Minimally invasive adrenalectomy: a multicenter comparison of transperitoneal and retroperitoneal approaches.

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.

[Minimally invasive adrenalectomy: transperitoneal vs. retroperitoneal approach]. / Surrenalectomia mininvasiva: confonto tra approccio transperitoneale e retroperitoneale.

Laparoscopic adrenalectomy is now regarded as the procedure of choice for most adrenal glands presenting surgical pathology. The primary adrenal-specific contraindication to laparoscopic adrenalectomy today is the presence of a large adrenal mass with evidence of local infiltration or venous invasion. We used our multicentre experience to compare the transperitoneal (TLA) and retroperitoneal (RLA) minimally invasive approaches. In our study we found statistically significant differences between RLA and TLA in terms of duration of surgery (148 minuti vs. 112; p < 0.005), intra-operative blood loss (439 cc vs 333 p < 0.005; p < 0.005) and time of first oral intake (1.2 +/- 0.5 days vs 1.8 +/- 1.08 days; p < 0.005). The RLA approach is preferable in cases of previous abdominal surgery, but its learning curve is extremely steep. TLA access needs a less demanding learning curve and tends to be faster than RLA, where the working area is penalised by limited manoeuvring space. There is no clear preference between TLA and RLA in the literature. However, the experience of the surgeon still remains the most important variable when choosing between the two approaches.

Improved device for sutureless aortic anastomosis applied in a case of cancer.

To reduce the time needed for clamping or circulatory arrest (or both) during substitution of a prosthesis for the thoracic aorta, we developed an expandable device that can be used with any commercially available prosthetic graft to enable sutureless aortic anastomosis. Improvements upon a previous version of the device include the use of nickel-titanium alloy (Nitinol) instead of stainless steel. This, together with an improved wire-looping design, now enables continuous control of diameter, even when the device is in contact with blood. A further improvement consists of 4 metallic hooks on the outer surface, which enable firm fixation to the aortic stump. In March 2001, a 47-year-old man was admitted to our institution for evaluation of left upper-lobe bronchogenic adenocarcinoma that had infiltrated the distal aortic arch and upper descending aorta. Re-staging of the neoplasm ruled out distant metastasis. We resected the infiltrated aortic wall en bloc with the upper lobe. The expandable device enabled the distal anastomosis of the aortic prosthesis to be performed easily, in less than 3 minutes. The main advantages of this device are an easier, quicker anastomosis and the absolute prevention of suture-line hemorrhage (no suture line). The expandable device overcomes the drawbacks of the intraluminal ringed prosthesis used in the past.