Langenbecks Arch Surg (2010) 395:111–114 DOI 10.1007/s00423-009-0563-z
CURRENT CONCEPTS IN ENDOCRINE SURGERY
Energy-based hemostatic devices in laparoscopic adrenalectomy Paola Vincenza Sartori & Fabrizio Romano & Fabio Uggeri & Giovanni Colombo & Roberto Caprotti & Cristina Giannattasio & Mauro Alessandro Scotti & Alberto Delitala & Massimo Prada & Franco Uggeri
Received: 13 September 2009 / Accepted: 12 October 2009 / Published online: 25 November 2009 # Springer-Verlag 2009
Abstract Purpose In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy. Methods Forty-six patients, aged 54.6±46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27± 4.8 kg/m2. Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age. Results Mean operating time was 126.5±52 min, blood losses were 101±169 mm, conversion rate was 6.5%,
morbidity was 26%, and hospitalization was 5.3±2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p=0.007) and had more complications (p=0.016) than those undergone operation on the right side. Conclusions Obesity (BMI>30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon’s preference.
P. V. Sartori (*) : F. Romano : F. Uggeri : G. Colombo : R. Caprotti : M. A. Scotti : A. Delitala : F. Uggeri 1st Surgical Department, S. Gerardo Hospital, University of Milan Bicocca, Via Pergolesi 33, 20052 Monza, Italy e-mail:
[email protected]
Since the first operation performed in 1992 by Gagner [1, 2], laparoscopy is now considered the standard of care for the treatment of functioning and nonfunctioning adrenal pathology, even in case of potentially malignant tumor [3]. Dissection and hemostasis of adrenal-feeding vessels, until few years ago, had been achieved, respectively, by electric hook and by titanium clips or laparoscopic staplers. In more recent years, new energy-based devices suitable for both hemostasis and dissection such as the Harmonic scalpel (Ethicon Endosurgery, Inc., Cincinnati, OH) and the Ligasure vessel sealing system (Tyco Valleylab, Boulder, CO) have increasingly been used in laparoscopic as well as in open surgery. However, while in other surgical fields like laparoscopic splenectomy [4, 5] or thyroid [6–9], hepatic [10–12] and colonic [13, 14] surgery, there are a lot of papers addressing this topic, up to now, only one paper
C. Giannattasio Department of Medicine and Prevention, University of Milan Bicocca, Via Pergolesi 33, 20052 Monza, Italy M. Prada Pathology Department of S. Gerardo Hospital, University of Milan Bicocca, Via Pergolesi 33, 20052 Monza, Italy
Keywords Adrenal surgery . Laparoscopy . Hemostasis . Ligasure . Ultracision
Introduction
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compares the two instruments in laparoscopic adrenal surgery [15]. The aim of this study is to analyze the outcome of laparoscopic adrenalectomies performed either by Ligasure or by Harmonic scalpel to evaluate if any of them has any advantage over the other. As secondary end points, the impact of body mass index (BMI) and tumor size on the indication and the outcome of laparoscopic adrenalectomy were analyzed.
Materials and methods Retrospective sequential cohort study involved 46 consecutive patients, 17 males and 29 females (mean age 54.6± 46 years), who were submitted to laparoscopic adrenalectomy by the transperitoneal lateral approach from January 2003 to December 2008. All the operations were performed by an endocrine surgery team at First Surgical Department of Milan Bicocca University. All the patients were preoperatively screened for hormonal secretion and submitted to computed tomography scan and/or magnetic resonance imaging; when there was the suspicion of pheochromocytoma, a 131 I metaiodobenzyl guanedine scintigraphy was added. Twenty-two patients were affected by secreting cortical adenomas (18 Conn, 4 Cushing), 7 were affected by pheochromocytomas, 14 had nonsecreting adenomas or nodular hyperplasia larger than 35 mm, 2 patients had an enlarging cystic lesion, and 1 had a metastasis from lung cancer. In 24 patients, pathology involved the left gland, and in 22 the right. Mean tumor size was 4.61±3 cm, and masses larger than 5 cm were considered large. Mean BMI was 27±4.8 kg/m2; five patients had a BMI >30 kg/m2 and were considered obese. All the patients received preoperative antithrombotic prophylaxis with low molecular weight heparin and ultrashort-term antibiotic prophylaxis with intravenous first generation cephalosporin. Patients with pheochromocytomas underwent preoperative preparation with doxazosin 4 mg/day and were monitored for the first postoperative day in an intensive care unit. In 26 patients operated from January 2003 until April 2005, hemostasis was achieved by Harmonic Scalpel® (HS) 5 mm. Ultracision LCSC 5 HA (group A). Beginning in May 2005, on the basis of our previous experience in laparoscopic splenectomy [4, 5], we decided to switch to the Electric Bipolar Vessel Sealing System Ligasure® Atlas 10 mm, which was employed in 20 patients (group B). Groups were well matched for histology, tumor size and site, BMI, gender, and age.
