Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K
Department of Urology, Hamamatsu University School of Medicine, Hamamatsu, Japan.
J Urol. 2001 Aug;166(2):437-43.
To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches.
From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40.
To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive.
Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.
为阐明腹腔镜肾上腺切除术的手术方法特点，我们对三种手术方法的临床结果进行了背景匹配分析。
1992年2月至2000年7月，我们对115例肾上腺肿瘤患者实施了118例腹腔镜肾上腺切除术。其中46例采用经腹前路手术，32例采用经腹侧路手术，40例采用后腹腔镜侧路手术。
为排除学习曲线效应，我们剔除了最初采用经腹前路手术治疗的20例患者。为使三组背景匹配，我们还排除了14例肿瘤直径超过5 cm的患者、6例中转开腹手术的患者以及1例因套管针穿刺口出血导致腹膜后血肿而需卧床休息5天的患者。最终分析包括分别经腹前路、经腹侧路和后腹腔镜侧路手术治疗的16例、25例和36例患者。经腹侧路手术的平均手术时间明显更短。经腹侧路和后腹腔镜侧路两组术后恢复情况无显著差异。术后并发症包括2例轻度麻痹性肠梗阻，经腹手术组有4例出现肩峰部疼痛，可能是由于二氧化碳气腹和肠道准备导致的腹膜刺激。我们的结果表明，最简单的手术方法是经腹侧路手术，但后腹腔镜侧路手术的创伤性略小。
尽管必须记住本研究并非前瞻性随机试验，因此存在一定偏差，但我们认为，如果肿瘤直径超过5 cm和/或外科医生对腹腔镜肾上腺切除术尚不熟练，经腹侧路手术是最合适的方法。如果外科医生至少已进行过20例手术，肾上腺肿瘤为单侧且病变小于5 cm，后腹腔镜侧路手术因其微创性似乎更合适。有上腹部手术史的患者也更倾向于选择后腹腔镜侧路手术。随着技术和新器械的改进，后腹腔镜侧路手术所需时间已显著缩短。
