Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

Abstract

Background: Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure.

Methods: Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence.

Results: The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p=0.64), postoperative hospital stay (6 vs 6 days; p=0.67), and postoperative complications (2 vs 3 patients; p=1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p=0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p=0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p=0.03).

Conclusions: The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.

Fig. 1

Incision and port sites for the standard procedure and the laparoendoscopic single-site (LESS) procedure. A Schematic representation of port placement for LESS and standard retroperitoneoscopic adrenalectomies. Ports 1, 2, and 3 were used for standard retroperitoneoscopic adrenalectomy. For the standard procedure, 1 is a 5-mm port below the 12th rib in the posterior axillary line, 2 is a 12-mm port under the subcostal margin in the anterior axillary line, and 3 is a 10-mm port above the iliac crest in the midaxillary line for the laparoscope. The site indicated by 4 is a 2.5- to 3-cm transverse skin incision made below the lower margin of the 12th rib in the midaxillary line for the Triport used in the LESS procedure. B Actual Triport placement for a right LESS retroperitoneoscopic adrenalectomy

Fig. 2

Internal views of the laparoendoscopic single-site retroperitoneoscopic adrenalectomy (LESS-ARA) procedure. A Gerota’s fascia is incised longitudinally along the posterior peritoneal reflection (white arrows) .B The adrenal tumor (AT) is identified in the first dissection plane between the perirenal fat and the anterior Gerota’s fascia (GF) located at the superomedial side of the upper kidney pole (UKP). C By grasping the periadrenal fat cephalad, the bottom of the adrenal gland or tumor is separated from the parenchymal surface of the upper kidney pole, after which the third dissection plane is developed. D The upper adrenal arteries (UAA) are transected