Laparoscopic adrenalectomy. Personal experience in 78 patients.

Laparoscopic adrenalectomy has proved to be the technique of choice for the treatment of benign pathologies of the adrenals and also for the treatment of isolated adrenal metastases, especially arising from lung tumor, but it shouldn't be performed for primitive adrenal carcinoma. The harmonic scalpel is very useful for laparoscopic adrenalectomy showing a significant reduction in operative time. The Authors retrospectively investigated 78 laparoscopic adrenalectomies performed from April 1995 to April 2000 using a transperitoneal approach with the patient on a lateral position as suggested by Gagner. Special care was taken to improve the surgical approach to the adrenals also by means of new technological devices as the Harmonic scalpel. The 78 laparoscopic adrenalectomies were performed in 70 cases for benign neoplasms: incidentalomas 24, Cushing's disease 16, Conn's disease 20, pheochromocytomas 9, myelolipoma 1. In the remaining 8 patients laparoscopic adrenalectomy was performed in 7 cases for isolated adrenal masses (5 metastases, 2 adenomas) in neoplastic patients, and in 1 patient for a preoperatively diagnosed adrenal carcinoma. Patients operated for functioning neoplasms had all remission or improvement of symptoms and humoral parameters; patients operated for isolated adrenal metastases showed this survival: 3 patients 3 years asymptomatic and disease free, 1 patient 18 months, and 3 patients are still alive and healthy after 6-12-15 months. A fast onset of local recurrence was seen in a patient operated for a preoperatively diagnosed adrenal carcinoma. We analyzed the operating time dividing the patients in three groups: a) 14 patients operated in the first semester of 1998 when we completed the training curve (average operative time 120.7 minutes); b) 14 patients operated from 1998-1999 (average operative time 118 minutes); c) the last 14 patients (operated from December 1999 to April 2000) where surgery was performed using the Harmonic scalpel (HS) (average operative time 94 minutes). The analysis of the average operative time comparing groups B and C using T-Student Test showed a significant reduction (p = 0.004). The morbility rate was 2.6%, mortality 1.3%, and a conversion rate of 2.6%. Laparoscopic approach results to be an extremely reliable procedure also for the treatment of incidentalomas up to 4-5 cm in which the incidence of adrenal carcinoma is about 13%. Doubts may yet result for the treatment of adrenal carcinomas preoperatively diagnosed. When laparoscopic adrenalectomy in performed using HS the operative time is significantly reduced and surgery is easier.