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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic single-site synchronous bilateral cortex-preserving adrenalectomy using conventional trocars and instruments for large bilateral adrenal pheochromocytomas Santosh Kumar,1 Gautam Ram Choudhary,1 Arawat Pushkarna,1 Seema Prasad2 & Bhuvnesh Nanjappa1 1 Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India 2 Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Keywords Adrenalectomy; laparoscopic; pheochromocytoma Correspondence Santosh Kumar, Department of Urology, Post graduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel: +91 172 2756321 Fax: +91 172 2744401 Email: [email protected]
Abstract Laparoendoscopic single-site surgery is being adapted for widespread indications because it offers minimal invasiveness. Herein, we report a case of synchronous bilateral cortex-preserving adrenalectomy for bilateral large adrenal pheochromocytomas. We used conventional laparoscopic instruments and trocars through a single-port site. The total operative time was 110 min. There were no perioperative complications. Single-incision multiport laparoendoscopic surgery, also known as SIMPLE surgery, can be safely used for bilateral adrenalectomy. This modification holds promise with its minimally invasive nature and reduced cost.
Received: 22 May 2013; revised 17 October 2013; accepted 17 November 2013 DOI:10.1111/ases.12089
Introduction Laparoendoscopic single site surgery (LESS) is being adapted for widespread indications because it offers minimal invasiveness. Herein, we report a case of synchronous bilateral cortical-sparing adrenalectomy for bilateral large adrenal pheochromocytomas using a modified LESS technique. This single-incision multiport laparoendoscopic surgery, also known as SIMPLE surgery, holds promise with its minimally invasive nature and reduced cost.
Case Presentation A 29-year woman presented with a history of accelerated hypertension (260/120 mmHg) associated with episodic headaches, palpitations and sweating. Contrast-enhanced CT showed bilateral heterogeneous ovoid masses; there was a 55 × 43 × 37-mm mass on the left and a 57 × 35 × 35-mm mass on the right in the suprarenal regions (Figure 1a). PET-CT performed with a 68Ga-DOTATATE showed somatostatin receptor-expressing mass lesions in
the bilateral suprarenal regions (Figure 1b). Biochemical and hematological work-up were normal. Endocrine work-up included a non-suppressible overnight dexamethasone suppression test (cortisol at 8 AM, 434 nmol/L) and showed elevated plasma free metanephrines of 137 pg/mL (normal < 90 pg/mL), normal free normetanephrines of 21.80 pg/mL (normal < 180 pg/mL) and normal calcitonin 5.05 pg/mL (normal < 11.5 pg/mL). Genetic work-up for multiple endocrine neoplasia and von Hippel–Lindau disease was negative. Diagnosis of sporadic bilateral adrenal pheochromocytoma was considered and bilateral adrenalectomy was planned. Preoperatively, blood pressure was controlled with prazosin and metoprolol, and the patient was hydrated with intravenous fluid supplementation 24 hours prior to surgery. Under general anesthesia, the patient was placed in the flank position with the right side elevated 70°, and pnemoperitoneum was created using a Veress needle. We placed two 10-mm and one 5-mm conventional laparoscopic access trocars at three separate sites in a sheath coming out through a 3-cm supraumbilical skin incision
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
175
SIMPLE technique
S Kumar et al.
Figure 1 (a) Contrast-enhanced CT showing bilateral adrenal masses. (b) PET-CT (68Ga-DOTATATE) showing somatostatin receptor-expressing mass lesions in the bilateral suprarenal regions.
a
b
d
c
e
Figure 2 (a) Two 10-mm and one-5 mm conventional laparoscopic access ports through a single 2.5-cm supraumbilical incision. (b) Excision of the right adrenal tumor. (c) Excision of the left adrenal tumor. (d) Specimen retrieval through the umbilical incision in a custom-made plastic bag without morcellation. (e) Gross specimen of both adrenal tumors.
