Erratum Laparoscopic Adrenalectomy: A Report of the First Experience in Iran SIMFOROOSH N*, AHMADNIA H, ZIAEE AM, MORADI M Urology/Nephrology Research Center, Shaheed Labbafinejad Medical Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran Volume1, Number 2, pages 77-81: Some technical errors mainly due to Persian to English translation were unnoticed and the published version was not the edited one. The correct version of the article follows. The publisher regrets this error. ABSTRACT Purpose: To report the first experience in laparoscopic adrenalectomy and to study its efficacy and safety in the treatment of different adrenal diseases. Materials and Methods: From March 1997 to July 2001, 11 patients underwent laparoscopic adrenalectomy through transperitoneal approach, five of whom were males and 6 were females. Their mean age was 35.5 (range 28 to52) years. Lesion was located on the left side in 6 patients and on the right side in 5. All necessary evalua- tions were done preoperatively including CT scan, MRI, MIBG scan, and endocrine tests such as ACTH, cortisol, mineralocorticoid, 17-hydroxyprogesterone, and urinary VMA. Three (5, 10, and 12 mm) trocars were used in left laparoscopic adrenalectomy and three or four (12, 10, 5, and 5 mm) trocars were applied in right laparoscopic adrenalectomy. All the patients were followed up for three months with physical exam- ination and paraclinical tests. Results: Mean operative time (including anesthesia and surgery) was 205±65.95 (range 130 to 310) minutes. No significant difference was seen between the operative time in the left side and the right side adrenalectomy (p=0.5). Mean hospitalization was 5.54±3.4 (range 3 to15) days. Mean size of mass was 5.45±1.7 (range 2 to 8) cm. Blood transfusion was performed in 2 patients and open surgery was conducted for one because of extensive adhesions. No mortality was reported. During a 3-month fol- low-up, hormonal tests and blood pressure were normal for all the patients, with no medical treatment being required. Conclusion: Our study demonstrated that transperitoneal laparoscopic adrenalecto- my is an effective and safe approach in the treatment of adrenal masses with the least morbidity. KEY WORDS: adrenal neoplasm, laparoscopy, adrenalectomy 221 Urology Journal UNRC/IUA Vol. 1, No. 3, 221-225 Summer 2004 Printed in IRAN Introduction The first laparoscopic adrenalectomy was per- formed in 1992 by Ganger.(1-3) This approach was quickly developed because of less hemorrhage during operation, shorter hospitalization, and faster postoperative improvement.(4-6) Laparos- copic adrenalectomy may be conducted either transperitoneally or retroperitoneally.(4, 5, 7, 8) In this study, transperitoneal approach was the preferable method, which is the first report of laparoscopic adrenalectomy in Iran and to our Accepted for publication in August 2003 *Corresponding author: Department of Kidney Transplantation, Shaheed Labbafinejad Medical Center, Boustan 9, Pasdaran, Tehran, Iran. email: simforoosh@iurtc.org.ir LAPAROSCOPIC ADRENALECTOMY: A REPORT OF THE FIRST EXPERIENCE IN IRAN knowledge the first one in a renal transplanted patient worldwide. Materials and Methods From March 1997 to July 2001, 11 patients underwent laparoscopic adrenalectomy through transperitoneal method, five of whom were males and 6 were females. Their mean age was 35.5 (range 28 to 52) years. Table 1 indicates clinical and pathological details. Ultrasonography and abdominal CT scan was preoperatively performed for all patients (fig. 1). MRI was conducted if CT scan was unclear. MIBG scan would be performed if pheochromocy- toma was suspected and if MRI or CT scan were not helpful. Routine biochemical tests such as serum potassium and sodium levels, fasting blood sugar, and endocrine analyses such as serum ACTH, cortisol, minralocorticoids, and 17-hydrox- yprogesterone, and 24-hour urinary VMA were conducted too. Details of the procedure, its com- plications, and the probability of conversion to open surgery were explained for all of the patients. Bowel preparation was performed 24 hours before the procedure. NG tube and urethral catheter were inserted under general anesthesia. Then patients were secured in flank position with an angle of approximately 60 degrees. The bed was flexed 30 degrees and was reversed to Trendelenburg 10 degrees to retract intestine from the field of surgery. After the preparation of patient Veress needle was used through an umbilical incision and pneumoperitoneum was induced using CO2. Trocars were placed when the pressure reached 19 to 20 mmHg and then it was reduced to 14 to 15 mmHg. Three 12, 10, and 5 mm trocars were applied in left adrenalectomy (for 6 patients). A 12 mm tro- car was applied through umbilical incision and used for telescope. A 10 mm trocar was applied on breast line parallel to umbilicus and a 5 mm trocar was applied on midline between xiphoid and umbilicus. Then peritoneum was opened from the colonic spleen curve to sigmoid on Toldt line and colon was pushed inside. Then Gerota fascia was opened on renal vein, so that adrenal gland and vein were seen. Adrenal vein was cut after clipping bilaterally. Then