Laparoscopic right adrenalectomy: Is it necessary to use liver retraction trocar?

doi:10.21203/rs.3.rs-4853095/v1

Background and aims:

We aimed to evaluate the surgical outcomes and complications in patients who underwent right laparoscopic adrenalectomy (RLA) with or without using a liver retractor trocar.

Materials and Methods

In this cohort study, all patients who were candidates for RLA were included. One surgeon did not use a liver retractor at all while it was used by the others. All the pre-operative, peri-operative and surgical complications including hospitalization, surgical duration, Hb drop and pack cell injection, conversion to open surgery, and ICU admission were compared between the two groups.

Results

A total of 228 patients were included in this study: 60 patients in the group without liver retraction and 168 patients in the group with liver retraction. There were no differences in pre-operative data including sex (p = 0.740), history of surgery (p = 0.618), age (0.682), BMI (0.864), risk of anesthesia (p = 0.418), and tumor size (p = 0.218) between two groups. There were also no significant differences in peri-operative data and surgical complications including pack cells injection (p = 0.882), re-hospitalization (0.682), conversion of procedure to open surgery (p = 0.990), ICU admission (p = 0.782), hemoglobin drop (p = 0.662), surgical duration (p = 0.188), hospitalization duration (p = 0.062) and pathology report (0.916) between the two groups

Conclusion

According to the results of this study, the use or non-use of liver retraction in laparoscopic right adrenalectomy by an expert surgeon has no significant impact on peri-operative and post-operative outcomes and surgical complications. We do not recommend the routine use of a liver retractor trocar for this surgery, but only when the surgeon feels the need for it intraoperatively, which is rare in experienced surgeons.

Right adrenalectomy

Laparoscopic adrenalectomy

Adrenal mass

Surgical complications

Liver retraction

Laparoscopic adrenalectomy (LA) is considered as standard and highly effective treatment for both functional and non-functional adrenal tumors with small to medium sizes (≤ 6 cm) [1–3]. Consequently, LA has become the gold standard for adrenal surgery in benign tumors [4–6]. However, the increasing experience with LA has expanded its indications, even suggesting it for large and potentially malignant adrenal tumors [7, 8]. LA was first reported by Gagner in 1992 [9]. With advancements in surgical instruments and surgeons' skills, there has been a reduction in intraoperative bleeding, operative time, and length of hospital stay, leading to improved outcomes [10–12].

Several retrospective and comparative studies have explored the advantages of minimally invasive adrenalectomy, particularly with less postoperative pain, improved patient satisfaction, shorter hospital stays, and quicker recovery compared to open adrenalectomy [1, 10, 13]. These recent findings have been confirmed by several national surveys in the United States, affirming that laparoscopic adrenalectomy results in significantly fewer intraoperative complications and shorter hospitalizations [14, 15].

Adrenal glands are situated in a retroperitoneal space with limited exposure and are in close contact with major abdominal vessels, the liver, spleen, kidneys, and renal pedicle. The right adrenal gland is partly retrocaval in its anatomy, positioned posterior to the inferior vena cava (IVC) and directly drains into the IVC through a short central vein [16, 17]. Conversely, the left adrenal gland is located medially adjacent to the spleen, superior to the splenic artery and vein, laterally to the abdominal aorta, and anterior to the diaphragm. Due to anatomical characteristics, right laparoscopic adrenalectomy (RLA) can be more challenging than left laparoscopy [16, 18]. The right adrenal gland is situated under the liver bed that the liver lies on its right side, necessitating the need to displace the liver to access and manipulate the right adrenal gland. Conversely, in the left-sided anatomy, the spleen merely resides in proximity to the left adrenal gland without overlapping. Therefore, the incorporation of liver retraction is implemented to facilitate surgical access for adrenalectomy.

Transabdominal laparoscopic lateral adrenalectomy (TLA) is currently the most commonly used approach because it allows for optimal comprehensive visualization of the adrenal location and surrounding structures, providing a suitable working space. An additional benefit of the transabdominal approach is the possibility of exploring the abdominal cavity, facilitating the management of associated abdominal pathologies within the same procedure. Furthermore, this approach offers the option for rapid conversion to hand-assisted surgery or open surgery in cases of challenging dissection or intraoperative bleeding.

Most studies have shown that laparoscopic adrenalectomy with a transabdominal lateral approach is a safe method with low intraoperative complications and rare postoperative mortality [19–33]. Assessing the average reported complication rates for TLA due to the lack of standardized definitions in various studies is challenging. However, the average complication rates appear to be less than 9%, ranging from 2.9–15.5% [1, 19, 21, 23–25, 29–33].