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Patients were positioned in full lateral decubitus. Four trocars were used for right adrenalectomy and three when operating on the left side, with the first trocar always placed with open technique under direct view to avoid accidental lesions. Both Ligasure Atlas and Ultracision LCSC 5 HA were the only devices applied for dissection, as well as for hemostasis, during the whole operation. HS is homologated for hemostasis of vessels up to 5 mm. Therefore, when the adrenal vein diameter, visually estimated during surgery, exceeded 5 mm. In group A patients, a titanium clip was applied to close it. This never happened in group B patients, since Ligasure can control bleeding in larger vessels than HS. Other instruments utilized were a 10-mm 30° telescope, an endoscopic grasper, and on the right side, an endoretractor for the liver. Surgical specimens were extracted into an endobag through one of the 10-mm port sites; larger glands required a small incision. Intraoperative blood losses were estimated by measuring the blood into the collector of the suction device at the end of the operation. A suction drainage was always placed and removed after 24 h. Associated surgical procedures due to comorbidities, already known preoperatively, were performed in five patients: three with a right lesion, one with a left mass who received cholecystectomy because of gallbladder stones, and in another, with a left adenoma, a splenic artery aneurysm warranted splenectomy. All the patients were hospitalized postoperatively at least for 4 days as required by our endocrine department to check blood pressure values and adrenal function. Patients’ characteristics for each group are detailed in Table 1. The following parameters were gathered: age, gender, BMI, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, length of hospital stay (LOS), complications, and conversion rate. In patients with associated surgical procedures, Table 1 Patients’ characteristics in each group
Patients Operating time (min) Blood losses (ml) LOS (days) Morbidity (n) Conversion rate (n)
Group A (HS)
Group B (Ligasure)
26 118 82.22 4.95 7 2
20 143 120.6 5.75 5 1
LOS length of hospital stay, HS harmonic scalpel, n number, min minutes, ml milliliters
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operating time was calculated subtracting the time required for the associated procedure from the whole surgical time. Statistical analysis was performed by SPSS 15th edition (SPSS Inc., Chicago, Illinois, USA). Results are expressed as mean ± standard deviation. Continuous data were compared by one-way analysis of variance and Spearman’s correlation, and categorical ones were analyzed by means of Fischer exact test. Significance threshold was set at p0.05). Laparoscopic approach is widely accepted for small tumors, but its role in removal of larger neoplasms (>5 cm) is still questioned [3]. Whether surgical time is significantly affected by tumor size is controversial. Soon in 2008 reported a significant difference between patients with small and those with large tumors [24]. Our experience is opposite: in fact, as reported by Pugliese et al. in 2006 [25], we did not find any significant lengthening in surgery due to tumor dimension. The Marseille group in 2008 observed a higher complication rate in patients with left-sided lesions [26]. On the contrary, Scaini [27], in the same year, reported no significant difference between left and right masses, but noticed a significant correlation between the size of the lesion and blood losses.
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We did not observe any difference in surgical time due to the site, but patients undergone left adrenalectomy had larger intraoperative blood losses (p=0.007) and were more prone to complications (p=0.016), than those with rightsided tumors, irrespective of the hemostatic tool. They had also a significantly longer LOS (p=0.037).
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Conclusions The choice of the hemostatic device is up to surgeon’s preference, since HS and Ligasure do not significantly impact the outcome. Patient’s BMI and the size of the gland have no influence on surgical time and blood losses, therefore obesity (BMI>30) and large masses are not a contraindication for laparoscopic adrenalectomy. Left and right adrenalectomies have similar surgical time, but in operation on the left gland, there is a larger intraoperative bleeding and also a higher morbidity rate.
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