(Figure 2a). We used conventional laparoscopic instruments and a 30° laparoscope. A 5-mm laparoscopic EnSeal Tissue Sealing and Hemostasis System (Ethicon EndoSurgery, San Angelo, USA) was used. We incised Toldt’s line, reflected the colon medially, and the inferior vena cava and right renal vein were visualized. The peritoneum lateral to the vena cava was incised and the right adrenal tumor was exposed (Figure 2b). The tumor was well encapsulated, and the plane between the tumor and normal adrenal cortex could be easily developed; this allowed a cortex-sparing tumor excision, and the medullary tissue was sucked out while preserving the adrenal vein. Tumor excision and hemostasis were accomplished using a 5-mm laparoscopic EnSeal. The patient’s position was changed to the opposite flank position without disturbing the ports and drapes. The left colon was medialized by incising Toldt’s line. Gerota’s fascia was incised and a well-encapsulated adrenal tumor was found
176
(Figure 2c). Similar to that performed on the right, tumor excision was performed on the left. Both specimens were placed in a custom-made bag and retrieved through the port-site incision without morcellation (Figure 2d,e). No drainage tubes were placed. The fascia was closed with 1-0 Vicryl (Ethicon Endo-Surgery), and the skin was closed with a skin stapler (Figure 3). Intraoperative hemodynamics were normal. The total operative time was 110 min, including 5 min for position change so that the cortical tissue on both sides could be preserved. The blood loss was minimal. On postoperative day 1, the visual analog pain score was 3 of 10. The patient started ambulation on postoperative day 1, and her blood pressure was normal (128/82 mmHg) without any anti-hypertensive medication in the postoperative period. The histopathological examination revealed bilateral pheochromocytoma, and no capsular breach was seen. No steroid replacement was necessary
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
SIMPLE technique
S Kumar et al.
Figure 3 Photograph showing the periumbilical scar after healing.
in the postoperative period, and serum cortisol was also normal on postoperative day 3 (cortisol at 8 AM, 423 nmol/L).
Discussion LESS has been a significant advancement in the arena of minimal access surgery, as reducing the number of ports necessary to complete the surgery potentially reduces postoperative morbidity and improves cosmesis (1). Although LESS has been shown to be feasible in various urological surgeries, its benefit over conventional laparoscopic surgery has not yet been proven. The major hindrance to the widespread acceptance of LESS in developing countries such as India has been the additional cost of specialized ports coupled with a lack of proven benefit over conventional laparoscopic surgery. We tried to inculcate the conceptual benefit of the LESS surgery into conventional laparoscopic surgery while retaining a lower cost. Jeong et al. reported their initial experience with LESS surgery using a homemade single-port devise through an umbilical incision. Later they reported the first case of synchronous bilateral LESS adrenalectomy (2). They used a commercially available OCTO Port (Dalim SurgNet, Seoul, South Korea), which has four airtight instrument channels of various diameters that allow a wide range of motion, one insufflation and one smoke exhaust valve, and a detachable cap to enable easy extraction of the specimen. The price of such commercially available ports is about $300–400 (3). Colon et al. successfully performed LESS for cholecystectomy and appendectomy using standard laparoscopic instruments, a laparoscope, and trocars (4). In our LESS technique for bilateral adrenalectomy, we also
used conventional laparoscopic instruments, trocars and a laparoscope, making the cost of our procedure the same as that for conventional laparoscopic surgery. By doing this, we could avoid the five to seven bilateral trocar incisions used in conventional laparoscopic surgery. In this case, we used two 10-mm ports and one 5-mm port inserted through a 30-mm supraumbilical skin incision. Several studies have reported the safety and technical feasibility of laparoscopic simultaneous bilateral adrenal surgery (5–7). Cortex-preserving surgery in patients with functioning tumors mitigates the need for long-term steroid replacement, even though the procedure has a longer operative time and an approximately 7.5% risk of recurrence 8.5 years (median) after surgery (8). There is also minimal risk of adrenal insufficiency in bilateral corticalpreserving procedure. Pheochromocytoma commonly occurs as a component of hereditary endocrine syndromes, including multiple endocrine neoplasia type 2 and von Hippel–Lindau disease. Surgical resection remains the treatment of choice for affected patients (8). The cortex may be preserved unilaterally or bilaterally according to feasibility. Leaving approximately 15%–30% of well-vascularized tissue after the medulla is removed necessary (9). Cadaveric studies by Anson et al. found that the adrenal vein is supplied by approximately 60 small arteries from the aorta and other branches, so until mobilized much vascularity usually not hampered. In the literature, adrenal vein preservation is not emphasized much, with functionality given greater importance (10). By performing bilateral cortex-sparing surgery, we could help the patient avoid the need for lifelong steroid replacement. The patient has been normotensive postoperatively, with normal serum cortisol on postoperative day 3. In this case, we presented a modified synchronous bilateral LESS surgery. Cortex-sparing surgery has the obvious benefit of preventing lifelong steroid replacement. Although in familial cases the recurrence rate is about 7.5%, the importance of follow-up cannot be underestimated. Increased acceptance and familiarity with this approach might improve the results further.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this study.
