Background. We report a single surgeon’s experience of 52 transperitoneal laparoscopic adrenalectomies (LAs) performed between 2001 and 2010. In addition, we compared this series with our first published series of LAs performed between 1994 and 2001. Methods. Our series includes 24 left, 20 right, and 4 bilateral LAs performed in 48 patients. To estimate the learning curve, we chronologically divided the sample of unilateral LAs into two groups of 22 patients and compared the operating time, estimated blood loss, maximum diameter of the lesion, complications, and length of hospital stay. Results. Mean operating time was significantly lower (94 versus 78？min, ) and mean intraoperative blood loss was significantly lower (156 versus 60？mL, ) after more experience had been gained. Additionally, a trend towards removing larger lesions was observed. There was no significant difference in terms of hospital stay. Conclusions. Observing a single surgeon’s experience of nine years in laparoscopic adrenalectomy, this study indicates that it takes approximately 20–25 procedures to flatten the learning curve. Thus, for single centers with a volume of approximately five LAs performed per year, we suggest a selection of a few experienced surgeons to perform LAs in order to improve outcomes. 1. Background Since its first performance in 1992, laparoscopic adrenalectomy (LA) has quickly become the standard method for surgical treatment of benign and selected malignant adrenal pathologies [1, 2]. Although there are no randomized controlled studies comparing open adrenalectomy versus LA, the multitude of retrospective analyses and case reports clearly demonstrate the benefits of LA in terms of feasibility, safety, morbidity, hospital stay, and recovery time [2–7]. We have already affirmed the benefits of LA with our first series of 22 LAs performed between 1994 and 2001. Compared with open adrenalectomy, LA resulted in less blood loss, lower postoperative analgesic requirements, and shorter hospital stays [8]. The aim of this paper is to present our subsequent series of 52 consecutive transperitoneal LAs performed between 2001 and 2010 in order to evaluate the learning curve associated with this technique. We reevaluated the major parameters (indications, morbidity, hospital stay, blood loss, and lesion size) and especially focused on operative duration over time. 2. Methods For this survey, we retrospectively included all patients in whom unilateral or bilateral transperitoneal LA was performed between April 2001 and November 2010. The most common indication was a
References
[1]
M. Gagner, A. Lacroix, and E. Bolté, “Laparoscopic adrenalectomy in adrenalectomy in cushing's syndrome and pheochromocytoma,” The New England Journal of Medicine, vol. 327, no. 14, article 1033, 1992.
[2]
M. Gagner, A. Lacroix, R. A. Prinz et al., “Early experience with laparoscopic approach for adrenalectomy,” Surgery, vol. 114, no. 6, pp. 1120–1124, 1993.
[3]
R. Prinz, “A comparison of laparoscopic and open adrenalectomies,” Archives of Surgery, vol. 130, no. 5, pp. 489–492, 1995.
[4]
L. M. Brunt, G. M. Doherty, J. A. Norton, N. J. Soper, M. A. Quasebarth, and J. F. Moley, “Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms,” Journal of the American College of Surgeons, vol. 183, no. 1, pp. 1–10, 1996.
[5]
G. B. Thompson, C. S. Grant, J. A. Van Heerden et al., “Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients,” Surgery, vol. 122, no. 6, pp. 1132–1136, 1997.
[6]
D. Hazzan, E. Shiloni, D. Golijanin, O. Jurim, D. Gross, and P. Reissman, “Laparoscopic vs open adrenalectomy for benign adrenal neoplasm: a comparative study,” Surgical Endoscopy, vol. 15, no. 11, pp. 1356–1358, 2001.
[7]
P. K. Gupta, B. Natarajan, P. K. Pallati, H. Gupta, J. Sainath, and R. J. Fitzgibbons Jr., “Outcomes after laparoscopic adrenalectomy,” Surgical Endoscopy and Other Interventional Techniques, vol. 25, no. 3, pp. 784–794, 2011.
[8]
M. Bolli, D. Oertli, J.-J. Staub, and F. Harder, “Laparoscopic adrenalectomy: the new standard?” Swiss Medical Weekly, vol. 132, no. 1-2, pp. 12–16, 2002.
[9]
M. Gagner, A. Lacroix, E. Bolte, and A. Pomp, “Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position,” Surgical Endoscopy, vol. 8, no. 2, pp. 135–138, 1994.
[10]
C. D. Smith, C. J. Weber, and J. R. Amerson, “Laparoscopic adrenalectomy: new gold standard,” World Journal of Surgery, vol. 23, no. 4, pp. 389–396, 1999.
[11]
L. M. Brunt, “Minimal access adrenal surgery,” Surgical Endoscopy and Other Interventional Techniques, vol. 20, no. 3, pp. 351–361, 2006.
[12]
C. Sturgeon and E. Kebebew, “Laparoscopic adrenalectomy for malignancy,” Surgical Clinics of North America, vol. 84, no. 3, pp. 755–774, 2004.
[13]
W. S. Cobb, K. W. Kercher, R. F. Sing, and B. T. Heniford, “Laparoscopic adrenalectomy for malignancy,” American Journal of Surgery, vol. 189, no. 4, pp. 405–411, 2005.
[14]
F. Sebag, F. Calzolari, J. Harding, M. Sierra, F. F. Palazzo, and J. F. Henry, “Isolated adrenal metastasis: the role of laparoscopic surgery,” World Journal of Surgery, vol. 30, no. 5, pp. 888–892, 2006.