Several risk factors for complications and conversion to open surgery, such as surgeon and hospital volume [20–26], tumor-related characteristics, and patient factors [19, 27–33], have been evaluated in single-center studies [19, 24, 30, 31, 33] and national studies [20–23, 25–27, 32].

In this study, we aim to investigate whether the inclusion of liver retraction has an impact on surgery parameters such as surgical duration, length of hospital stays, anesthesia risk, bleeding and visceral injury. Is it primarily beneficial for surgeons in the process of navigating the learning curve, or do experienced surgeons also benefit from its utilization?

In this prospective cohort study, all patients who presented to the urology clinic of Labbafinejad Hospital in the year 2020 to 2023 and were candidates for right laparoscopic adrenalectomy were enrolled. The study was not randomized, but patients sought different surgeons randomly. Patient information was recorded in a prospective manner. Additionally, patients were followed up with in-person visits after surgery, and other necessary data were collected. The surgical characteristics of these patients, including the operative duration, postoperative hemoglobin drop, length of hospital stay, and other necessary variables before and after surgery, were recorded. The outcomes were collected in two groups: those who used liver retraction (hepatobiliary retractor) and those who did not, and they were compared.

It's worth mentioning that in this center, one of the surgeons does not employ liver retraction at all, while the rest of the surgeons use liver retraction during laparoscopic adrenalectomy. All surgeons involved in this study have over 10 years of experience in performing laparoscopic adrenalectomy. A total 228 patients who presented to this center and were candidates for right laparoscopic adrenalectomy were include in the study.

Patients with any contraindications to laparoscopic surgery, lack of patient consent for participation in study and patients for whom follow-up was not possible for any reason were excluded from the study. In this study, we did not perform sample size calculation or sampling because all patients who presented to this center during the year of 2020 to 2023 and underwent right laparoscopic adrenalectomy had their information recorded.

Patient's position and retractors

The patient’s position and surgical setup for Transabdominal Lateral Adrenalectomy (TLA) require general anesthesia with controlled muscle relaxation. Current guidelines for prophylactic antibiotic therapy [34] and venous thromboembolism prevention [35] can be used for most adrenal pathologies, although some diseases (such as Cushing's syndrome) are associated with higher operative and postoperative risks [36]. Surgeons stand on the side of the patient's abdomen and face the monitor at the head of the patient. Otherwise, pneumoperitoneum is created at the first trocar site using an open access technique, followed by placement of the trocar. Pressure of 12 to 14 mmHg is usually used for CO2 insufflation.

Right laparoscopic adrenalectomy (surgical technique)

Right laparoscopic adrenalectomy requires a 10–12 mm trocar for endoscopy in the para-rectus area in line with the navel. Then, a diagnostic laparoscopy is performed. The ascending colon, right kidney, liver, diaphragm, and duodenum are examined. Under direct vision, the second trocar, measuring 5 mm, is placed laterally to the first trocar in the subcostal area. Through this trocar, graspers are used to expose the surgical field, and 3–4 mm instruments for achieving sufficient hemostasis. The third and fourth trocars (5 mm) are positioned superior and inferior to the first trocar, a blunt retractor may be introduced to retract the liver throughout the procedure through a 5mm trocar inferior to xiphoid. After placing the trocars, first, the adrenal gland is carefully separated from the kidney by fine dissection (Fig. 1). Then, by holding the adrenal gland up by grasper with the left hand, the adrenal gland is separated from the IVC with the help of bipolar cautery and scissors (or ligature). And finally, the adrenal gland is separated from the liver and the mass is removed by an endobag.

Ethical approval

The research received ethical approval from the Ethics Committee of Shahid Beheshti University of Medical Sciences, Urology and Nephrology Research Center, and all participants provided informed consent prior to the study. Researchers strictly adhere to all ethical principles, including patient confidentiality, and at no stage are patient names and addresses disclosed or revealed. The study was conducted in compliance with the ethical standards outlined in the 1964 Declaration of Helsinki, as revised in 2000 (Ethics code: IR.SBMU.MSP.REC.1402.016).

Statistical analysis

Initially, demographic information of the patients was presented using descriptive methods and frequency distributions. Subsequently, outcomes were compared across different groups using cross-tabulations and T-tests. Quantitative and qualitative variables that were identified were described using frequency tables. Data analysis was performed using SPSS software, specifically the Windows version 26.0. A significance level of p-value<0.05 was used to determine statistical significance.

Patients and pre-operative data: A total of 228 patients were included in this study, consisting of 60 patients (26.3%) in the group without liver retraction and 168 patients (73.7%) in the group with liver retraction. There were no differences in sex (p=0.740), history of surgery (p=0.618), age (0.682), BMI (0.864), risk of anesthesia (p=0.418) and tumor size (p=0.218) between two groups. All the patients’ characteristics are shown in table 1 in each group, separately.

