Surgical technique
Transperitoneal laparoscopic adrenalectomy
Suprarrenalectomía laparoscópica transperitoneal
J.A. Virseda, R. Ruiz-Mondéjar, M.J. Donate, P. Carrión
, J. Martínez-Ruiz, C. Martínez-Sanchiz, M. Perán, H. Pastor
Corresponding author
Servicio Urología, Complejo Hospitalario Universitario de Albacete, Spain
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Virseda, R. Ruiz-Mondéjar, M.J. Donate, P. Carrión, J. Martínez-Ruiz, C. Martínez-Sanchiz, M. Perán, H. Pastor" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J.A." "apellidos" => "Virseda" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Ruiz-Mondéjar" ] 2 => array:2 [ "nombre" => "M.J." "apellidos" => "Donate" ] 3 => array:4 [ "nombre" => "P." "apellidos" => "Carrión" "email" => array:1 [ 0 => "pedrocarrion1980@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Martínez-Ruiz" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Martínez-Sanchiz" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Perán" ] 7 => array:2 [ "nombre" => "H." "apellidos" => "Pastor" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio Urología, Complejo Hospitalario Universitario de Albacete, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Suprarrenalectomía laparoscópica transperitoneal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1107 "Ancho" => 2070 "Tamanyo" => 102202 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Annual surgeries.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urology has always been a pioneer, along with other surgical disciplines, in the application of minimally invasive approaches to surgery. There is no organ in the genitourinary system on which minimally invasive surgery has had no impact.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The approach of the adrenal gland laparoscopically was implanted quickly after Gagner, in 1992, communicated the first laparoscopic experience in the removal of the adrenal gland.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since then, multiple centers have reported their initial experience demonstrating both the advantages of this surgical access and its safety and efficacy.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the results of the first 70 laparoscopic adrenalectomies that have been performed by the same surgical team at the Department of Urology, University Hospital of Albacete, and in a private center in the city.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Retrospective observational study was done of the first 70 transperitoneal laparoscopic adrenalectomies that have been performed at our center, by the Department of Urology, between July 2002 and December 2010. The patients were referred to the Department of Urology after having been previously studied in the Nephrology, Endocrinology and Internal Medicine consultations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">By reviewing medical records, we have established: age, sex, personal history, reason for consultation, additional tests (ultrasound, CT or MRI), surgery-related variables (date of the intervention, tumor size and location, and duration of surgery), preoperative preparation, surgical and postoperative complications, need for transfusion, and rate of conversion to open surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 70 patients, 35 were men and 35 women (1:1) with a mean age of 58.2 years (82.2–29.1). The following diagnoses were established: 22 Conn's syndrome (31.42%), 18 nonfunctioning adenomas (25.71%), 10 cases of Cushing's syndrome (14.28%), 7 pheochromocytomas (10%), 4 myelolipomas (5.71%), 6 cases of metastasis after treatment of primary nonadrenal neoplasia (8.57%), a ganglioneuroma (1.42%), an adrenal gland hematoma (1.42%), and an adrenal carcinoma (1.42%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The predominant location was left in 41 cases (58%), compared to right in 29 cases (42%). No patient showed bilateral involvement.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Transperitoneal laparoscopic adrenalectomy was performed in all cases in lateral decubitus position at 90° with respect to the operating table without pellet (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This position facilitates (on the left side) the gravity displacement of the spleen and the pancreatic tail medially, making direct access to the adrenal glands possible. We used 0° optic. Before the start of the surgery, a nasogastric and a bladder catheter were placed in all the patients.