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The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique.

Introduction Laryngeal ultrasound has been increasingly used for the evaluation of the vocal cords mobility after thyroid and parathyroid surgery. The sensitivity and positive predictive value of the method are reported to be higher than 80%. Nevertheless, the visualization rate in male patients remains low; therefore, ultrasound is not attractive for the perioperative workup in those patients. In the present study, we evaluate the ability to improve the visualization rate for male patients by using a gel pad as an interface between the skin and the ultrasound probe. Methods and Materials Between December 2018 and January 2019, 92 male patients (mean age 49 years; range: 20-80 years) referred to our hospital with different thyroid pathologies received a laryngeal ultrasound without (TLUS) and subsequently with gel pad (G-TLUS). TLUS was performed by B-scan (probe 5-13 MHz, aperture 40 mm). The data were prospectively collected and statistically analyzed. ResultsThe visualization rate in the TLUS group was 35% (32 out of 92 patients). The use of the gel pad could increase the rate to 78% (p \ 0.0001). For both groups, visualization rates are lower in older patients ([ 50 years) compared to younger individuals (TLUS: 25% vs. 45%, p \ 0.05; G-TLUS: 75% vs 82%, p = 0.45). ConclusionThe gel pad significantly improves the vocal cord visualization rate in male patients and should be used routinely.

This Simplified Hernia Repair is safe and avoids additional foreign body implantation. Therefore, it is our method of choice for recurrent inguinal hernias after TEP.

Dear Sir, With great interest we read the comments of Dr. Balta and coauthors on our paper "A simplified surgical technique for recurrent inguinal hernia repair following total extraperitoneal patch plastic" and are thankful for their hints for improvement.In 31 of 35 cases the initial TEP procedure was performed by us. Twenty of these 31 patients had lateral, 11 medial inguinal hernias. For TEP we place three ports in the midline. A 10-mm port was inserted through a subumbilical incision and used for the camera (10 mm-30°-endoscope). CO 2 was inflated with a pressure of 12 mmHg. The working space was created by blunt dissection using the tip of the camera; a dilating balloon was not used. The two working trocars were inserted about 5 cm above the pubic bone (10 mm port) and a 5-mm port between the two initial incisions. In medial hernias the sac was pushed cranially; in lateral hernias it was dissected from the spermatic cord. We always (since 2003) used the same type of non-resorbable heavyweight mesh (Parietex, Medtronic ® ). The mesh was not fixed. A suction drainage was used in all cases and removed on the first postoperative day.The majority (72%) of the recurrent hernias were lateral causing an abdominal wall weakness almost always at the lower edge of the implanted mesh. In these cases the hernia sac was resected (not in medial hernias) as in conventional open hernioplasty. Of course, we could not identify the reasons for recurrence in our series. Shrinkage-as commented by Dr. Balta-seems to be an option. Early dislocation may be another reason. Nevertheless, recurrence after TEP is rare and was just 2% compared to our primary cases.In the first cases of our new simplified method, we planned a Shouldice operation or a Lichtenstein procedure. We were surprised that we could identify the lower edge of the mesh and could fixate it to the inguinal ligament closing a defect of 1-2 cm. This is indeed "simplified" compared to previously mentioned alternative techniques. We strongly recommend the use of that new surgical technique in recurrent inguinal hernias after TEP as it combines the advantages of the anterior and the posterior approach. We could successfully use this method in 35 of 54 cases (65%). The latter information was deleted during the review process.In addition, from our point of view, TEP is not a laparoscopic but an extraperitoneal technique. "Laparoscopy" per se means taking a look into the abdominal cavity. That should not happen in TEP.

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Background Pheochromocytomatosis is a rare but dramatic complication of pheochromocytoma surgery. In this study, we collected and analysed our experience with the surgical treatment of cases of this rare condition. Methods In total 9 patients were operated on between December 2001 and August 2022 at the Kliniken Essen-Mitte due to pheochromocytomatosis. There were 5 female and 4 male patients, mean age of 58 ± 18 (range: 22 to 86). The data was prospectively collected and retrospectively analysed. Results All patients were initially operated on due to pheochromocytoma (2 with SDHB-Syndrome and 1 with MEN-IIa-Syndrome). In 4 cases an intraoperative tumour capsule injury during the initial surgery was described. The operation due to pheochromocytomatosis was performed minimally invasive in 8 cases, 1 patient was operated on by open approach. The mean time between the primary surgery and the pheochromocytomatosis operation was 107 ± 60 months. Operation time was 246 + 119 minutes. Follow-up data were available for 8 patients (mean follow-up time 12 years). 2 patients were cured at the time of the last follow-up. 7 patients developed recurrent disease: loco-regional recurrence in 6 cases and distant metastasis in 3 cases. 4 patients with loco-regional recurrence were reoperated within 54 ± 50 months (range 10–137 months). By the follow-up, 3 patients died. Conclusion Pheochromocytomatosis is a potentially lethal complication of pheochromocytoma surgery. Even if the initial pheochomocytomatosis could be managed minimally invasive, the recurrence rate is extremely high.