References 1. Tracy CR, Raman JD, Cadeddu JA et al. Laparoendoscopic single-site surgery in urology: Where we have been and where are we heading? Nat Clin Pract Urol 2008; 5: 561–568.
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
177
SIMPLE technique
S Kumar et al.
2. Jeong BC, Park YH, Han DH et al. Laparoendoscopic singlesite and conventional laparoscopic adrenalecctomy: A matched case-control study. J Endourol 2009; 23: 1957–1960. 3. Jeong CW, Park YH, Shin CH et al. Synchronous bilateral laparoendoscopic single-site adrenalectomy. J Endourol 2010; 24: 1301–1305. 4. Colon MJ, Telem D, Divino CM et al. Laparoendoscopic single site surgery can be performed completely with standard equipment. Surg Laparosc Endosc Percutan Tech 2011; 21: 292–294. 5. Takata MC, Kebebew E, Clark OH et al. Laparoscopic bilateral adrenalectomy: Results of 30 consecutive cases. Surg Endosc 2008; 22: 202–207. 6. Hawn MT, Cook D, Deveney C et al. Quality of life after laparoscopic bilateral adrenalectomy for Cushing’s disease. Surgery 2002; 132: 1064–1069.
178
7. Vella A, Thomson GB, Grant CS et al. Laparoscopic adrenalectomy for adrenocorticotropic-dependent Cushing’s syndrome. J Clin Endocrinol Metab 2001; 86: 1596–1599. 8. Grubbs EG, Rich TA, Ng C et al. Long-term outcomes of surgical treatment for hereditary pheochromocytoma. J Am Coll Surg 2013; 216: 280e289. 9. Walz MK. Extent of adrenalectomy for adrenal neoplasm: Cortical sparing (subtotal) versus total adrenalectomy. Surg Clin North Am 2004; 84: 743e753. 10. Walz MK, Peitgen K, Diesing D et al. Partial versus total adrenalectomy by the posterior retroperitoneoscopic approach: Early and long-term results of 325 consecutive procedures in primary adrenal neoplasias. World J Surg 2004; 28: 1323e1329.
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic single-site synchronous bilateral cortex-preserving adrenalectomy using conventional trocars and instruments for large bilateral adrenal pheochromocytomas Santosh Kumar,1 Gautam Ram Choudhary,1 Arawat Pushkarna,1 Seema Prasad2 & Bhuvnesh Nanjappa1 1 Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India 2 Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Keywords Adrenalectomy; laparoscopic; pheochromocytoma Correspondence Santosh Kumar, Department of Urology, Post graduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel: +91 172 2756321 Fax: +91 172 2744401 Email: [email protected]
Abstract Laparoendoscopic single-site surgery is being adapted for widespread indications because it offers minimal invasiveness. Herein, we report a case of synchronous bilateral cortex-preserving adrenalectomy for bilateral large adrenal pheochromocytomas. We used conventional laparoscopic instruments and trocars through a single-port site. The total operative time was 110 min. There were no perioperative complications. Single-incision multiport laparoendoscopic surgery, also known as SIMPLE surgery, can be safely used for bilateral adrenalectomy. This modification holds promise with its minimally invasive nature and reduced cost.
Received: 22 May 2013; revised 17 October 2013; accepted 17 November 2013 DOI:10.1111/ases.12089
Introduction Laparoendoscopic single site surgery (LESS) is being adapted for widespread indications because it offers minimal invasiveness. Herein, we report a case of synchronous bilateral cortical-sparing adrenalectomy for bilateral large adrenal pheochromocytomas using a modified LESS technique. This single-incision multiport laparoendoscopic surgery, also known as SIMPLE surgery, holds promise with its minimally invasive nature and reduced cost.
