteristics of the patients, such as age, sex, the size and location of tumors were included. Surgical indications were classified in terms of their radiologic and biochemical investigations. Type of the surgery (lateral transperitoneal laparoscopic or open approach), the incision used in these surgeries (midline, subcoastal and paramedian), the length of operation, the length of hospital stay, postoperative complications and the final pathology results were all examined. Results: During the afformentioned period, adrenalectomy was performed in 106 patients. Eighty of these patients (%75,4) were operated by open and 26 of them (%24,6) by lateral transperitoneal laparoscopic surgery. Subcostal incision was used 61 of 80 patients (% 82,4), whereas 17 patients (% 22,9) were operated by midline incision and 2(% 2,7) were by paramedian incision. No mortality was encountered. Operation time was statistically significantly shorter in the open group (p<0,0166). Duration of hospital stay was statistically significantly longer in open group (p<0,0083). Hospital stay time was statistically significantly longer in midline incision group (p<0,0083). Except for the weight of masses, statistically significant difference was not found between two groups (laparascopic and open surgery) in demographic and operative features (age,gender,side,pathological diagnose,size of mass) releated to postoperative complications. Conclusion: In carefully selected group of patients laparoscopic adrenalectomy offered lesser postoperative hospital stay than the open adrenalectomy. The longer operative time can be decreased when more experience is gained in laparascopic adrenalectomy. Laparoscopic adrenalectomy should be preferred in adrenal disease as the gold standard in centers with completed learning curve. "The list of authors in our article, which was published in the 2021-July issue, was made inadvertently. Considering the contribution of the author in the previous poster paper of the article in 2014, the list of authors has been changed." The original article was published on 01 July 2021. http://journal.acibadem.edu.tr/en/pub/issue/62213/862954

Laparoscopic Surgeries in Urology: Initial Burgeoning Experience at National Transplant Centre, Nepal

Background This study focuses on experience of laparoscopic surgery at Shahid Dharma Bhakta National Transplant Centre (SDNTC), Nepal; which could enable us to gain knowledge regarding its benefits over conventional surgery. The present study revealed the frequency of various forms of laparoscopic surgeries done at our centre. Moreover, this study accomplishes laparoscopic donor nephrectomy “a historical milestone achieved in Nepal for kidney transplantation on 18th November 2018” which was the first Laparoscopic donor nephrectomy done in Nepal by Nepalese team. Objective The present study assesses the feasibility and safety of laparoscopic surgery at government hospital of Nepal. Method This hospital based cross-sectional study included all patients of age group 10 to 60 years, coming to outpatient department of SDNTC and those having indications for nephrectomy. We excluded patient having previous history of open surgeries of kidney, bleeding disorders, uncontrolled Diabetes Mellitus and uncontrolled Hypertension. The study duration was 15 months from November 2017 to January 2019. The total number of patients enrolled in the study was fifty where transperitoneal laparoscopic surgery was performed in all 50 patients. The demographic data, indications for surgery, duration of surgery, complications of surgery and perioperative outcomes were analyzed. Result Out of 50 cases, 34 (68%) underwent simple lap nephrectomy, 6 (12%) were lap pyeloplasty, 6 (12%) lap nephrectomy along with ureterectomy of long segment of diseased ureter, 1 (2%) lap radical nephrectomy, 1 (2%) lap donor nephrectomy for kidney transplantation, 1 (2%) lap heminephrectomy and 1 (2%) lap nephrectomy for hydronephrotic non functioning left crossed ectopia. Amongst all nephrectomies, 27 (54%) patients were operated on right side while 23 (46%) patients on left. The median age of the patient was 38.56 years. Out of total cases 32 (64%) were male and 18 (36%) female. The median operative time and hospital stay was 122.3 minutes and 5 days respectively. The median estimated blood loss was 74.1 cc. Only one patient required blood transfusion intra-operatively. 2 (4%) patients were converted to open surgery. Conclusion Laparoscopic surgery is feasible and safe procedure in government setup hospital with less cumbersome procedure and minimum complications associated with it.

