Elsevier

Surgery

Volume 146, Issue 4, October 2009, Pages 621-626
Surgery

Central Surgical Association
Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy

https://doi.org/10.1016/j.surg.2009.06.057Get rights and content

Background

For the past 14 years, we have been performing laparoscopic adrenalectomy via the lateral transabdominal as well as the posterior retroperitoneal approach. The aim of this study is to describe patient selection criteria for each approach with comparison of perioperative outcomes.

Methods

In patients with smaller tumors, low body mass index (BMI), history of previous abdominal operations, appropriate body habitus, and bilateral pathology, we have performed preferentially the posterior approach. Data regarding clinical pathology, tumor size, BMI, estimated blood loss (EBL), operating time (OT), morbidity, mortality, and duration of stay were analyzed retrospectively. Data are expressed as mean ± standard error of the mean (SEM).

Results

One hundred seventy-two laparoscopic adrenalectomy procedures were performed in 159 patients between 1994 and 2008. The lateral approach was used in 69 patients (right side: 39%, left side: 55%, bilateral: 6%) and the posterior approach in 90 patients (right side: 42%, left side: 48%, bilateral: 10%). The incidence of prior abdominal surgery was greater in the posterior group (26% vs 19%, NS). The lateral approach was used in 9% (3/34) of aldosteronoma, 38% (9/24) of Cushing's disease/syndrome, 47% (18/38) of nonsecreting cortical adenoma, 66% (23/35) of pheochromocytoma, 41% (7/17) of malignant lesions, and 73% (8/11) of others. Thirty percent of the bilateral adrenalectomies were performed via lateral and 70% via posterior approach. Two patients in the posterior approach were converted to the laparoscopic lateral approach, and 2 patients in the lateral approach were converted to open. Overall, patient age and sex were similar between groups. BMI was higher in patients undergoing adrenalectomy via lateral vs posterior approach (32.4 vs 28.4; P = .005). Tumor size was larger than 6 cm in 11 (16%) and 1 (1%) of the patients in the lateral and posterior groups, respectively. On univariate analysis, mean OT for lateral and posterior approaches was similar for unilateral cases (157 ± 7 vs 138 ± 6 min, respectively; P = NS). This was also true on multivariate analysis when corrected for patient selection factors. EBL was 35 ± 7 mL for lateral versus 25 ± 6 mL for posterior approach (P = .05). The duration of stay in lateral and posterior approaches was 1 day in 56% vs 82%, 2 days in 29% vs 13%, and more than 2 days in 15% vs 5% of the patients, respectively. Two patients in the lateral group died postoperatively because of cardiac and pulmonary causes, and 2 patients in the posterior group developed temporary neuralgia.

Conclusion

This series compares 2 different approaches for laparoscopic adrenalectomy. Our study shows that the lateral and posterior techniques have a similar peri-operative outcome when patients are selected for each option based on certain criteria.

Section snippets

Methods

We reviewed the records of all patients undergoing laparoscopic adrenalectomy at the Cleveland Clinic, Section of Endocrine Surgery, from 1994 to 2008. Data were extracted from an Institutional Review Board-approved database. We reviewed the preoperative data with respect to patient selection. Data extracted included patient age, sex, body mass index (BMI), operative history, tumor size, side of disease, bilateral versus unilateral involvement, characteristics on computed tomography, and

Results

During the last 14 years (1994–2008), 172 laparoscopic adrenalectomies were performed in 159 patients. Of these procedures, the PR approach was used in 90 patients and the LT approach in 69. Patient and disease characteristics are shown in Table I. Age and sex distribution were not significantly different between the 2 groups. BMI was greater in the LT group (32.4 vs 28.4; P = .005).

Side of the diseased gland was similarly distributed among the 2 groups. The incidence of previous abdominal

Discussion

One year after the LT adrenalectomy was reported, Mercan et al2 described the technique performing the procedure via an PR approach using a balloon dissector to create a potential space. Our group reported subsequently a modification of the Mercan technique with the addition of percutaneous and laparoscopic intraoperative ultrasound.3 Subsequently, Walz et al6 described using greater insufflation pressures to maintain the operative fields without disturbing hemodynamic stability.

With this large

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