A novel method of tunneling retroperitoneoscopic adrenalectomy: a prospective study

Abstract

Background: To introduce the surgical technique and our team's extensive experience with tunnel method in laparoscopic adrenalectomy.

Methods: From July 2019 to June 2022, we independently designed and conducted 83 cases of " Tunnel Method Laparoscopic Adrenalectomy," a prospective study. There were 45 male and 38 female patients, ages ranged from 25 to 73 years(mean: 44.6 years).The cases included 59 adrenal cortical adenomas, 9 pheochromocytomas, 6 cysts, 4 myelolipomas, 1 ganglioneuroma, and 4 cases of adrenal cortical hyperplasia. In terms of anatomical location, there were 39 cases on the left side, 42 on the right side, and 2 bilateral cases. Tumor diameters ranged from 0.6 to 5.9 cm(mean: 2.9 cm). Utilizing ultrasound monitoring, percutaneous puncture was made either directly to the target organ or its vicinity, and the puncture path was manually marked. Then, under the direct view of a single-port single-channel laparoscope, the path to the target organ in the retroperitoneum or its vicinity was further delineated and separated. This approach allowed for the insertion of the laparoscope and surgical instruments through the affected adrenal gland, thereby separating the surface of the target organ to create sufficient operational space for the adrenalectomy.

Results: All 83 surgeries were successfully completed. A breakdown of the surgical approach reveals that 51 surgeries were done using one puncture hole, 25 with two puncture holes, and 7 with three puncture holes. The operation time ranged from 31 to 105 min (mean: 47 min), with a blood loss of 10 to 220mL (mean: 40 mL). Notably, there were no conversions to open surgery and no intraoperative complications. Postoperative follow-up ranged from 6 to 28 months, during which after re-examination using ultrasound, CT, and other imaging methods, there were no recurrences or other complications detected.

Conclusions: The completion of the tunnel method laparoscopic adrenalectomy represents a breakthrough, transitioning from the traditional step-by-step separation of retroperitoneal tissues to reach the target organ in conventional retroperitoneoscopic surgery. This method directly accesses the target organ, substantially reducing the damage and complications associated with tissue separation in retroperitoneoscopic surgery, As a result, it provides a new option for minimally invasive surgery of retroperitoneal organs and introduces innovative concepts to retroperitoneoscopic surgery.

Keywords: Adrenalectomy; Retroperitoneoscopic surgery; Tunneling.

Fig. 1

Injection of methylene blue solution for localization (A); Insertion of a 0° lateral-view laparoscope (B)

Fig. 2

Insertion of the sheath by the closed method (A); Fatty tissue connected by semi-transparent connective tissue. Under direct vision, the methylene blue marking was located (B)

Fig. 3

Dissect along the methylene blue markings to the Gerota’s fascia and create a small opening (A). Continue the dissection to form a tunnel (B) leading to the adrenal tumor (C) or to the surface of the upper pole of the kidney (D)

Fig. 4

Pull out one end of the specimen bag through the incision (A), and extract the specimen (B)

Fig. 5

Make a transverse incision of 1.2 cm at the posterior axillary line beneath the twelfth rib (Point A). The puncture hole is located approximately 5 cm medial to Point A, 1–3 cm beneath the twelfth rib (Point B), along the midaxillary line below the rib margin (Point C)