Comparison of Laparascopic and Open Adrenalectomy

An Erratum to this article was published on 01 January 2022. http://journal.acibadem.edu.tr/en/pub/issue/65423/1049054 Purpose Laparoscopic adrenalectomy, which was performed successfully for the first time in 1992, has become the preferred method in adrenal surgery especially in benign adrenal diseases. In this study, our aim is to compare the postoperative results of laparoscopic and open adrenalectomies performed in the general surgery clinic of our hospital. Methods The records of the patients who were operated in hospital due to a surrenal mass between August, 2006 and December 2012 have been retrospectively assessed. Demographic characteristics of the patients, such as age, sex, the size and location of tumors were included. Surgical indications were classified in terms of their radiologic and biochemical investigations. Type of the surgery (lateral transperitoneal laparoscopic or open approach), the incision used in these surgeries (midline, subcoastal and paramedian), the length of operation, the length of hospital stay, postoperative complications and the final pathology results were all examined. Results During the afformentioned period, unilateral adrenalectomy was performed in 106 patients. Eighty of these patients (%75,4) were operated by open surgery and 26 of them (%24,6) were operated by lateral transperitoneal laparoscopic surgery. Subcostal incision was used 61 of 80 patients (% 82,4), whereas 17 patients (% 22,9) were operated by midline incision and 2(% 2,7 were by paramedian incision. No mortality was encountered. The length of operation was statistically significantly shorter in the open group (p<0,0166).The length of hospital stay was statistically significantly longer in open group (p<0,0083). The length of hospital stay was statistically significantly longer in midline incision group(p<0,0083). No statistically meaningful difference was found in terms of age, sex and patological diagnosis releated to postoperative complications. Conclusion In carefully selected group of patients laparoscopic adrenalectomy offered lesser postoperative hospital stay and lesser postoperative complications than the open adrenalectomy. The longer operative time can be decreased when more experience is gained in laparascopic adrenalectomy. Complication rates of laparoscopic adrenalectomies are lower than conventional adrenalectomy and should be preferred as the gold standard in centers with completed learning curve. An Erratum to this article was published on 01 January 2022. http://journal.acibadem.edu.tr/en/pub/issue/65423/1049054

Virtual Reality Simulator Face Validity for Topographic Real Situation of Inflated Abdomen

Objective: The aim of this study is to investigate the face validity of LapSIM® (haptic feedback Xitact™ IHP, Mentice AB, Sweden) for the topographic real condition of the inflated abdomen in upper urinary tract laparoscopic interventions. Materials and Methods: The present study was conducted with 30 urologists with experience in transperitoneal laparoscopic renal surgery. Surgeons were divided into three groups: novices, intermediate experience, and experts. After performing the tasks, the participants were then asked to finish a five-item questionnaire regarding the face validity of the simulator. Participants answered questions with ratings from 1 (not realistic/useful) to 5 (very realistic/useful). Results: The mean age of the study group was 38.33 ± 5.45 (29–47) years. The mean years of experience of the doctors were 4.27 ± 1.89 (1–7) years. All the variables showed significant differences from the ideal value of 5. We also tested whether the medians differed from 3, and the restrained body posture of the surgeon, the monitor position, and the trocar position not show significance with one-sidedPvalue ofP= 0.825,P= 0.992, andP= 0.265, respectively. Conclusion: Although the LapSIM® virtual reality simulator provides face validity for the topographic real condition of the inflated abdomen, it should be improved.

Combined Retroperitoneal and Transperitoneal Laparoscopic Procedures by a Single Surgeon: Boon to Economically and Medically Backward Areas.