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">We performed the position of the trocars in a systematic way. On the left side, we used 4 trocars, a 12-mm Hasson trocar (located 2<span class="elsevierStyleHsp" style=""></span>cm above the navel at the level of the outer edge of the anterior rectus abdominis, through which we introduce the laparoscope), a 10-mm trocar (near the costal margin, in the midclavicular line, right hand of the surgeon), and two 5-mm trocars, a subcostal one in the internal axillary line (for the surgeon's left hand), and the other one near the left iliac fossa, similar to the one used in the radical nephrectomy (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). On the right side, we used 4 more: Hasson trocar for the optics, and 10-mm trocar in a similar position to the left approach (in the costal margin at the level of the midclavicular line for the right hand of the surgeon), 5-mm trocar (subcostal, at the level of the axillary line for the left hand of the surgeon), and another 5-mm trocar in the inner costal margin, below the xiphoid appendix, allowing the assistant to separate the liver during the surgery (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">We always start the adrenalectomy with the approach and section of the adrenal vein and subsequent dissection of the adrenal gland. On the left side, we perform decollation of the splenic flexure of the descending colon in the first place, so the spleen and the tail of the pancreas are medially displaced, which provides access to the adrenal gland. We proceed to the identification of the left renal vein and the left adrenal vein, crucial reference point for the approach of the left adrenal gland. On the right side, it is essential, and prior to any move, to explore hepatic mobility; and the partial section of the triangular ligament of the liver is performed in order to facilitate it. This allows for the sufficient hepatic mobility to expose the adrenal area and the anterior side of the vena cava through the peritoneum. Then, we proceed to perform the Kocher maneuver with exposure of the anterior side of the vena cava and then careful dissection of the right adrenal vein, as its lesion produces a bleeding difficult to control due to its direct drainage into the vena cava. In both cases, the adrenal veins were clipped with conventional clips, two or three proximal, and one distal (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). In both approaches, the adrenal vein ligation is essential as a first step, but sometimes it will also depend on the nature of the lesion, size, and technical difficulties in its removal.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The average size of the surgical piece was 5.11<span class="elsevierStyleHsp" style=""></span>cm (14–1.5) with a surgical time of 119.2<span class="elsevierStyleHsp" style=""></span>min (240–50). The average size of the tumors of incidental finding was 5.72<span class="elsevierStyleHsp" style=""></span>cm (4.2–8). The mean hematic loss was 147.6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> (800–30), requiring the transfusion of packed red blood cells in only three patients (4.2%).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patients started to develop oral tolerance to liquid 17<span class="elsevierStyleHsp" style=""></span>h after surgery (5 days–8<span class="elsevierStyleHsp" style=""></span>h), establishing intravenous analgesic treatment scheduled every 8<span class="elsevierStyleHsp" style=""></span>h in the first 24<span class="elsevierStyleHsp" style=""></span>h of the surgery, and orally on demand from the second postoperative day. The mean duration of hospital stay was 4.3 days (15–2).</p><p id="par0060" class="elsevierStylePara elsevierViewall">We have divided our sample into two groups: the first 35 patients operated against the latter, in order to check the evolution of our learning curve, and we have observed how in the first 35 patients the mean surgical time was 141.2<span class="elsevierStyleHsp" style=""></span>min for a medium-sized piece of 4.3<span class="elsevierStyleHsp" style=""></span>cm, while in the second group the time spent was significantly lower (100.5<span class="elsevierStyleHsp" style=""></span>min) for a larger surgical piece (5.4<span class="elsevierStyleHsp" style=""></span>cm). Moreover, the average period of hospital stay for the first group was 5.2 days, compared to 3.9 days in the second one.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Among the complications presented, two surgical wound infections, a prolonged paralytic ileus for 5 days with a good evolution after conservative treatment and management with a nasogastric tube, a case of splenic laceration, and one of bowel perforation stand out. In these two cases, along with a patient with metastatic lung cancer of 14<span class="elsevierStyleHsp" style=""></span>cm, conversion to open surgery (4.28%) was necessary. After reviewing medical records, 5 patients had died since July 2002, but none as a result of surgery: 3 lung cancer patients, a chronic myeloid leukemia one, and 1 acute myocardial infarction patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Despite starting the program of laparoscopic adrenalectomy in our center in 2002, it was from 2006 when we began to perform a greater number of interventions and considered the laparoscopic approach as a usual technique, operating on increasingly larger masses (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The laparoscopic approach of the adrenal gland is currently one of the clearest indications of laparoscopic surgery in our specialty, leaving behind those large lumbotomic incisions to treat small adrenal lesions, which were the cause of a morbidity and mortality that could reach up to 40%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Laparoscopic adrenalectomy is considered to be a minimally invasive surgery that once the learning curve is overcome can be performed in just over an hour, with a short hospital stay, and a rapid recovery of the patient, allowing for an early incorporation to the daily activities.