Laparoscopic transperitoneal adrenalectomy in the large adrenal tumor from single center experience

Abstract

Background The role of laparoscopic adrenalectomy (LA) in a large adrenal tumor is controversial due to the risk of malignancy and technical difficulty. In this study, we compared the perioperative outcomes and complications of LA on large (≥ 6 cm) and (< 6 cm) adrenal tumors. Methods We retrospectively reviewed all clinical data of patients who underwent unilateral transperitoneal LA in our institution between April 2000 and June 2019. Patients were classified by tumor size into 2 groups. Patients in group 1 had tumor size < 6 cm (n = 408) and patient in group 2 had tumor size ≥ 6 cm (n = 48). Demographic data, perioperative outcomes, complications, and pathologic reports were compared between groups. Results Patients in group 2 were significant older (p = 0.04), thinner (p = 0.001) and had lower incident of hypertension (p = 0.001), with a significantly higher median operative time (75 vs 120 min), estimated blood loss (20 vs 100 ml), transfusion rate (0 vs 20.8%), conversion rate (0.25 vs 14.6%) and length of postoperative stays ( 4 vs 5.5 days) than in group 2 (all p < 0.001). Group 2 patients also had significantly higher frequency of intraoperative complication (4.7 vs 31.3%; adjust Odds Ratio [OR] = 9.67 (95% CI 4.22–22.17), p-value < 0.001) and postoperative complication (5.4 vs 31.3%; adjust OR = 5.67 (95% CI 2.48–12.97), p-value < 0.001). Only eight (1.8%) major complications occurred in this study. The most common pathology in group 2 patient was pheochromocytoma and metastasis. Conclusions Laparoscopic transperitoneal adrenalectomy in large adrenal tumor ≥ 6 cm is feasible but associated with significantly worse intraoperative complications, postoperative complications, and recovery. However, most of the complications were minor and could be managed conservatively. Careful patient selection with the expert surgeon in adrenal surgery is the key factor for successful laparoscopic surgery in a large adrenal tumor. Trial registration: This study was retrospectively registered in the Thai Clinical Trials Registry on 02/03/2020. The registration number was TCTR20200312004.

Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes

“…All adenomas treated by PRA were ≤ 6.2 cm, supporting the recommendation for a 6 cm limit. 6,10,13,14,21,22 Once PRA became the dominant technique, TPA was typically reserved for benign tumours > 6 cm, which accounts for the median tumour size increasing in Cohort 2.…”

“…This contradicts studies reporting 0% incidence following PRA 13,15,20 and occurring after TPA only (0.4%-1.5%). 1,6,15,20 Deep vein thromboses were located in basilic or soleal veins, with the former event leading to a newly discovered thrombophilia mutation. Both minimally invasive approaches had a small rate of incisional hernias, echoing other studies.…”

“…Both minimally invasive approaches had a small rate of incisional hernias, echoing other studies. 6,10,13,18 Key advantages of this study were its 17-year duration, large cohort size, and location in a high-volume centre, therefore providing an additional Australian perspective to existing small-sized studies on phaeochromocytomas. 11,14,22,23 Despite phaeochromocytoma being a rare malignancy, it represented the second most frequent indication with a rising number in Cohort 2, which could reflect an increase in pathology or referral bias.…”

“…3,4 Initially, minimally invasive techniques were only performed for ≤ 6 cm, benign adrenal masses, 5 but as experience improved, laparoscopic adrenalectomy became feasible for larger tumours and isolated adrenal metastases. 4,6 Over the last two decades, PRA has been increasingly utilized. 4,5 PRA may offer reduced blood loss, post-operative pain, and hospital stay, and earlier ambulation compared to TPA.…”

“…Since the early 1990s, TPA has been the preferred approach for benign adrenal tumours 3,4 . Initially, minimally invasive techniques were only performed for ≤ 6 cm, benign adrenal masses, 5 but as experience improved, laparoscopic adrenalectomy became feasible for larger tumours and isolated adrenal metastases 4,6 . Over the last two decades, PRA has been increasingly utilized 4,5 .…”