IntroductionThis study was done to evaluate our experience of combining a retroperitoneal laparoscopic urological operation with other transperitoneal laparoscopic operations.Materials and methodsWe present a retrospective study of a series of 20 cases of retroperitoneal laparoscopic urological surgeries combined with at least one transperitoneal laparoscopic procedures, performed by a senior minimally invasive surgeon, between March 2013 and August 2020. We have excluded three patients where either of the procedures required conversion to open surgery. We retrospectively reviewed all the data regarding the patient’s demographics, combined surgical procedures done, operative time taken, blood loss, intraoperative and postoperative complications, and days of hospital stay.ResultsTotal of 20 patients had undergone simultaneous retroperitoneal and transperitoneal laparoscopic procedures. A total of nine (45%) cases comprised a combination of retroperitoneal laparoscopic ureterolithotomy and laparoscopic cholecystectomy. Two patients had undergone a combination of three laparoscopic procedures in the same operation. The mean hospital stay was 3.6 days. Blood loss was minimal to moderate in all the patients, none needed any perioperative blood transfusion. No major complications were noted in any patients.ConclusionCombining a retroperitoneal laparoscopic urological procedure with another transperitoneal laparoscopic surgery is very much feasible. It becomes even easier and relevant provided both the procedures are performed by a single, experienced laparoscopic surgeon.

Retrospective Study on Safety and Efficacy of Transperitoneal Laparoscopic Surgery and Open Surgery for Retrocaval Ureter

Introduction: Retrocaval ureter is a rare congenital anomaly which remains silent until the 3rd or 4th decade of life. But once a patient develops symptoms, it mandates treatment in the form of surgical management. Open surgery has traditionally been considered as the standard of care but it has its own downside or limitations. It requires a relatively large skin incision causing significant postoperative pain and thus prolonging convalescence. Transperitoneal laparoscopic approach is the preferred approach by most surgeons owing to large working space and familiar anatomy. Aim: To compare the safety and efficacy of transperitoneal laparoscopic and open surgery for definitive management of retrocaval ureter. Materials and Methods: Clinical data of fifteen patients, that underwent surgery for retrocaval ureter from December 2013 to January 2020 and the study of this data was done from June 2020, at Urology Department were analysed retrospectively. Out of 15 patients, seven were treated by open surgery while eight underwent transperitoneal laparoscopic surgery. Ureter was transpositioned to normal anatomic position followed by uretero-ureterostomy. Student t-test was applied to interpret and analyse the data obtained in both the groups using SPSS version 24. Results: Total of 15 patients data was studied (7 open surgery + 8 transpertional laparoscopic surgery, age 21-45 years). Intraoperative and postoperative data were compared between the transperitoneal laparoscopic and open surgery group. A statistically significant difference was found for operative time (p-value &lt;0.001), estimated blood loss (p-value &lt;0.05), analgesic requirement (p-value &lt;0.001), drain removal (p-value &lt;0.05) and hospital stay (p-value &lt;0.001) between the two groups. Superficial surgical site infection was noted in two patients in open surgery group. For rest 13 patients postoperative period was uneventful. The follow-up of all patients was done for 12-36 months. Conclusion: Transperitoneal laparoscopic uretero-ureterostomy as a definitive treatment of retrocaval ureter is safe, effective and reliable option with less trauma and faster recovery. This minimally invasive technique can be considered as the first choice for treatment of retrocaval ureter on account of familiar anatomy and easier learning curve in contrast to retroperitoneal laparoscopic or robotic surgery.

Retroperitoneal metastasis of metaplastic breast cancer causing hydronephrosis

Metaplastic breast carcinoma (MpBC) accounts for <5% of all cases of breast cancer. Retroperitoneal metastasis is also a rare metastatic site of breast cancer. We report a case of retroperitoneal metastasis of MpBC which was extirpated by transperitoneal laparoscopic surgery. The patient was free of disease for 30 months. We also discuss the presentation, diagnosis and treatment of retroperitoneal metastasis of MpBC causing hydronephrosis.

Fast, Easy, and Safe Establishment of Pneumoperitoneum in Laparoscopic Surgery: The Fingertip Technique.