Surgical Information and Postoperative Outcomes and Complications: There were no significant differences in peri-operative data, surgical outcomes and complications such as the number of injected pack cells for patients during and after the operation (p=0.882), fever (p=0.776), re-hospitalization (0.682), conversion of procedure to open surgery (p=0.990), hospitalization in ICU (p=0.782), hemoglobin drop (p=0.662), surgical duration (p=0.188) and hospitalization duration (p=0.062) between the two groups (Table 2). The results of the histopathological examination in the two groups are provided in detail in Tables 2. As observed, the pathology frequency of all cases in both groups is quite similar, and there is no significant difference.

Over the past two decades, minimally invasive techniques have replaced most open surgical approaches to reduce surgical injuries and shorten recovery times [37]. Laparoscopic adrenalectomy (LA) was introduced as a minimally invasive method for adrenal masses by Gagner and colleagues in 1992 [9] and has since become the gold standard surgical treatment for benign adrenal pathologies[4, 6, 38]. This procedure can be performed through transperitoneal or retroperitoneal approaches, with the choice of technique often depending on the surgeon's preference, experience, the size of the adrenal tumor and patient’s body habitus [12, 39].

LA on the right side can be more challenging due to the specific anatomical location of the right adrenal gland. During laparoscopic dissection, accessing the superior and medial aspects of the right adrenal gland and its vein can be problematic because these structures are in close proximity to the posterior surface of the liver, making exposure difficult. Classically, these vital areas are exposed by briefly retracting the liver upwards with an additional laparoscopic port placed under the liver. However, achieving static liver retraction is crucial and may be limited, especially in obese or large-liver patients. Laparoscopic adrenalectomy provides excellent exposure of the adrenal gland, which otherwise requires larger incisions and open approaches. It offers superior visualization of the suprarenal space, enhancing safety during dissection. Laparoscopic adrenalectomy can be performed through either a retroperitoneal or transperitoneal approach, with the surgeon's preference and experience being key factors in determining the best approach. The transperitoneal approach may require less experience in laparoscopy, provides a larger workspace, and offers more anatomical landmarks [39-41].

In a meta-analysis conducted by Yaxuan Wang and colleagues in 2022, five articles meeting specific criteria were selected and subjected to meta-analysis. The final findings suggest a higher risk of bleeding and a greater likelihood of conversion to open surgery, making right-sided adrenalectomy more hazardous and deserving of more attention [42]. Milena Duralska and colleagues, in a study conducted in 2022, examined adrenalectomy outcomes in the past two decades. They reported a reduction in complications during and after surgery and a decreased need for open surgery during recent years. Significant differences were observed between these two decades [43]. The impact of surgeon volume and hospital volume on postoperative outcomes in adrenal surgery appears to vary in different experiences [20-26]. In a population-based retrospective analysis by Park and colleagues [21], they found significantly higher complication rates (18.3% vs. 11.3%) and longer hospital stays (5.5 vs. 3.9 days) for procedures performed by low-volume surgeons among 3144 adrenalectomies. In a national study by Palazzo and colleagues [25], the authors found that the average length of hospital stay and the rate of readmission within 30 days were significantly higher in low-volume surgeons compared to high-volume surgeons.

Bergamini and colleagues [23] reported that age, BMI of patients, tumor size, and the diagnosis of pheochromocytoma are risk factors for complications, but they assessed these complications considerably lower in referral centers compared to non-referral centers. On the other hand, Gallagher and colleagues [26] found no correlation between surgeon volume and complication rates or length of hospital stay. However, the definition of high-volume surgeon vs. low-volume surgeon in different studies is likely highly variable due to the absence of a standardized method for determining the volume threshold. A recent nationwide study in the United States, which included a large number of patients undergoing adrenalectomy, demonstrated that higher surgeon volume is associated with better outcomes and lower patient-related costs, indicating that a higher volume is associated with larger tumors equal to or greater than 6 cm [20]. In line with these studies, we recommend right laparoscopic adrenalectomy without using hepatic trocar to surgeons who have a lot of experience in this surgery and operate in a high patient volume center.

Among the patient characteristics that significantly affect the outcomes of laparoscopic adrenalectomy, the most relevant risk factors for complications and surgical approach conversion included obesity [19, 33, 44], prior abdominal surgery history [19, 31, 45], tumor location [29], comorbidities [33], and the diagnosis of pheochromocytoma [33]. Obesity, with a body mass index (BMI) of 30 or greater, has been reported as a risk factor for adverse outcomes in laparoscopic adrenalectomy [44].