Case Presentation A 29-year woman presented with a history of accelerated hypertension (260/120 mmHg) associated with episodic headaches, palpitations and sweating. Contrast-enhanced CT showed bilateral heterogeneous ovoid masses; there was a 55 × 43 × 37-mm mass on the left and a 57 × 35 × 35-mm mass on the right in the suprarenal regions (Figure 1a). PET-CT performed with a 68Ga-DOTATATE showed somatostatin receptor-expressing mass lesions in
the bilateral suprarenal regions (Figure 1b). Biochemical and hematological work-up were normal. Endocrine work-up included a non-suppressible overnight dexamethasone suppression test (cortisol at 8 AM, 434 nmol/L) and showed elevated plasma free metanephrines of 137 pg/mL (normal < 90 pg/mL), normal free normetanephrines of 21.80 pg/mL (normal < 180 pg/mL) and normal calcitonin 5.05 pg/mL (normal < 11.5 pg/mL). Genetic work-up for multiple endocrine neoplasia and von Hippel–Lindau disease was negative. Diagnosis of sporadic bilateral adrenal pheochromocytoma was considered and bilateral adrenalectomy was planned. Preoperatively, blood pressure was controlled with prazosin and metoprolol, and the patient was hydrated with intravenous fluid supplementation 24 hours prior to surgery. Under general anesthesia, the patient was placed in the flank position with the right side elevated 70°, and pnemoperitoneum was created using a Veress needle. We placed two 10-mm and one 5-mm conventional laparoscopic access trocars at three separate sites in a sheath coming out through a 3-cm supraumbilical skin incision
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
175
SIMPLE technique
S Kumar et al.
Figure 1 (a) Contrast-enhanced CT showing bilateral adrenal masses. (b) PET-CT (68Ga-DOTATATE) showing somatostatin receptor-expressing mass lesions in the bilateral suprarenal regions.
a
b
d
c
e
Figure 2 (a) Two 10-mm and one-5 mm conventional laparoscopic access ports through a single 2.5-cm supraumbilical incision. (b) Excision of the right adrenal tumor. (c) Excision of the left adrenal tumor. (d) Specimen retrieval through the umbilical incision in a custom-made plastic bag without morcellation. (e) Gross specimen of both adrenal tumors.
(Figure 2a). We used conventional laparoscopic instruments and a 30° laparoscope. A 5-mm laparoscopic EnSeal Tissue Sealing and Hemostasis System (Ethicon EndoSurgery, San Angelo, USA) was used. We incised Toldt’s line, reflected the colon medially, and the inferior vena cava and right renal vein were visualized. The peritoneum lateral to the vena cava was incised and the right adrenal tumor was exposed (Figure 2b). The tumor was well encapsulated, and the plane between the tumor and normal adrenal cortex could be easily developed; this allowed a cortex-sparing tumor excision, and the medullary tissue was sucked out while preserving the adrenal vein. Tumor excision and hemostasis were accomplished using a 5-mm laparoscopic EnSeal. The patient’s position was changed to the opposite flank position without disturbing the ports and drapes. The left colon was medialized by incising Toldt’s line. Gerota’s fascia was incised and a well-encapsulated adrenal tumor was found
176
(Figure 2c). Similar to that performed on the right, tumor excision was performed on the left. Both specimens were placed in a custom-made bag and retrieved through the port-site incision without morcellation (Figure 2d,e). No drainage tubes were placed. The fascia was closed with 1-0 Vicryl (Ethicon Endo-Surgery), and the skin was closed with a skin stapler (Figure 3). Intraoperative hemodynamics were normal. The total operative time was 110 min, including 5 min for position change so that the cortical tissue on both sides could be preserved. The blood loss was minimal. On postoperative day 1, the visual analog pain score was 3 of 10. The patient started ambulation on postoperative day 1, and her blood pressure was normal (128/82 mmHg) without any anti-hypertensive medication in the postoperative period. The histopathological examination revealed bilateral pheochromocytoma, and no capsular breach was seen. No steroid replacement was necessary
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
SIMPLE technique
S Kumar et al.
Figure 3 Photograph showing the periumbilical scar after healing.
in the postoperative period, and serum cortisol was also normal on postoperative day 3 (cortisol at 8 AM, 423 nmol/L).