Background and Objectives:There is no consensus on an ideal abdominal entry in laparoscopic surgery; as such, we aimed to assess the feasibility of the fingertip technique for safe entry and the establishment of pneumoperitoneum in transperitoneal laparoscopic surgery.Methods:We prospectively assessed 96 consecutive patients who underwent laparoscopic transperitoneal surgery between December 2018 and September 2019. For all patients, pneumoperitoneum was performed using the fingertip technique, which we recently defined. The duration of time for initial entry, the occurrence of gas leakage, and the complications were evaluated.Results:The median duration of initial entry was 90 (75 – 145) seconds. Pneumoperitoneum was established on the first attempt in all patients. Some events were encountered at the time of implementation of the fingertip technique, such as subcutaneous minor bleeding (5.2%) and gas leakage (4.1%). These events were controlled with cauterization and suturing. There was no visceral or major vascular injury in any patient case.Conclusions:The fingertip technique is a fast, safe, and feasible method for establishing pneumoperitoneum in transperitoneal laparoscopic surgery.

Evolution of adrenal surgery in a tertiary referral centre.

Laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy have largely replaced open adrenal surgery, particularly in benign disease. Laparoscopic surgery results in less post-operative pain, fewer surgical site complications and reduced length of hospital stay. The aim of this retrospective study was to analyse the characteristics of patients and evolution of surgical technique in adrenal surgery at Cork University Hospital over a 12-year period. All cases of adrenalectomy between January 1st, 2007 and December 31st, 2018 were retrospectively reviewed. Patient demographics, diagnosis, surgical approach, length of hospital stay, histology and complications were evaluated. Comparisons were made between open, laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy cases. There were 57 adrenalectomies performed on 55 patients over the 12-year period. Twenty-six patients (46%) were male, and the mean age was 49years (range 14-84years). Twenty-two (39%) right-sided adrenalectomies were performed, 33 (57%) left sided and 2 (4%) patients underwent bilateral surgery. Seventeen adrenalectomies were performed using an open transperitoneal approach, 30 via a laparoscopic transperitoneal approach and 10 using the retroperitoneoscopic technique. Adenoma and pheochromocytoma were the most common indications for surgery (42% and 40%, respectively). Seven percent were performed for malignancy and 5% for other benign indications. The complication rate for open adrenalectomy was 18% versus 10% in laparoscopic transperitoneal adrenalectomy and 0% for retroperitoneoscopic adrenalectomy. Two patients (7%) undergoing laparoscopic transperitoneal surgery required conversion to an open procedure. There were no 30-day mortalities and no disease recurrence within the study time frame. The mean length of hospital stay was 7.6days in the open group, 5.8days for the laparoscopic transperitoneal group and 3days for the retroperitoneoscopic group (p = 0.03). Adrenalectomy is a safe procedure and in our setting was primarily performed for pheochromocytoma and non-functioning adenomas. Minimally invasive adrenalectomy has become the standard of care internationally and is associated with fewer complications, shorter hospital stay and a low conversion rate.

Advantages and surgical experience of laparoscopic anatomical surgery for adrenal tumors

Objective To analyze the advantages and surgical experience of laparoscopic anatomical surgery for adrenal tumors. Methods A total of 156 patients with benign or malignant adrenal tumors admitted to our hospital from April 2012 to September 2016 were enrolled and underwent laparoscopic anatomical surgery in the study.The curative effect and advantages of the operation were analyzed, and surgical experiences of laparoscopic anatomical surgery for adrenal tumors were summarized. Results Laparoscopic adrenalectomy was successfully completed in 155 of the 156(99.4%)patients and 1 patient with pheochromocytoma underwent open surgery due to pneumothorax caused by an accidental diaphragm injury.Postoperative pulmonary embolism occurred in 1 case and hematoma in right adrenal region in 6 cases, all of whom were completely relieved after intervention.Postoperative surgical specimen of adrenal glands in 54 patients were histopathologically examined, the results of which showed the negative boundaries in all patients.Patients were followed up for a mean of 11.6 months(range, 4 to 26 months). All patients had a good recovery after surgery without recurrence of malignant tumor in local or trocar site. Conclusions As compared with open surgery, the transperitoneal laparoscopic adrenal surgery provides a larger operation area for good orientation and vision, and has such advantages as shorter hospital stay, fewer postoperative complications and better prognosis in patients with malignant adrenal tumors, which is worthy of clinical selection. Key words: Adrenal gland neoplasms; Laparoscopy

Transperitoneal laparoscopic surgery in large adrenal masses.

