Laparoscopic trans- and retroperitoneal adrenal surgery for large tumors

Abstract

BACKGROUND:Laparoscopic adrenalectomy for tumors larger than 6 cm is currently a matter of controversial discussion because of difficult mobilization from surrounding organs and a possible risk of capsule rupture.MATERIALS AND METHODS:Data of consecutive patients undergoing laparoscopic adrenalectomy between 1/1994 and 7/2012 were collected and analysed retrospectively. Intra- and postoperative morbidity in patients with tumors ≤6 cm (group 1, n = 227) were compared to patients with tumors >6 cm, (group 2, n = 52).RESULTS:Incidence of adrenocortical carcinoma was significantly higher in group 2 patients (6.3% vs. 0.4%, P = 0.039) whereas the incidence of aldosterone-producing adenoma was lower (2% vs. 25%, P = 0.001). Mean duration of surgery was longer (105 min vs. 88 min, P = 0.03) and the estimated blood loss was higher (470 mL vs. 150 mL) in group 2 patients. Intraoperative bleeding rate (5.7% vs. 0.8%, P = 0.041), and the conversion rate were significantly higher (5.7% vs. 1.3%, P = 0.011) in group 2. Also, postoperative complication rate was significantly higher in group 2 (11.5% vs. 3.0%, P = 0.022). However, only two major complications occurred, one in each group.CONCLUSION:Minimally invasive adrenal surgery can be performed by an experienced surgeon even in patients with large tumors (>6 cm) with an increased but still acceptable intra- and postoperative morbidity.

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors

“…Some authors consider a diameter of ≥6 cm a relative contraindication to laparoscopic adrenalectomy [3,4]. On the other hand, there are recent publications where authors report the feasibility of laparoscopic adrenalectomy of large tumors [15,16,17,18,19,20]. …”

“…Moreover, there are reports of high rate of intraoperative complications [14]. However, tumor size as a limitation for laparoscopic adrenalectomy is questioned by some authors [15,16,17,18,19,20]. …”

Retroperitoneal laparoscopic adrenalectomy with transient renal artery occlusion for large adrenal tumors (≥8 cm)

“…Furthermore, there is a possibility of safely performing the operation in patients who have undergone multiple previous abdominal surgeries and achieving a more favorable postoperative course . However, RLA may pose serious additional technical difficulties, such as a smaller working space, poor surgical landmarks, a steeper learning curve, and discomfort when working with tumors larger than 8 cm . As the size of the adrenal tumor increases, the surrounding anatomy is disturbed; the tumor tends to exhibit local invasion with intense adhesions to periadrenal structures, the vessels in the tumor vicinity become more dilated, and there is a greater number of intraoperative hemodynamic events in pheochromocytomas .…”

“…12 However, RLA may pose serious additional technical difficulties, such as a smaller working space, poor surgical landmarks, a steeper learning curve, and discomfort when working with tumors larger than 8 cm. 13,14 As the size of the adrenal tumor increases, the surrounding anatomy is disturbed; the tumor tends to exhibit local invasion with intense adhesions to periadrenal structures, the vessels in the tumor vicinity become more dilated, and there is a greater number of intraoperative hemodynamic events in pheochromocytomas. 15,16 Therefore, adrenal masses >8 cm are technically more difficult to remove, because the tumor limits manipulation with devices and obstructs the operative field.…”

Risk factors for possible complications in laparoscopic adrenal surgery

“…Однако, по данным A. Agha и соавт. [27], часто-та возникновения осложнений при крупных опу-холях возрастает (11,5% против 3%; p=0,022). При этом здесь следует отметить, что авторы использо-вали в своей работе не только трансабдоминальный, но и ретроперитонеальный доступ.…”