fat tissue and the rest of the vessels were cut by Mets or electro- cautery after clipping bilaterally, so that adrenal gland was totally freed. Three to four (12, 10, 5, and 5 mm) trocars were used in right adrenalec- tomy (for 5 patients). Similar trocars were applied in left. The second 5 mm trocar was inserted on the breast line at the rib margin to retract the liver if needed. Adrenal gland was seen at the right side behind peritoneum after retracting the liver upward. Hepatocolic and peri- toneal ligaments were cut; thus, anterior surface of adrenal gland was revealed. After freeing the gland at inferior, lateral, posterior, and finally medial surfaces and cutting adrenal vein, follow- ing bilateral clipping, adrenal gland was removed through an umbilical incision made for 12 mm trocar, after enlarging it (depending on the size of gland) (fig. 2). As a drain, an 18 F Nelaton 222 No. Age Gender Adrenal Pathology Side of Operation 1 43 Male Conn’s syndrome Right 2 40 Female Conn’s syndrome Left 3 52 Male Pheocromocytoma Right 4 32 Male Pheocromocytoma Right 5 35 Male Pheocromocytoma Left 6 34 Female Pheocromocytoma Left 7 39 Female Adrenal Medolary Hyperplasia Left 8 28 Male Pheocromocytoma Left 9 29 Female Pheocromocytoma Left 10 31 Female Conn’s syndrome Right 11 28 Female Myelolipoma Right TABLE 1. Patients' clinical and pathological charac- teristics FIG. 2. laparoscopic surgical operation and the tumor FIG. 1. A 35-year-old woman with dysuria. A 7 cm tumor in left adrenal gland was revealed. LAPAROSCOPIC ADRENALECTOMY: A REPORT OF THE FIRST EXPERIENCE IN IRAN catheter was applied through 10 mm trocar for two or three days for all the patients. They were followed up with paraclinical tests and physical examination for three months (fig. 3,4). Student's t test was used for comparison of the size of mass and time of the procedure. Results The mean time of the procedure (including anesthesia and surgery) was 205±64.95 (range 130 to 310) minutes. Mean time for left side was 227.5±53.1 (range 145 to 305) minutes. There was no significant difference in the time of procedure between left and right sides (p=0.5). Mean hospi- talization was 5.54±3.4 (range 3 to 15) days. The mean size of mass was 5.45±1.7 (range 2 to 8) cm. No significant difference was seen between the size of left sided masses and right sided ones (p=0.6). A 28-year female with a history of a 15-year renal transplantation was among the patients. She underwent laparoscopic adrenalectomy because of an adrenal mass, pathologic report of which was myelolipoma. Blood transfusion was performed in 2 cases. Normal diet was started for 9 patients at the first postoperative day. Open surgery due to severe adhesion was con- ducted for one patient (9%), who underwent laparoscopic adrenalectomy because of pheochro- mocytoma. Hypertensive crisis occurred during the procedure in one pheochromocytoma case, which was properly managed without any prob- lem by the anesthesiologist. Postoperative compli- cations were reported in only one patient with left adrenalectomy. This patient underwent open surgery due to postoperative hemorrhage. No her- nia or infection was seen at the site of trocars and no mortality was reported. Blood pressure and hormonal tests were normal with no medical treatment during eight-month follow-up period. Discussion Surgical intervention is regarded as the main approach in several adrenal disorders. Familiarity with adrenal gland anatomy and its pathophysiol- ogy is important for a successful procedure. Open surgical incisions for adrenal mass removal con- sist of thoracoabdominal, flank, anterior, and pos- terior (lumbar). Selecting the appropriate method depends on adrenal pathology, patient's physical structure, history of surgical operation, and sur- geon's experience.(9) Laparoscopic adrenalectomy is an effective and safe method to treat various endocrine and neo- plasic adrenal diseases,(4,6,10,12) as it was shown in this study. Several studies reported that the mor- bidity rate in laparoscopic adrenalectomy is less than that in open surgery.(4,5,7,13-15) Previously, laparoscopic surgery needed a longer time than open surgery; however, the progress of technolo- gy and more laparoscopic experience have led to similar operative times.(14) Patients in laparoscop- ic surgeries would be hospitalized shorter and would return to their normal activities sooner. Younger patients could return to their sport activ- ities sooner with no limitation. Regarding cosmet- ic point of view, short incisions at trocar sites instead of long incisions would be more consider- able particularly for females.(14) Magnification by laparoscope would lead to easier detection of small vessels around adrenal mass which causes a distinguishable decrease of hemorrhage compar- ing to open adrenalectomy.(16) It also brings about a more accurate view of surgical anatomy of adre- nal gland and helps differential diagnosis between adenoma and normal tissue of gland. Elective 223 FIG. 4. Unrecognizable port site scars FIG. 3. Pathology: adrenaladenoma LAPAROSCOPIC ADRENALECTOMY: A REPORT OF THE FIRST EXPERIENCE IN IRAN removal of adrenal lesion without total removal of the gland, which is problematic in open sur- gery, is more practical in laparoscopic surgery. Guazzoin et al reported successful removal of 2 adrenal cysts without adrenal removal after which adrenal function was normal.