IntroductionThe laparoscopic adrenalectomy (LA) has become the gold standard since the transperitoneal laparoscopic approach was first reported.AimTo evaluate the applicability, safety and short-term results of laparoscopic surgery in adrenal masses over 6 cm.Material and methodsDemographic data, hormonal activities, imaging modalities, operative findings, operation time, conversion rates, complications, duration of hospital stay and histopathologic results of 128 patients who underwent laparoscopic adrenalectomy were evaluated retrospectively. Patients included in the learning curve (n = 23), robotic surgery cases (n = 15) and patients with suspected metastasis (n = 4) were excluded from the study. Six cm mass size was taken as a reference and two groups were formed (group 1: < 6 cm, group 2: ≥ 6 cm). The results of the two groups were compared.ResultsThere were 64 cases in group 1 and 22 cases in group 2. Functional mass ratio and mass sides were similar between the groups (p = 0.30 and p = 0.17, respectively). The mean mass size in group 1 was 36.4 ±11.2 mm and in group 2 82.4 ±15.5 mm. The conversion rate was similar between the two groups (p = 0.18). The duration of surgery was 135.5 ±8.29 min in group 1, 177.0 ±14.9 min in group 2 (p = 0.014). Morbidity and lengths of hospital stay were similar (p = 0.76, p = 0.34 respectively). Adrenocortical carcinoma was detected in three cases in group 1, which were completed laparoscopically, and in two cases in group 2, which were converted to open surgery (p = 0.46).ConclusionsAlthough open surgery is still recommended in the guidelines, studies are now being carried out to ensure that laparoscopy can be safely performed on masses over 6 cm. There was no difference between short-term follow-up and histopathologic results in our study.

Effect of Intra-abdominal Pressure Rise on Hematological Parameters in Laparoscopic Urologic Surgery.

To determine the potential utility of hematological parameters in the diagnosis of intra-abdominal hypertension (IAH). Cross-sectional descriptive study. Health Sciences University, Samsun Training and Research Hospital, Samsun, Turkey, from January 2016 to July 2017. Forty-two patients who underwent transperitoneal laparoscopic urologic surgery were included. Blood samples were obtained during periods of pre-insufflation, insufflation, and desufflation to determine the effects of increased intraabdominal pressure (IAP) on hematological parameters, respectively. Leukocyte and neutrophil median values changed with time (p<0.001). The median pre-insufflation, insufflation, and desufflation values for leukocytes were 6.3 fL (4.2-7.8 fL), 7.2 fL (4.4-9.9 fL), and 8.1 fL (4.9-13.5 fL), respectively. In the pre-insufflation period, the median value for neutrophils was 3.7 x 103 &micro;L (2.0-6.2 x 103 &micro;L), increasing 5.1 x 103 &micro;L (2.1-9.7 x 103 &micro;L) during insufflation and 6.1 × 103 &micro;L (3.1-10.0 x 103 &micro;L) during desufflation. The median values obtained in pre-insufflation period were significantly lower than those recorded in the other periods. There was no difference between the median values obtained during insufflation and those obtained during desufflation. The mean platelet volume (MPV) values during pre-insufflation, insufflation, and desufflation were 8.2 fL (6.3-9.6 fL), 8.8 (6.2-10.3 fL), and 8.1 (6.6-10.6 fL), respectively. There was a statistically significant increase in MPV values during high IAP (p<0.001). The rise in MPV during IAP rise indicated that this parameter may be used to detect IAH.

Surgical intervention for renal cell carcinoma with inferior vena cava extension combined with laparoscopic procedure.