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The criteria on which we rely to indicate surgery are: functioning adrenal mass, incidentaloma<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm or incidentalomas between 4 and 5<span class="elsevierStyleHsp" style=""></span>cm in patients younger than 50 years, nonfunctioning adrenal lesion with progressive growth or solitary adrenal metastasis. As in other recently published series in Spanish literature, our most frequent diagnosis was the presence of functioning mass (55.71%).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a> We must mention that, over recent years, the indications for the removal of a tumor of incidental diagnosis have varied, according to various authors, from a threshold of 5.6–2.3<span class="elsevierStyleHsp" style=""></span>cm, according to different criteria that exceed the interest of this article.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">We perform transperitoneal approach to feel more familiar with this route and provide greater comfort for the wide surgical field against the retroperitoneal route. The trans- or retroperitoneal approach seems to depend primarily on the surgeon, each having advantages over the other, but without demonstrating that a way is different from the other regarding the final result and complications.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> We place the patient in the unchanged 90° position, since we use a 0° optic, and that allows us to better visualize the vascular pedicle. We systematically use 4 trocars, as described above, on the right and left side, since on the one hand it facilitates dissection and reduces surgical time and, on the other hand, it allows for the active participation of the assistant at surgery, without increasing morbidity this being a 5-mm accessory trocar. We performed the first access to the abdominal cavity through a minilaparotomy, placing a Hasson trocar, as it gives us more security to avoid bowel injuries. Another particular modification we made usually on the left side is the placement of the fourth trocar (5<span class="elsevierStyleHsp" style=""></span>mm) near the left iliac fossa, the same as in radical nephrectomy, more inferior than most authors, using the assistant to separate the spleen, to breathe in, etc. This position provides greater comfort for the surgeon and the assistant and it has a lower risk of injury to surrounding structures, especially the spleen, in our experience. On the right side, we have also slightly modified, according to our experience, the position of the fourth trocar (5<span class="elsevierStyleHsp" style=""></span>mm) placing it in the inner costal margin, below the xiphoid appendix, allowing the assistant to separate the liver and help the surgeon in the dissection during the progression of the surgery.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Currently, the size is not so much a relative contraindication as the preoperative diagnosis, since, in our experience, myelolipomas of a significant size will be less difficult to remove than smaller malignant lesions. Henry et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> performed laparoscopic adrenalectomies in 19 patients with potentially malignant tumors, all of them over 6<span class="elsevierStyleHsp" style=""></span>cm, requiring conversion in two cases and concluding that laparoscopic adrenalectomy is feasible in selected patients and experienced hands, needing open adrenalectomy in the event of local invasion during surgery. In our work, we provide 6 adrenalectomies for adrenal metastases, three secondary to lung cancer, two for renal cancer, and one for colon cancer, in the case of lesions smaller than 5<span class="elsevierStyleHsp" style=""></span>cm, except one of 14<span class="elsevierStyleHsp" style=""></span>cm that required conversion to open surgery. Therefore, laparoscopy must be considered as a reference in the treatment of functioning and nonfunctioning benign lesions of the adrenal gland under 12<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Open surgery is recommended only for lesions larger than 10–12<span class="elsevierStyleHsp" style=""></span>cm or tumors with clearly malignant features on preoperative imaging.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding the conversion rate to open surgery, the largest series published, such as the Japanese series with 4900 patients<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> or that by Shen et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> present a conversion rate of 3–18%. In our case, conversion was required in 4.28% of the cases (three patients). The first case involved a 14<span class="elsevierStyleHsp" style=""></span>cm adrenal mass of metastatic origin, secondary to a lung cancer, widely attached to the psoas muscle and of difficult resection that required early conversion after splenic laceration and subsequent active bleeding. The case of intestinal perforation occurred when performing minilaparotomy for Hasson trocar insertion, as a consequence of intestinal adhesions secondary to previous abdominal surgery. In the third patient, conversion due to splenic bleeding was required.