Clipless and Sutureless Laparoscopic Adrenalectomy Carried Out With the LigaSure Device in 32 Patients
Onder Surgit, MD
Background: Laparoscopic adrenalectomy has become the standard procedure for treating patents with adrenal masses. The purpose of this study was to evaluate the use of the LigaSure vessel closure system during laparoscopic adrenalectomy.
Methods: The LigaSure device was used in 32 patients undergoing laparoscopic adrenalectomy for adrenal masses. Adrenalectomy was carried out without the use of clips or sutures for vessel closure. In 1 patient the adrenal tumor had invaded the ipsilateral kidney, so laparoscopic nephrectomy was also carried out during the same operation. In another patient, a renal cell carcinoma in the left kidney had metastasized to the right adrenal gland. Both the kidney and the contralateral adrenal gland were removed laparoscopically during the same operation.
Results: Adrenal masses had a mean greatest diameter of 3.48 cm (range 2 to 11 cm). Mean operative time was 83.2 minutes (range 30 to 190 min). Mean blood loss was 36.2mL (range 10 to 140 mL). No conversions to open surgery were necessary. No patients experienced major bleeding intraoperatively or postoperatively. Adrenal tumor types included adrenocortical adenoma (16 patients), pheochromocytoma (13 patients), malignant pheochro- mocytoma (1 patient), chromophobic carcinoma (1 patient), and metastasis from a renal cell carcinoma (1 patient).
Conclusions: For vessel closure during laparoscopic adrenalectomy, the LigaSure device seems to be safe and effective. For patients with conditions such as renal cell carcinoma combined with metastasis to the contralateral adrenal gland, nephrectomy, and contralateral adrenalectomy can be carried out during the same laparoscopic operation.
Key Words: Laparoscopy, adrenalectomy, hemostatic techniques (Surg Laparosc Endosc Percutan Tech 2010;20:109-113)
L aparoscopic adrenalectomy, first reported by Gagner et al,1 has become a standard method of treatment for patients with adrenal tumors. With developments in technology such as the ultrasonic scalpel and the LigaSure vessel closure device, advanced laparoscopic techniques are becoming safer, quicker, and easier to carry out. Compared with conventional electrocautery, the LigaSure device has reduced surgery-related blood loss2,3 and minimized the risk of thermal injury to the neighboring tissues.3 The LigaSure device is a bipolar system that uses thermal energy to close vessels permanently, and can be used for vessels up to 7 mm in diameter.4 The aim of this study was to
evaluate the use of the LigaSure device for vessel closure during laparoscopic adrenalectomy.
MATERIALS AND METHODS
During the period of March 2005 to December 2008, 32 patients (20 female, 12 male) with adrenal masses underwent surgery with the use of the 10-mm LigaSure device (Valleylab, Boulder, CO, USA) for intraoperative vessel closure. Adrenal masses were on the right side in 19 patients and on the left in 13. The patients’ demographic and clinical information is summarized in Table 1.
All patients provided a detailed medical history and underwent a thorough physical examination. Laboratory investigations for all patients included 24-hour urine collection for the measurement of catecholamines. For imaging, ultrasonography, computed tomography with contrast, and magnetic resonance were used in combina- tion.
For laparoscopy, all patients were in the lateral decubitus position and a transperitoneal approach was used. For vessel closure during tissue dissection and adrenalectomy, the LigaSure device was used; no clips or sutures were used. The adrenal vessels were not isolated. For right adrenalectomy, a blunt dissector was placed alongside the vena cava and was gently retracted medially to provide a few millimeters of safe working space whereas the adrenal vessels were closed with the LigaSure device.
In 1 patient the adrenal tumor had invaded the ipsilateral kidney, so laparoscopic nephrectomy was also done during the same operation.
In another patient, right adrenalectomy and left nephrectomy were necessary and these were done laparo- scopically during the same operation. The patient was a 76- year-old man who had presented with a history of bilateral lower back pain. On computerized tomography, the left
| TABLE 1. Clinical and Operative Data | |
| Patients | 32 |
| Female | 20 |
| Male | 12 |
| Mean age | 47.5 (26-76) |
| Adrenal masses | |
| Right | 19 |
| Left | 13 |
| Preoperative diagnosis | |
| Pheochromocytoma | 14 |
| Others | 18 |
| Mean tumor size | 3.48 cm (2-11 cm) |
| Mean blood loss | 36.2 mL (10-140mL) |
| Mean operative time | 83.2 min (30-190 min) |
| Conversions to open surgery | None |
| Complications | None |
From the Department of General Surgery, Fatih University School of Medicine, Ankara, Turkey.