Clear cell renal cell carcinoma (ccRCC) shows extreme hypervascularity, which may cause significant bleeding during surgery. For this reason, control of arterial blood supply is an important factor in the choice of operative procedure and in avoiding perioperative complications. This case series reports the successful dissection of renal artery in the preliminary stage of laparoscopic procedure in three ccRCC patients with inferior vena cava (IVC) extension. Patient 1 had right renal cell carcinoma (RCC) with level I tumor thrombus through two renal veins, and the renal artery was successfully dissected by retroperitonealscopic approach. Patient 2 had right invasive, immobilized RCC with significant infiltration to IVC and liver. Ligation of renal artery was performed by transperitoneal laparoscopic procedure. Patient 3 had left RCC with level III tumor thrombus and lung metastasis. Ligation of left renal artery and mobilization of peritoneal organs and kidney were performed by transperitoneal laparoscopic surgery. These cases suggest that combined laparoscopic-open surgery for RCC with IVC extension may facilitate early control of arterial blood supply.

Clinical investigation on minimal invasive surgery for Cushing syndrome caused by adrenocortical adenoma: experience of 121 cases in a single center

Objective To explore the efficacy and safety of minimal invasive adrenal sparing surgery for the treatment of Cushing syndrome caused by adrenocortical adenoma. Methods Patients who underwent minimal invasive adrenal surgery for adrenocortical adenoma in our institution from January 2010 to December 2015 were retrospectively analyzed. Preoperative, intraoperative, and postoperative variables were reviewed from the database. The mean patient age at diagnosis was 39 years and male∶female ratio was 10∶111. Of the 121 adenomas, 50 were located in the right adrenal and 71 in the left. The mean tumor size was 2.6 cm.84 cases had hypertension (69.4%), 36 cases had diabetes mellitus (29.8%), and 45 cases had obesity (37.2%). Postoperative follow-up was performed by evaluating adrenal gland function and imaging. Results Mininal invasive partial adrenalectomy was performed in 121 cases and the success rate of operation was 99.2%(120/121). Sixty-two cases received operation through retroperitoneal approach, and 59 cases were through transperitoneal approach. The median operative time was 50 min with a median blood loss of 50 ml. The mean postoperative hospital stay were (5.0±3.2) days.The vascular injury occurred in 2 cases (1 case in each surgical approach), while the abdominal organ injury occurred in 2 cases with 1 case of spleen injury and 1 case of liver injury (both in transperitoneal approach). Postoperative complications were observed in 6 cases: 1 case of deep venous thrombosis, 1 case of wound hematoma, 4 cases of wound infection. Cortisol substitution was given in 2 to 12 months (mean 6.2 months) postoperatively. One year after operation, the remission rate of hypertension, diabetes and obesity was 58.3%(49/84), 30.6%(11/36) and 60.0%(30/45), respectively. Conclusions Minimal invasive adrenal surgery using retroperitoneal and transperitoneal laparoscopic technique can be performed with low morbidity and achieve an excellent outcome.The perioperative hormone therapy may also play an important role. Key words: Cushing syndrome; Partial adrenalectomy; Transperitoneal laparoscopic surgery; Retroperitoneal laparoscopic surgery

Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intraoperative period: A prospective randomized study