(14) Most authors agree on the effectiveness of laparoscop- ic therapy for Conn's and Cushing's syndromes.(4) Because of hypertensive crisis during surgery, pheochromocytoma surgery differs form other adrenal tumoral surgeries.(4,5,17) It was believed that laparoscopic methods are contraindicated in pheochromocytoma, for the produced ponomo- peritoneum with CO2 and the increase of abdom- inal pressure would lead to hemodynamic changes and the release of catecholamines as well.(18) Furthermore, CO2 could cause hypercap- nia and respiratory acidosis that would lead to hypertension during laparoscopy.(17,19) Sprung et al have recently shown that laparoscopic hemody- namic changes are comparable with those of open surgery methods. The number of hypertension episodes and the highest level of hypertension during surgery were equal in both methods, while hypotension severity was lower in laparoscopic methods than open surgery.(20) Consequently, pheochromocytoma could be treated by laparo- scopic surgery, although large lesions could increase the chance of hemorrhage, hypertension and postoperative complications due to increased number of vessels.(21) In this study hypertension occurred only in one patient (out of 6) with pheochromocytoma, which was controlled with no complication. Since Ganger has indicated that lesions larger than 13 cm could be treated by laparoscopic adrenalectomy, the size of adrenal mass was no more considered as a limiting factor in laparoscopic surgery.(4,12) Thus, larger masses which could mostly be malignant, would be removed by laparoscopic surgery, though, enlarg- ing the incision of umbilicus would be essen- tial.(14) Dissection would be more difficult and the surgery would last in a way that could be beyond patient's tolerance.(21) Moreover, large masses have many abnormal vessels which could increase hemorrhage.(22) Bilateral adrenalectomy for Cushing's syndrome after unsuccessful treatment of hypophysis adenoma (surgery or radiotherapy) or for secondary Cushing's syndrome could lead to improper discharge of ACTH.(23,24) In our study, the decrease of wound infection risk, bet- ter postoperative respiratory capacity and short- er hospitalization would be main advantages of laparoscopy.(21) Laparoscopy is used in the treat- ment of nonfunctional adrenal masses too, espe- cially when their malignant nature is proved.(25) This is a common case as 20-22% of laparoscopic adrenalectomies are because of incidentaloma removal.(4,6) Porpiglia et al reported that the inci- dence of incidentaloma was 30% of the whole laparoscopic adernalectomies.(21) Several factors such as a mass larger than 6 cm (in CT Scan or sonography), non-homogenized mass in CT scan and an increase of DHEA or estradiol are used to distinguish malignant adrenal masses from benign.(26) In spite of these factors, adrenalectomy may be performed for an incidentaloma where cortical carcinoma may be detected by the analysis of pathologic sample. Porpiglia et al reported such a carcinoma after laparoscopic removal of the mass. No sign of recurrence was reported after 40 months follow-up.(21) It is commonly believed that this treatment would be sufficient for proved malignant adrenal masses provided that the neo- plasm is limited to the gland and a perfect and accurate laparoscopy is performed.(4,5) Laparoscopic transperitoneal removal of adre- nal glands includes anterior and lateral transperi- toneal methods. In anterior transperitoneal method, adrenal anterior margin is usually freed at the end that occasionally leads to upward movement of adrenal, which makes it difficult to pull downward.(16) However, in this study anteri- or margin of adrenal gland was easily freed at the beginning after the retraction of the liver or spleen toward midline through lateral transperi- toneal approach. Thus, it seems that lateral transperitoneal approach would be better than anterior transperitoneal, particularly for large tumors. Conclusion This study indicated that transperitoneal laparoscopic adrenalectomy is an effective and safe approach, which should be performed by a skilled laparoscopic surgeon to minimize poten- tial intraoperative and postoperative complica- tions such as infection and to avoid open incision. Clinical outcomes of laparoscopic surgery in such circumstances would be much better than open surgery and its morbidity would be much lesser. 224 LAPAROSCOPIC ADRENALECTOMY: A REPORT OF THE FIRST EXPERIENCE IN IRAN References 1. Ganger M, Lacroix A, Bolte E. Laparoscopic adrenalecto- my in Cushing's syndrome and pheochromocytoma. N Engl J Med 1992; 327: 1003. 2. Ganger M, Lacroix A, Printz RA, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery 1993; 114: 1120. 3. Ganger M. Lacroix A, Bolte E. Laparoscopic adrenalecto- my. Surg Endosc 1993; 7: 122. 4. Ganger M, Pomp A, Heniford BT, et al. Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. 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