Modified versus three-level technique of retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm: a retrospective, case-controlled study

Abstract

Objectives: The modified three-level technique for retroperitoneal laparoscopic adrenalectomy (RLA) has proven beneficial in the treatment of adrenal lesions in patients with BMI≥25 Kg/m². This paper aims to summarize our institution's seven-year experience using this technique for all patients with Adrenal Lesions ≤ 6cm.

Patients and methods: Between January 2016 and December 2022. The patients underwent laparoscopic adrenal surgery were categorized into Zhang's technique (ZT) (Three-level Technique) group and modified technique (MT) group. The fundamental characteristics and perioperative data were analyzed, with statistical significance set at p<0.05.

Results: In total, 731 patients were stratified into two groups: ZT (n=448) and MT (n=283). Statistically significant distinctions were not detected between the two groups regarding sex, BMI, tumor location, tumor size, tumor type, or American Society of Anesthesiologists (ASA) score (p>0.05). The MT group demonstrated superior outcomes compared to the ZT group in terms of operative time, estimated blood loss, drainage volume, diet recovery time, complication rates, and postoperative hospitalization duration (p<0.05). 17 (4.34%) in the ZT group required unplanned adrenalectomy, while there was none in MT group (P<0.05).

Conclusion: MT retroperitoneal laparoscopic adrenalectomy has demonstrated its benefits in the treatment of adrenal lesions across all patients with adrenal lesions ≤ 6cm, serving as a valuable point of reference for the surgical management of adrenal diseases.

Patient summary: We have made modifications to the classic retroperitoneal laparoscopic adrenalectomy and achieved superior surgical outcomes, resulting in a procedure known as modified retroperitoneal laparoscopic adrenalectomy. This technique is suitable for both obese individuals and the general population with adrenal lesions ≤ 6cm.

Keywords: adrenal gland; adrenal lesions; adrenalectomy; minimally invasive surgery; modified technique; retroperitoneal laparoscopy.

Figure 1

The flow-chart of a retrospective, case-control study on retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm.

Figure 2

Surgical video still and surgical video. (A) The first separation level, the relatively avascular space between the Perirenal fat (PF) and the anterior Gerota’s fascia (AGF). (B) The second separation level, the relatively avascular space was between the dorsal side of PF and the psoas muscle (PM). (C) The modified third separation level, here latively avascular space bet we endorsalside of the adrenal gland (AG) and PF. After reaching the adrenal gland, the adrenal gland and the adenoma were exposed along the edge of the AG. Upper pole of the kidney (UPK).The video of Modified Three-Level Technique of Retroperitoneal Laparoscopic Partial Adrenalectomy was published by Chinese Journal of Endourology (Electronic Edition). (D) The video of Modified Three-Level Technique of Retroperitoneal Laparoscopic Partial Adrenalectomy was published by Chinese Journal of Endourology (Electronic Edition).

Figure 3

The schematic diagram of modified and three-level technique of retroperitoneal laparoscopic adrenalectomy. The modified third separation level, between dorsal side of the adrenal gland (AG) and PF. The dashed line indicates the direction of separation for the third layer of ZT. The auxiliary hand could then pull the peri-renal fat outwards and downwards to create a large enough operation space at the upper pole of the kidney. To eliminate interference from the PF and expose the AG and adenoma better, compared with ZT.