A safe and optimal pneumoperitoneal pressure (PP) for laparoscopic renal surgery in infants is difficult to define. In a broad sense, a safe and optimal PP should cause least intraoperative and postoperative physiological stress for the infants and should be optimal for surgeon's technical feasibility. Unfortunately, the safe and optimal PP in infant for transperitoneal laparoscopic surgery has not been established by well validated study. To determine safe and optimal PP for laparoscopic renal surgery (LRS) in infants less than 10kg. In a prospective and randomized setting, between July 2008 and June 2014, 46 infants of <10kg (Group I, n=23, PP=6-8mmHg and Group II, n=23, PP=9-10mmHg) who underwent LRS, were analyzed. Hemodynamic, respiratory, and blood gas changes were measured at four points: before CO2 insufflation (T0), 10min after insufflation (T1), before desufflation (T2) and 10min after desufflation (T3). Any required adjustments of ventilator parameters were noted. Time to resume feeding and postoperative pain at 1, 6, and 12h, including requirement for postoperative rescue analgesia, were assessed. Technical feasibility with allocated PP was evaluated by means of successful completion of surgery, duration of surgery, and intraoperative complications. At T1 and T2, changes in hemodynamic and respiratory parameters were significantly higher in Group II. At T3, most of the parameters statistically restored back to baseline in Group I but not so in Group II. Required adjustments in ventilatory parameters were 14 vs. 25 times in Group I vs. Group II (p=0.007, R=0.552). Mean postoperative pain score, requirement for analgesia, and time to resume feeding were significantly greater in Group II. Surgeries were successfully completed in all the patients in both groups, with comparable duration of surgery and similar intraoperative complications (Table). It was found that hemodynamic and respiratory changes were more pronounced with higher pneumoperitoneal pressure in infants for renal laparoscopic surgery. With a PP of 6-8mmHg, intraoperative accessibility is optimal, and physiological changes are minimal. Interestingly, we found that infants with PP of 6-8mmHg enjoy smooth and early postoperative recovery. There was no direct objective criterion to assess level of difficulty with allocated PP, which may be considered a limitation of the present study. Pneumoperitoneal pressure of 6-8mmHg appears to be a safe and optimal range for transperitoneal laparoscopic renal surgery in infants.

Clinical analysis of pure laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus

Objective To assess the safety and feasibility of pure laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus. Methods We retrospectively analyzed 6 cases of renal cell carcinoma with inferior vena cava tumor thrombus from December 2010 to October 2014. The patients were all male.Their age ranged from 50 to 69 years and the body mass index ranged from 21.6 to 30.9 kg/m2. Clinical manifestations included painless hematuria in 4 cases, low back pain in 1 cases and physical examination noticing in 1 cases. Imaging suggested the right renal tumor in 4 cases and left renal tumor in 2 cases. The tumor size ranged from 4.0 to 10.6 cm.The inferior vena cava tumor thrombus was found in all patients, including type Ⅰ thrombus in 3 cases and type Ⅱ thrombus in 3 cases. The length of type Ⅱ tumor thrombus ranged from 4.0 to 4.2 cm. We completed pure laparoscopic nephrectomy and inferior vena cava tumor thrombectomy in all patients. We chose retroperitoneal laparoscopic surgery to treat right renal tumor with inferior vena cava thrombus and chose retroperitoneal combined with transperitoneal laparoscopic surgery to treat left renal tumor with inferior vena cava thrombus. Results All surgery were successful. Cancer embolus defluxion didn't occur during the opearation. The operation time was 224–873 min and the intraoperative blood loss was 200–5 000 ml. There were 4 patients get transfusion, which the transfusion volume ranged from 400 to 2 800 ml. For 1 case of left renal cell carcinoma with level Ⅱ inferior vena cava tumor, the operation time was 873 min, the blood loss was 5 000 ml, and the transfusion volume was 2 800 ml. Postoperative hospital stay was 7–14 days. And the pathological results were all renal clear cell carcinoma. In those patients, the Fuhrman grade classification was Ⅱ–Ⅲ. All patients were treated by targeted medicine to control tumor recurrence and metastasis. During the 6–48 months following up, no recurrence and metastasis were reported. Conclusions Pure laparoscopic surgery for right renal cell carcinoma with inferior vena cava tumor thrombus and left renal cell carcinoma with level Ⅰ inferior vena cava tumor thrombus is safe and feasible. However, long learning curve should be necessary for performing the left renal cell carcinoma with level Ⅱ inferior vena cava tumor thrombus. The effect of total laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus is definite. Key words: Carcinoma, renal cell; Inferior vena cava tumor thrombus; Laparoscopic surgery

548 Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intra-operative period: A prospective and randomized study

548 Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intra-operative period: A prospective and randomized study