Page 31 - Journal of Laparoscopic Surgery

WJOLS

A decade of Laparoscopic Adrenalectomy
rate and adenomas a 10%. Chi-squared analyses showed supports the growing body of evidence stating that a
there was no relationship between complications and large tumor size is not an absolute contraindication to
5-8
size of a tumor, nor pathology of a tumor. Four cases laparoscopy.
(~4%) were partial adrenalectomies, of which one was an Quite a large number (40%) of cases were incidentalomas,
incidentaloma. Complication rates were exactly equal for demonstrating how increasing usage of broader imaging
cases in the public or private hospital. 6% of cases predicted modalities (such as high-resolution CT) have changed
28
a pathology which was different on the final pathology. the caseload for adrenalectomies. There was also no
significant difference in complication rate for different
DISCUSSION tumor pathologies, which would indicate that it is safe to
Published complication rates range from 7.5–12%, 20-22 so a use the laparoscopic approach for metastatic tumor deposits
complication rate of 8% is comparable to the lower end of and pheochromocytomas. Interestingly there was one case
this range. It is also interesting to note that there was no of high blood pressure and heart rate when operating on
difference between public and private complication rates. a pheochromocytoma, demonstrating that despite the
Looking at the data for the operative time it is clear laparoscopic approach being the most appropriate 14,29 the
that as the number of cases performed by surgeons in risk of an androgenic crisis must be mitigated. 14,15 There were
this area increased, there was a decrease in operative also a small number of tumors where the final pathology
time, particularly after 2008. Other procedures have did not match the expected pathology, mostly where
been analyzed to look at the learning curve, including asymptomatic tumors were predicted to be adenomas and
23
laparoscopic cholecystectomy, laparoscopic colorectal had different characteristics after microscopic pathological
25
24
surgery, laparoscopic inguinal hernia repair and examination (e.g., ganglioneuroma, pheochromocytoma,
26
laparoscopic fundoplication. These studies all measured metastatic deposit).
operative time and complication rate to determine a There were only a small number of partial adrena-
learning curve expressed as a number of cases before lectomies in this study, and they were not predominantly
stabilization of these two variables. As an exercise, used for incidentalomas. While Kaye, Storey 19 strongly
measuring the learning curve of a procedure is support increased use of partial adrenalectomy for small
potentially useful for training purposes, but also is useful tumors, it has not become common practice in most places,
from a health economics perspective as operating theatre as demonstrated by the small number of cases in this study.
27
costs are likely higher during the learning phase. In While there is an increasing number of studies supporting
this study, half of the complications documented were the use of partial adrenalectomy as it retains functional
within the first three years of adrenalectomy, before the adrenal tissue 30-33 there are still instances where it is seen
34
significant decrease in surgeon time. Therefore, it would to be less effective which may explain why it remains a
seem that the complications and operative time stabilized less common procedure.
after 2008. Because the number of cases each surgeon
performed per year was not recorded, we cannot express CONCLUSION AND CLINICAL SIGNIFICANCE
this as a number of cases. However, the same surgeons Overall, the results of this study add to the current body
were operating for the whole decade and so we can say of research demonstrating that the laparoscopic approach
that there was a demonstrable learning curve. to adrenalectomy is safe and effective in a variety of
The data in Table 2 shows the complication rate for tumor sizes and pathologies. It also neatly demonstrates
each size group of a tumor. As there was no significant diminishing operative time as surgeon experience
difference in complication rates between the three increased over a decade, demonstrating a considerable
categories of tumor size it supports the idea that both small learning curve in performing this procedure. While there
and large tumors can be approached laparoscopically. are now moves towards retroperitoneal and other novel
Despite early concerns about the feasibility and safety of approaches, it is useful to evaluate the usefulness of the
approaching large tumors laparoscopically, our findings standard laparoscopic approach now that it is possible to
are backed up by a number of more recent papers and
look at data over longer periods of time.

Table 2: Tumor size and complications
Complication REFERENCES
Number of Number of rate for size 1. Guazzoni G, Montorsi F, Bocciardi A, Da Pozzo L, Rigatti P,
Tumour size cases complications group (%) Lanzi R, et al. Transperitoneal Laparoscopic Versus Open
< 4 cm 32 4 13 Adrenalectomy for Benign Hyperfunctioning Adrenal
4–6 cm 25 1 4 Tumors: A Comparative Study. The Journal of Urology. 1994
> 6 cm 29 3 10 May;153(5):1597-1600.
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