[15]
V. E. Strong, M. D'Angelica, L. Tang et al., “Laparoscopic adrenalectomy for isolated adrenal metastasis,” Annals of Surgical Oncology, vol. 14, no. 12, pp. 3392–3400, 2007.
[16]
L. R. McCauley and M. M. Nguyen, “Laparoscopic radical adrenalectomy for cancer: long-term outcomes,” Current Opinion in Urology, vol. 18, no. 2, pp. 134–138, 2008.
[17]
G. David, M. Yoav, D. Gross, and P. Reissman, “Laparoscopic adrenalectomy: ascending the learning curve,” Surgical Endoscopy and Other Interventional Techniques, vol. 18, no. 5, pp. 771–773, 2004.
[18]
M. Guerrieri, R. Campagnacci, A. De Sanctis, M. Baldarelli, M. Coletta, and S. Perretta, “The learning curve in laparoscopic adrenalectomy,” Journal of Endocrinological Investigation, vol. 31, no. 6, pp. 531–536, 2008.
[19]
R. T. Strebel, M. Müntener, and T. Sulser, “Intraoperative complications of laparoscopic adrenalectomy,” World Journal of Urology, vol. 26, no. 6, pp. 555–560, 2008.
[20]
Y. Erbil, U. Barbaros, G. Karaman, A. Bozbora, and S. ？zarma？an, “The change in the principle of performing laparoscopic adrenalectomy from small to large masses,” International Journal of Surgery, vol. 7, no. 3, pp. 266–271, 2009.
[21]
J. S. Rosoff, J. D. Raman, and J. J. Del Pizzo, “Laparoscopic adrenalectomy for large adrenal masses,” Current Urology Reports, vol. 9, no. 1, pp. 73–79, 2008.
[22]
I. Hara, G. Kawabata, S. Hara, Y. Yamada, K. Tanaka, and M. Fujisawa, “Clinical outcomes of laparoscopic adrenalectomy according to tumor size,” International Journal of Urology, vol. 12, no. 12, pp. 1022–1027, 2005.
[23]
M. G. Hobart, I. S. Gill, D. Schweizer, G. T. Sung, and E. L. Bravo, “Laparoscopic adrenalectomy for large-volume ( or = 5？cm) adrenal masses,” Journal of Endourology, vol. 14, no. 2, pp. 149–154, 2000.
[24]
P. S. H. Soon, M. W. Yeh, L. W. Delbridge et al., “Laparoscopic surgery is safe for large adrenal lesions,” European Journal of Surgical Oncology, vol. 34, no. 1, pp. 67–70, 2008.
[25]
L. Fernández-Cruz, A. Saenz, G. Benarroch, E. Astudillo, P. Taura, and L. Sabater, “Laparoscopic unilateral and bilateral adrenalectomy for Cushing's syndrome: ransperitoneal and retroperitoneal approaches,” Annals of Surgery, vol. 224, no. 6, pp. 727–734, 1996.
[26]
O. Miyake, K. Yoshimura, T. Yoshioka et al., “Laparoscopic adrenalectomy. Comparison of the transperitoneal and retroperitoneal approach,” European Urology, vol. 33, no. 3, pp. 303–307, 1998.
[27]
M. Takeda, “Laparoscopic adrenalectomy: transperitoneal vs retroperitoneal approaches,” Biomedicine and Pharmacotherapy, vol. 54, supplement 1, 2000.
[28]
Y. Naya, M. Nagata, T. Ichikawa et al., “Laparoscopic adrenalectomy: comparison of transperitoneal and retroperitoneal approaches,” BJU International, vol. 90, no. 3, pp. 199–204, 2002.
[29]
M. Rubinstein, I. S. Gill, M. Aron et al., “Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy,” Journal of Urology, vol. 174, no. 2, pp. 442–445, 2005.
[30]
J. M. Winter, M. A. Talamini, C. L. Stanfield et al., “Thirty robotic adrenalectomies: a single institution's experience,” Surgical Endoscopy and Other Interventional Techniques, vol. 20, no. 1, pp. 119–124, 2006.
[31]
L. Brunaud, A. Ayav, R. Zarnegar et al., “Prospective evaluation of 100 robotic-assisted unilateral adrenalectomies,” Surgery, vol. 144, no. 6, pp. 995–1001, 2008.
[32]
L. Brunaud, L. Bresler, A. Ayav et al., “Robotic-assisted adrenalectomy: what advantages compared to lateral transperitoneal laparoscopic adrenalectomy?” American Journal of Surgery, vol. 195, no. 4, pp. 433–438, 2008.
[33]
E. S. Hyams and M. D. Stifelman, “The role of robotics for adrenal pathology,” Current Opinion in Urology, vol. 19, no. 1, pp. 89–96, 2009.
[34]
A. M. Bruhn, E. S. Hyams, and M. D. Stifelman, “Laparoscopic and robotic assisted adrenal surgery,” Minerva Urologica e Nefrologica, vol. 62, no. 3, pp. 305–318, 2010.
[35]
A. S. Merseburger, T. R. Herrmann, S. F. Shariat et al., “EAU guidelines on robotic and single-site surgery in urology,” European Urology, vol. 64, no. 2, pp. 277–291, 2013.