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The learning curve is necessary in all surgical fields, but especially in laparoscopy. The 70 cases in our center have been intervened by three surgeons. We observe the difference in the reduction of the surgical time and hospital stay in the group of the second 35 adrenalectomies, although larger surgical pieces were intercepted. We cannot set a cut-off point at the time of establishing how many laparoscopic adrenalectomies are needed to overcome the learning curve, this being a surgeon-dependent situation, especially if we have previous experience in laparoscopic kidney surgery, but we can say observing our results and those of other recent series<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that progressive experience and the acquired security makes it possible to assume adrenal lesions of increasing size and complexity.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The results presented by numerous works regarding early oral tolerance, postoperative pain with good oral control, and the rapid incorporation to work have allowed for adrenalectomy to become a technique that, in selected cases, may be performed under a major ambulatory surgery regime.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In summary, laparoscopic adrenalectomy is a safe surgical technique, with a low complication rate, and that requires a shorter hospital stay. The choice of this access route will depend on the individual surgeon's experience, taking into account both the etiology and the size of the lesion in each case. It should therefore be considered the gold standard in the treatment of benign functioning and nonfunctioning lesions of the adrenal gland under 12<span class="elsevierStyleHsp" style=""></span>cm and some selected malignant lesions. In these, the surgeon's experience, the adhesions of the lesion and the size of the same are the main restrictive factors for its use. Compared with open surgery, laparoscopic adrenalectomy achieves superior results in terms of morbidity, recovery, satisfaction, and better cosmetic results of the patient.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In fact, since the incorporation of laparoscopy to surgery, in most urology departments, laparoscopic adrenalectomy performed by urologists with experience in laparoscopic nephrectomy does not imply an additional difficulty, which is why, the number of urology departments that publish their recent experience is increasing. Currently, it is likely that the learning curve for an adrenalectomy is shorter for an urologist with experience in laparoscopic renal surgery than for a general surgeon with laparoscopic experience; hence, we should claim this surgery in those centers where its care location has not been defined, within what we would call a retroperitoneal and adrenal gland urological unit.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres99963" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec87128" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres99962" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec87127" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-01-25" "fechaAceptado" => "2011-01-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec87128" "palabras" => array:3 [ 0 => "Adrenal" 1 => "Laparoscopy" 2 => "Transperitoneal" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec87127" "palabras" => array:3 [ 0 => "Suprarrenal" 1 => "Laparoscopia" 2 => "Transperitoneal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present our results with transperitoneal laparoscopic adrenalectomy after completion of 70 procedures.</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Between July 2002 and December 2010, transperitoneal laparoscopic adrenalectomy was performed in 70 patients with the following diagnoses: Conn syndrome (22 cases), nonfunctioning adenomas (18), Cushing syndrome (10), pheochromocytomas (7), myelolipomas (4), metastasis after treatment of primary nonadrenal tumors (6), ganglioneuroma (1), adrenal gland hematoma (1) and adrenal carcinoma (1). We describe the size, surgical and hospitalization times, blood loss, need for transfusion, surgical complications and rate of conversion to open surgery.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of 70 patients, 35 were men and 35 women (1:1) with a mean age of 58.2 years (range, 82.2–29.1). The most common site was left (58%) compared to right (42%). The mean size of the surgical specimen was 5.11<span class="elsevierStyleHsp" style=""></span>cm, mean surgical time was 119.2<span class="elsevierStyleHsp" style=""></span>min (50–240) and mean operative bleeding was 140.6 (30–800)<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>. Only 3 patients required blood transfusion. The mean time until oral feeding was 17<span class="elsevierStyleHsp" style=""></span>h, and the mean hospital stay was 4.3 (2–15) days. Complications were 2 cases of surgical infections, 1 of prolonged paralytic ileus, and 1 of splenic laceration and 1 of intestinal perforation, which both required reconversion to open surgery (4.28%).