The right suprarenal gland is partially retrocaval and directly drains into the IVC through a short central vein [16, 17]. Due to these anatomical features, right laparoscopic adrenalectomy can be more challenging than the left side [16, 18]. However, different studies have reported varying results[17, 46]. A liver retractor is used to improve field exposure in right adrenalectomy. Given the increasing diagnosis of adrenal masses, studies comparing outcomes and complications between right adrenalectomy with and without liver retraction are needed, particularly for large-volume cases. Moreover, in various articles, different results have been reported on the comparison of left and right adrenalectomy and their complications. Therefore, as a new method in this study, we compared right adrenalectomy without liver retraction with cases where liver retraction was used. According to the results there were no significant differences in demographic parameters, including sex, history of surgery age, BMI, and tumor size, between the two groups. Additionally, as observed, surgical outcomes and postoperative complications, did not show significant differences between the two groups. It is worth noting that in this study, no need for a change in approach to open surgery was found in any case. However, in various studies, different results in the impact of using liver retraction on the outcomes of surgery and complications have been reported, which may be due to differences in the surgical skills and experience of the surgeon and their assistant during surgery.

According to the results of this study, the use or non-use of liver retraction in laparoscopic right adrenalectomy by an expert surgeon has no significant impact on peri-operative and post-operative outcomes and surgical complications. We do not recommend the routine use of a liver retractor trocar for this surgery, but only when the surgeon feels the need for it intraoperatively, which is rare in experienced surgeons.

Centimeters: cm

Laparoscopic adrenalectomy: LA

Right laparoscopic adrenalectomy: RLA

Transabdominal laparoscopic lateral adrenalectomy: TLA

Ethics approval and consent participate

The research received ethical approval from the Ethics Committee of Shahid Beheshti University of Medical Sciences, Urology and Nephrology Research Center, and all participants provided informed consent prior to the study. The study was conducted in compliance with the ethical standards outlined in the 1964 Declaration of Helsinki, as revised in 2000 (Ethics code: IR.SBMU.MSP.REC.1402.016).

Consent for publication

Not Applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

There is no funding received for this article.

Authors’ contributions

MH.S. And H.H.: Conceptualization, Project administration, Formal analysis, Supervision.

S.J. And B.N.: Data curation, Review Editing and Investigation.

MM.D. And A.J. And M.D.: Writing-Review and Editing, Writing Original Draft.

Acknowledgements

Not Applicable.

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Table 1: Demographic and Characteristics

Variables	With liver retraction	Without liver retraction	P value
number	168	60
Sex Male Female	50 (29.7%) 118 (70.2%)	15 (25%) 45 (75%)	0.740
History of surgery	48 (28.6%)	17 (28.3%)	0.618
Age	40.70 13.60	44.5 13.05	0.682
BMI	27.40 6.12	27.10 5.85	0.864
Tumor size	52.20 3.12	41.85 28.21	0.218
Risk of anesthesia Low risk Intermediate risk High risk	20 (11.9%) 82 (48.8%) 66 (39.3%)	6 (10.0%) 31 (51.7%) 23 (38.3%)	0.418

Table 2: Outcomes and Surgical Complications

Variables	With liver retraction		Without liver retraction	P value
Pack cell injection	4 (2.4%)	1 (1.7%)		0.882
Fever	5 (3.0%)	1 (1.7%)		0.776
Re-hospitalization	4 (2.4%)	1 (1.7%)		0.682
Conversion to open surgery	0 (0.0%)	0 (0.0%)		0.990
ICU admission	126 (75.0%)	57 (95.0%)		0.782
Hemoglobin drop	1.1 0.20	1.35 0.80		0.662
Surgical time	103.50 48.08	101.83 43.14		0.188
Hospitalization time	2.20 0.70	3.48 0.81		0.062
Pathology report Myelolipoma Carcinoma Cyst Cushing Conn’s adenoma Pheochromocytoma others	14 (8.3%) 8 (4.8%) 9 (5.4%) 11 (6.5%) 22 (13.1%) 82 (48.8%) 10 (6.0%)	4 (6.7%) 4 (6.7%) 3 (5.0%) 4 (6.7%) 10 (16.7%) 31 (51.7%) 4 (6.7%)		0.916

No competing interests reported.

Laparoscopic right adrenalectomy: Is it necessary to use liver retraction trocar?

Status:

Version 1

Abstract

Background and aims:

Materials and Methods

Results

Conclusion

Figures

Introduction

Methods and materials

Patient's position and retractors

Right laparoscopic adrenalectomy (surgical technique)

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1