Discussion LESS has been a significant advancement in the arena of minimal access surgery, as reducing the number of ports necessary to complete the surgery potentially reduces postoperative morbidity and improves cosmesis (1). Although LESS has been shown to be feasible in various urological surgeries, its benefit over conventional laparoscopic surgery has not yet been proven. The major hindrance to the widespread acceptance of LESS in developing countries such as India has been the additional cost of specialized ports coupled with a lack of proven benefit over conventional laparoscopic surgery. We tried to inculcate the conceptual benefit of the LESS surgery into conventional laparoscopic surgery while retaining a lower cost. Jeong et al. reported their initial experience with LESS surgery using a homemade single-port devise through an umbilical incision. Later they reported the first case of synchronous bilateral LESS adrenalectomy (2). They used a commercially available OCTO Port (Dalim SurgNet, Seoul, South Korea), which has four airtight instrument channels of various diameters that allow a wide range of motion, one insufflation and one smoke exhaust valve, and a detachable cap to enable easy extraction of the specimen. The price of such commercially available ports is about $300–400 (3). Colon et al. successfully performed LESS for cholecystectomy and appendectomy using standard laparoscopic instruments, a laparoscope, and trocars (4). In our LESS technique for bilateral adrenalectomy, we also
used conventional laparoscopic instruments, trocars and a laparoscope, making the cost of our procedure the same as that for conventional laparoscopic surgery. By doing this, we could avoid the five to seven bilateral trocar incisions used in conventional laparoscopic surgery. In this case, we used two 10-mm ports and one 5-mm port inserted through a 30-mm supraumbilical skin incision. Several studies have reported the safety and technical feasibility of laparoscopic simultaneous bilateral adrenal surgery (5–7). Cortex-preserving surgery in patients with functioning tumors mitigates the need for long-term steroid replacement, even though the procedure has a longer operative time and an approximately 7.5% risk of recurrence 8.5 years (median) after surgery (8). There is also minimal risk of adrenal insufficiency in bilateral corticalpreserving procedure. Pheochromocytoma commonly occurs as a component of hereditary endocrine syndromes, including multiple endocrine neoplasia type 2 and von Hippel–Lindau disease. Surgical resection remains the treatment of choice for affected patients (8). The cortex may be preserved unilaterally or bilaterally according to feasibility. Leaving approximately 15%–30% of well-vascularized tissue after the medulla is removed necessary (9). Cadaveric studies by Anson et al. found that the adrenal vein is supplied by approximately 60 small arteries from the aorta and other branches, so until mobilized much vascularity usually not hampered. In the literature, adrenal vein preservation is not emphasized much, with functionality given greater importance (10). By performing bilateral cortex-sparing surgery, we could help the patient avoid the need for lifelong steroid replacement. The patient has been normotensive postoperatively, with normal serum cortisol on postoperative day 3. In this case, we presented a modified synchronous bilateral LESS surgery. Cortex-sparing surgery has the obvious benefit of preventing lifelong steroid replacement. Although in familial cases the recurrence rate is about 7.5%, the importance of follow-up cannot be underestimated. Increased acceptance and familiarity with this approach might improve the results further.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this study.
References 1. Tracy CR, Raman JD, Cadeddu JA et al. Laparoendoscopic single-site surgery in urology: Where we have been and where are we heading? Nat Clin Pract Urol 2008; 5: 561–568.
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
177
SIMPLE technique
S Kumar et al.
2. Jeong BC, Park YH, Han DH et al. Laparoendoscopic singlesite and conventional laparoscopic adrenalecctomy: A matched case-control study. J Endourol 2009; 23: 1957–1960. 3. Jeong CW, Park YH, Shin CH et al. Synchronous bilateral laparoendoscopic single-site adrenalectomy. J Endourol 2010; 24: 1301–1305. 4. Colon MJ, Telem D, Divino CM et al. Laparoendoscopic single site surgery can be performed completely with standard equipment. Surg Laparosc Endosc Percutan Tech 2011; 21: 292–294. 5. Takata MC, Kebebew E, Clark OH et al. Laparoscopic bilateral adrenalectomy: Results of 30 consecutive cases. Surg Endosc 2008; 22: 202–207. 6. Hawn MT, Cook D, Deveney C et al. Quality of life after laparoscopic bilateral adrenalectomy for Cushing’s disease. Surgery 2002; 132: 1064–1069.
178
7. Vella A, Thomson GB, Grant CS et al. Laparoscopic adrenalectomy for adrenocorticotropic-dependent Cushing’s syndrome. J Clin Endocrinol Metab 2001; 86: 1596–1599. 8. Grubbs EG, Rich TA, Ng C et al. Long-term outcomes of surgical treatment for hereditary pheochromocytoma. J Am Coll Surg 2013; 216: 280e289. 9. Walz MK. Extent of adrenalectomy for adrenal neoplasm: Cortical sparing (subtotal) versus total adrenalectomy. Surg Clin North Am 2004; 84: 743e753. 10. Walz MK, Peitgen K, Diesing D et al. Partial versus total adrenalectomy by the posterior retroperitoneoscopic approach: Early and long-term results of 325 consecutive procedures in primary adrenal neoplasias. World J Surg 2004; 28: 1323e1329.
Asian J Endosc Surg 7 (2014) 175–178 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