Reprints: Onder Surgit, MD, Department of General Surgery, Fatih
University School of Medicine, Alparslan Turkes Caddesi No. 57, 06510 Emek, Ankara, Turkey (e-mail: litotemexi@yahoo.com.tr).
Copyright @ 2010 by Lippincott Williams & Wilkins
kidney contained a mass measuring 69 × 83 × 90 mm, and the right adrenal gland contained a mass measuring 110 × 70× 70mm (Fig. 1). The patient otherwise seemed to be in good general health. The physical examination findings were normal. Chest x-ray, blood pressure, and electrocardio- gram were also normal. Routine blood and urine tests including tumor marker evaluations gave normal findings. Metabolic investigations of 24-hour urine samples for 17-ketosteroids, 17-hydroxycorticoids, metanephrines, corti- sol, and vanillylmandelic acid gave results within normal limits.
For this patient, we decided to remove the masses on both sides during the same laparoscopic operation, with the use of a transperitoneal approach. For removal of the right adrenal mass, the patient was first placed in a left lateral decubitus position (right side up). Below the right costal margin, four 10-mm trocars were inserted, and the right adrenal gland was dissected and removed. For blood vessel closure, the LigaSure device was used and no clips or sutures were needed. The adrenal gland and the mass it contained were placed in an Endobag (Covidien, Dublin, Ireland) and the port incision on the anterior axillary line was extended to permit removal of the Endobag. All trocars were removed and all incisions were closed by suturing of the skin, including the extended incision that was to be reopened for removal of the contralateral kidney. For the extended incision, interrupted sutures were placed. The patient was then turned and placed in a right lateral decubitus position (left side up). Under the left costal margin, four 10-mm trocars were inserted. The renal vein, renal arteries, and ureter of the left kidney were closed with clips and ligatures, and were then cut. The freed kidney was then left in place, and all trocars were removed and their
incisions were sutured, except for the trocar nearest the midline, which remained in place. The patient was then placed in a supine position. From the line of interrupted sutures in the extended incision on the patient’s right side, the most medial suture was removed and a 10-mm trocar was inserted. The suture in the earlier used incision on the midclavicular line on the patient’s right side was also removed and a trocar was reinserted. With these 3 trocars in place, an Endobag was introduced through the trocar in the extended incision. The kidney containing the mass was then placed in the Endobag. The rest of the sutures in the extended incision were then removed and the incision was opened to permit the withdrawal of the Endobag. The trocars were removed and all incisions were closed anatomically. Images taken during the operation are shown in Figure 2 (laparoscopic adrenalectomy) and Figure 3 (contralateral laparoscopic nephrectomy). Postoperative views of the incisions are shown in Figure 4.
RESULTS
In all patients, operations were completed laparosco- pically, and no conversions to open surgery were needed. All adrenalectomies were carried out with the use of the LigaSure device for blood vessel closure. Mean blood loss was 36.2 mL (range 10 to 140 mL). Amounts of blood loss were classified as: minimal (no suction needed during the procedure, < 10 mL); mild (occasional suction needed, 10 to 50 mL); moderate (frequent suction needed, 50 to 150 mL), and severe (>150mL).5 Mild bleeding was encountered in 25 patients, and moderate bleeding in the remaining 7. Severe bleeding was not encountered in any patients, and no patients required blood transfusion.
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Adrenal masses had a mean greatest diameter of 3.48 cm (range 2 to 11 cm). Mean operative time was 83.2 minutes (range 30 to 190 min).
On histopathologic examination, adrenal tumor types included these: adrenocortical adenoma (16 patients), pheochromocytoma (13 patients), malignant pheochromo- cytoma (1 patient), chromophobic carcinoma (1 patient), and metastasis from a renal cell carcinoma (1 patient) (Table 2).
For the patient who underwent adrenalectomy and contralateral nephrectomy, the total blood loss during surgery was 120 mL. Histopathologic examinations showed the adrenal tumor to be a metastasis from a renal cell carcinoma. No tumor cells were observed in the surgical margins. Postoperatively, no complications were encoun- tered and the patient was discharged on postoperative day 3. At the patient’s 6-month follow-up visit, computed tomography showed no recurrence of malignant disease.
DISCUSSION
Since Gagner et al1 accomplished the first laparoscopic adrenalectomy in 1992, the procedure has been used in increasingly wider fields and has now become the standard treatment for adrenal masses. Laparoscopic adrenalectomy has several advantages over open surgery and these have been shown in several original studies.6-16 These advan- tages include less postoperative pain, lower complication rates, and shorter hospital stay. Through new energy sources such as the LigaSure vessel closure system and
ultrasonic scalpel, laparoscopic adrenalectomy has become easier to carry out.
