Modified three-level techniques of retroperitoneal laparoscopic procedures to treat adrenal lesions for patients with BMI ≥ 25 Kg/m2

Abstract

Objective: To evaluate the modified Zhang's 'three-level' technique of retroperitoneal laparoscopic adrenalectomy (RLA) to treat adrenal lesions for patients with BMI of 25-30 Kg/m². Methods: A retrospective analysis was performed in all patients with BMI of 25-30 Kg/m² in our hospital from January 2014 to December 2019. Those who underwent laparoscopic adrenal surgery were divided into two groups on the basis of the technique used: the Zhang's technique (the ZT group) and the modified technique (the MT group). Results: Herein, 170 operations were included (ZT, 91 patients; MT, 79 patients). RLA was successfully performed in all of them. Compared with the ZT group patients, the MT group patients showed shorter operation time (p = 0.007), lesser intraoperative blood loss (p = 0.023), shorter operation time, earlier postoperative diet recovery (p < 0.001), shorter postoperative drainage time (p < 0.001) and shorter postoperative hospitalization period (p = 0.001). It was also worth noting that the unplanned total adrenalectomy rate was significantly less in the MT group than in the ZT group (0% vs. 10.8%, p = 0.020). There was no significant difference in the complications between the two groups (3.3% vs. 2.5%, p = 0.567). Conclusions: We found that MT was a beneficial retroperitoneal laparoscopic treatment for adrenal lesions in patients who had a BMI of 25-30 Kg/m². It may provide a reference for the treatment of adrenal surgical diseases in such patients.

Keywords: BMI; adrenal gland; fat; retroperitoneal laparoscopy.

Figure 1

Surgical approach of 'three-level' and modified 'three-level' methods. (A) The first level: between anterior Gerota's fascia (AGF) and perinephric fat (PF) that located at the superomedial side of the kidney. (B) The second level: between lateral perinephric fat (PF) and psoas muscle (PM). (C) The third level (shown by the arrow): between the bottom of adrenal tumour (AT) and upper pole of the kidney (UPK). (D) When adherent or large perinephric fat (PF) exists, the third level is not easy to obtain and the adrenal tumour is not easy to access. (E) The modified third level: pull the perinephric fat (PF) away, and the adrenal tumour (AT) is visible clearly. (F) A diagram of the modified 'three-level' approach. The green area is the redundant perinephric fat (PF) in this technique. This fat can be used as a pull position to give enough operation view to discover the adrenal tumour (AT).