Cestari_EU_Genito.qxp 7/8/07 12:42 pm Page 56
Urological Surgery
Figure 2: Trocar Placement for Right and Left
Results of Laparoscopic Transperitoneal Adrenalectomy
Transperitoneal Adrenalectomy
Guazzoni et al.
24
recently reviewed the results of a larger series of LA,
comparing the laparoscopic approach with the open approach and
Right
laparoscopic transperitoneal versus retroperitoneal adrenalectomy. Their
study states the superiority of the laparoscopic approach compared with
open adrenalectomy in terms of reduced blood loss, need for
transfusions, hospital stay and complication rate. Moreover, several
authors showed how LA is cost-effective compared with the open
approach. Compared with the retroperitoneoscopic approach,
transperitoneal adrenalectomy showed similar results in terms of
operating time and percentage of conversions and transfusions, while
retroperitoneoscopy was associated with reduced post-operative stay but
increased complication rates.
We recently reviewed our experience and cases.
25
In the period
between October 1992 and September 2006, 264 approaches to the
adrenal gland were performed at our institution employing the
transperitoneal route: 226 unilateral adrenalectomy, including 16 cases
of malignancy; 26 bilateral adrenalectomy; and 12 cases of
Left
conservative surgery (cysts enucleation). The mean operating time in
the three groups was 151 minutes in the unilateral group, 235 minutes
in the bilateral group and 79 minutes in the conservative group.
The laparoscopic procedure was converted into open surgery in five
cases (1.8%), mainly reflecting the learning curve of the procedure, and
delayed complications (3%) included three cases of hemoperitoneum
requiring surgery on post-operative day one, three cases of severe
blood loss treated conservatively (blood transfusion) and two cases of
wound infection, confirming the low complication rate of this well
codified surgical procedure.
Conclusions
LA should be considered the ‘platinum standard’ for the treatment of the
vast majority of adrenal diseases, including malignancy that is confined to
5 and 10 = 5 and 10mm trocar diameter, respectively.
the organ. The transperitoneal approach appears to be associated with
that may be difficult to secure. Once freed, the adrenal gland is extracted excellent results and reduced complication rates, although laparoscopist
intact in an organ-entrapped bag. The adrenal fossa is inspected carefully urologists should be confident with the retroperitoneoscopic approach as
for bleeding under reduced pneumoperitoneal pressure. When well in order to better decide the optimal approach in patients with
necessary, a drain is positioned and removed on first post-operative day. extended prior abdominal surgery. ■
1. Gagner M, Lacroix A, Bolte E, Laparoscopic adrenalectomy in patients outcome, Surgery, 2006;140:553–9. gland: the emerging role of laparoscopic surgery, Ann Surg
Cushing Syndrome and pheochromocytoma, NEJM, 1992;327: 9. Gill IS, The case for laparoscopic adrenalectomy, J Urol, Oncol, 2003;10:1191–6.
1033. 2001;166:429–36. 18. Sebag F, Calzolari F, Harding J, et al., Isolated adrenal
2. Guazzoni G, Montorsi F, Bocciardi A, et al., Transperitoneal 10. Fazeli-Matin S, Gill IS, Hsu THS, et al., Laparoscopic renal and metastasis: the role of laparoscopic surgery, World J Surg,
laparoscopic versus open adrenalectomy for benign hyper- adrenal surgery in obese patients: comparison to open surgery, 2006;30:888–92.
functioning adrenal tumors: a comparative study, J Urol, J Urol, 1999;162:655–69. 19. Lombardi CP, Raffaelli M, De Crea C, et al., Role of laparoscopy
1995;153:1597–1600. 11. Henry JF, Defechereux T, Gramatica L, et al., Should in the management of adrenal malignancies, J Surg Oncol,
3. Linos DA, Stylopoulos N, Boukis M, et al., Anterior, posterior or laparoscopic approach be proposed for large and/or potentially 2006;94:128–31.
laparoscopic approach for the management of adrenal diseases, malignant adrenal tumors?, Langensbeck Arch Surg, 1999;384: 20. Kim JH, Ng CS, Ramani AP, et al., Laparoscopic radical
Am J Surg, 1997;173:120–25. 366–9. adrenalectomy with adrenal vein tumor thrombectomy:
4. Winfield HN, Hamilton BD, Bravo EL, et al., Laparoscopic 12. Kazaryan AM, Mala T, Edwin B, Does tumor size influence the tecnical considerations, J Urol, 2004;171:1223–6.
adrenalectomy: the preferred choice? A comparison to open outcome of laparoscopic adrenalectomy?, J Laparendosc Adv 21. Filipponi S, Guerrieri M, Arnaldi G, et al., Laparoscopic
adrenalectomy, J Urol, 1998;60:325–9. Surg Tech A, 2001;11:1–4. adrenalectomy: a report on 50 operations, Eur J Endocrinol,
5. Janetschek G, Altarac S, Finkenstedt G, et al., Technique and 13. Misseri R, Adrenal surgery in pediatric population, Curr Urol 1998;138:548–53.
results of laparoscopic adrenalectomy, Eur Urol, 1996;30: Rep, 2007;8:89–94. 22. Gagner M, Laparoscopic adrenalectomy, Surg Clin North Am,
475–9. 14. Kamada P, Habib Z, Rossi L, Experience with laparoscopic 1996;76:523–37.
6. Kim HH, Kim GH, Sung GT, Laparoscopic adrenalectomy for adrenalectomy in children, J Pediatr Surg, 2004;39:764–76. 23. Basso N, De Leo A, Fantini A, et al., Laparoscopic direct
pheochromocytoma: comparison with conventional open 15. Elashry OM, Clayman RV, Soble JJ, et al., Laparoscopic supragastric left adrenalectomy, Am J Surg, 1999;178:308–10.
adrenalectomy, J Endourol, 2004;18:251–5. adrenalectomy for solitary metachronous controlateral 24. Guazzoni G, Cestari A, Montorsi F, et al., Laparoscopic
7. Flavio Rocha M, Faramarzi-Roques R, Tauzin-Fin P, et al., metastasis from renal cell carcinoma, J Urol, 1997;157: treatment of adrenal diseases: 10 years on, BJU Int, 2004;93:
Laparoscopic surgery for pheochromocytoma, Eur Urol, 1217–22. 221–7.
2004;45:226–32. 16. Sturgeon C, Kebebew E, Laparoscopic adrenalectomy for 25. Cestari A, Buffi N, Centemero A, et al., Transperitoneal
8. Wilhelm SM, Prinz RA, Barbu AM, et al., Analysis of large malignancy, Surg Clin North Am, 2004;84:755–74. laparoscopic adrenalectomy: the choice, Eur Urol, 2007;
versus small pheochromocytomas: operative approaches and 17. Sarela AI, Murphy I, Coit DG, et al., Metastasis to the adrenal 6:90(P15).
56 EUROPEAN GENITO-URINARY DISEASE 2007
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