The LigaSure vessel closure system uses a combination of pressure and bipolar thermal energy to seal vessels that are up to 7mm in diameter. This energy breaks down elastin and collagen in the vessel walls, thus enabling the walls to stick together. The sealing process is under the control of a feedback device that automatically monitors the progress of vessel sealing. The procedure is safe and permanent. An experimental study has shown this proce- dure to be as reliable as clips or ligatures.4
In standard laparoscopic adrenalectomy, the adrenal artery and particularly the adrenal vein require fine dissection and complete exposure before clips can be used. The vein is very fragile and the risk of injury to it is high, and when serious bleeding develops, the conversion to open surgery is necessary. In addition, during surgical manipula- tion, there is always a risk that the clips will move out of place, resulting in a loss of control of bleeding from the vein. With the LigaSure vessel closure system, dissection and exposure of the adrenal vein and arteries are not necessary, and after the vessels are sealed and cut, bleeding during surgical manipulation of the adrenal gland is no longer a possibility. During vessel closure, thermal spread to neighboring tissues is minimal.3 Another advantage of the 10-mm LigaSure device is that it can act like the finger of the surgeon, as its tip is blunt and smooth and does not traumatize the adrenal gland during dissection. The probe is also used to retract the gland without injuring the capsule, which is so essential in carrying out laparoscopic
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adrenalectomy. It also avoids bleeding and reduces the chances of conversion to an open procedure.
In all 32 of our patients, the LigaSure system was used continuously throughout laparoscopic adrenalectomy. All adrenalectomies were carried out with patients in the lateral decubitus position, through a transperitoneal approach. None of our patients required conversion to open surgery; however, during laparoscopic adrenalectomy the most common causes of conversion are loss of bleeding control, large tumor size, and periadrenal adhesions. Mean blood
loss was 36.2 mL, and no patient experienced severe blood loss (> 150 mL). The LigaSure device played a key role in reducing blood loss.
Use of the LigaSure system during laparoscopic adrenalectomy has been described in 3 reports.5,17,18 The numbers of patients in these series were lower than in this study, as were the number of patients with pheochromo- cytoma. It is known that in patients with pheochromo- cytoma, surgical manipulation can lead to hypertensive attacks, which in turn can put extreme stress on the
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| TABLE 2. Postoperative Histopathologic Diagnosis | |
| Adrenocortical adenoma | 16 |
| Pheochromocytoma | 14 |
| Benign | 13 |
| Malignant | 1 |
| Chromophobic carcinoma | 1 |
| Renal cell carcinoma | 1 |
methods used to provide ongoing hemostasis. In our 14 patients who had pheochromocytoma, the LigaSure system provided effective hemostasis.
Operative times in laparoscopic procedures have been shown to be shortened by the use of the LigaSure device.2 In a series of 23 patients undergoing laparoscopic adrenalectomy with the use of the LigaSure system,17 the mean operative time was 57 minutes (range 30 to 75 min). In a similar series of 14 patients,5 the mean operative time was 138 minutes (range 90 to 210 min). In our series, the mean operative time was between that of these 2 series, at 83.2 minutes (range 30 to 190 min). The longer mean operative time in our series compared with that in the series of 23 patients,17 can be accounted for by the larger number of patients with pheochromocytoma in our series (14 vs. 4). During surgery in these patients, the possibility of surgical manipulation of the adrenal gland is very limited until the vein is closed, owing to the risk of inducing hypertensive attack. When such an attack occurs, the operation must be stopped until the patient’s blood pressure is brought under control, and this increases operative time. In comparison with the series of 14 patients,5 our mean operative time was shorter, and this can be explained in terms of mean tumor size that was larger in that series (6.2 cm) than in ours (3.4cm).
One of the patients in our series was of particular interest, because he underwent a right adrenalectomy and a left radical nephrectomy during the same laparoscopic operation. To our knowledge, this is the first reported use of a single laparoscopic operation to treat renal cell carcinoma and a metastasis to the contralateral adrenal gland. Single-operation laparoscopic treatment has been reported for patients with bilateral masses in the adrenal glands.19-23 In these reports, there was no involvement of the kidney. Surgical treatment through more than 1 operation for renal cell carcinoma and metastasis to the contralateral adrenal gland has been reported.24-26 In the patients with this condition, the kidney was first removed in 1 operation, and the contralateral adrenal gland was removed in a separate operation. For closure of the adrenal blood vessels, clips and/or ligatures were used.
In conclusion, we found that in patients undergoing laparoscopic adrenalectomy, use of the LigaSure vessel sealing device made the procedure easier to do, with shorter operative times and less blood loss. For patients with conditions that require adrenalectomy and contralateral nephrectomy, these procedures can be carried out during the same laparoscopic operation.
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