</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic adrenalectomy is a safe procedure, with a low percentage of complications and a short hospital stay. The choice of this approach will depend on the surgeon's experience with the lesion etiology and size in each case.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentar nuestros resultados en suprarrenalectomía laparoscópica transperitoneal tras haber realizado 70 procedimientos.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Entre julio de 2002 y diciembre de 2010, 70 pacientes fueron sometidos a suprarrenalectomía laparoscópica transperitoneal con los siguientes diagnósticos: 22 de síndrome de Conn, 18 adenomas no funcionantes, 10 casos de síndrome de Cushing, 7 feocromocitomas, 4 mielolipomas, 6 casos de metástasis tras tratamiento de neoplasia primaria no adrenal, un ganglioneuroma, un hematoma de glándula suprarrenal y un carcinoma suprarrenal. Describimos el tamaño, el tiempo quirúrgico y de hospitalización, la pérdida sanguínea y la necesidad de transfusión, las complicaciones quirúrgicas y la tasa de conversión a cirugía abierta.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De los 70 pacientes 35 fueron hombres y otras 35 mujeres (1:1) con una edad media de 58,2 años (82,2 - 29,1). La localización predominante fue la izquierda (58%) frente a la derecha (42%). Con un tamaño medio de la pieza quirúrgica de 5,11<span class="elsevierStyleHsp" style=""></span>cm, el tiempo quirúrgico promedio fue de 119,2 minutos (50 - 240) y el sangrado operatorio medio de 140,6 cc (30 - 800), precisando tan sólo en tres pacientes transfusión sanguínea. El período promedio para alimentación oral fue de 17 horas y la estancia media hospitalaria fue de 4,3 días (15 - 2). Como complicaciones observamos dos casos de infecciones quirúrgicas, un íleo paralítico prolongado, un caso de laceración esplénica y otro de perforación intestinal; ambos precisaron reconversión a cirugía abierta (4,28%).</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La suprarrenalectomía por vía laparoscópica es una técnica quirúrgica segura, con un bajo porcentaje de complicaciones y que precisa breve estancia hospitalaria. La elección de esta vía de acceso dependerá de la experiencia individual del cirujano, teniendo en cuenta tanto la etiología como el tamaño de la lesión en cada caso.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Virseda JA, et al. Suprarrenalectomía laparoscópica transperitoenal. Actas Urol Esp. 2011;35:546–51.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1043 "Ancho" => 1400 "Tamanyo" => 230143 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Cushing's syndrome, (B) Conn's syndrome, (C) pheochromocytoma, and (D) adrenal hematoma.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 748 "Ancho" => 1000 "Tamanyo" => 140809 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Placement of the patient at 90° without pellet.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 715 "Ancho" => 950 "Tamanyo" => 130383 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Placement of trocars for left adrenalectomy.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 683 "Ancho" => 1000 "Tamanyo" => 97630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Placement of trocars for right adrenalectomy.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 731 "Ancho" => 822 "Tamanyo" => 139983 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clipping of the right adrenal vein.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1107 "Ancho" => 2070 "Tamanyo" => 102202 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Annual surgeries.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2018 March | 2 | 0 | 2 |
| 2018 February | 8 | 2 | 10 |
| 2018 January | 12 | 0 | 12 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 18 | 0 | 18 |
| 2017 October | 27 | 5 | 32 |
| 2017 September | 15 | 4 | 19 |
| 2017 August | 16 | 5 | 21 |
| 2017 July | 22 | 3 | 25 |
| 2017 June | 19 | 4 | 23 |
| 2017 May | 31 | 15 | 46 |
| 2017 April | 14 | 10 | 24 |
| 2017 March | 23 | 9 | 32 |
| 2017 February | 33 | 1 | 34 |
| 2017 January | 23 | 1 | 24 |
| 2016 December | 26 | 9 | 35 |
| 2016 November | 60 | 4 | 64 |
| 2016 October | 57 | 9 | 66 |
| 2016 September | 42 | 5 | 47 |
| 2016 August | 53 | 2 | 55 |
| 2016 July | 17 | 1 | 18 |
| 2016 June | 12 | 2 | 14 |
| 2016 May | 23 | 15 | 38 |
| 2016 April | 37 | 11 | 48 |
| 2016 March | 30 | 7 | 37 |
| 2016 February | 39 | 11 | 50 |
| 2016 January | 39 | 12 | 51 |
| 2015 December | 31 | 12 | 43 |
| 2015 November | 19 | 5 | 24 |
| 2015 October | 25 | 6 | 31 |
| 2015 September | 21 | 6 | 27 |
| 2015 August | 61 | 7 | 68 |
| 2015 July | 31 | 6 | 37 |
| 2015 June | 16 | 5 | 21 |
| 2015 May | 20 | 4 | 24 |
| 2015 April | 32 | 11 | 43 |
| 2015 March | 20 | 4 | 24 |
| 2015 February | 18 | 3 | 21 |
| 2015 January | 35 | 5 | 40 |
| 2014 December | 43 | 12 | 55 |
| 2014 November | 26 | 1 | 27 |
| 2014 October | 55 | 9 | 64 |
| 2014 September | 40 | 6 | 46 |
| 2014 August | 37 | 6 | 43 |
| 2014 July | 26 | 5 | 31 |
| 2014 June | 24 | 5 | 29 |
| 2014 May | 22 | 6 | 28 |
| 2014 April | 28 | 4 | 32 |
| 2014 March | 36 | 0 | 36 |
| 2014 February | 21 | 4 | 25 |
| 2014 January | 12 | 0 | 12 |
| 2013 December | 18 | 4 | 22 |
| 2013 November | 24 | 2 | 26 |
| 2013 October | 24 | 1 | 25 |
| 2013 September | 10 | 2 | 12 |
Show all
