Innovation in surgical oncology Vrielink, Otis
DOI:
10.33612/diss.173351128
IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.
Document Version
Publisher's PDF, also known as Version of record
Publication date:
2021
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):
Vrielink, O. (2021). Innovation in surgical oncology. University of Groningen.
https://doi.org/10.33612/diss.173351128
Copyright
Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).
Take-down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.
Chapter 5
Considerations in
minimally invasive adrenal surgery: the front door
or the backdoor?
O.M. Vrielink, P.H.J. Hemmer, S. Kruijff Minerva Chir. 2018 Fed;73(1):93-99
ABSTRACT
In the last decades, in minimally invasive adrenal surgery, the retroperitoneoscopic adrenalectomy (PRA) has shown favourable results when compared to the laparoscopic transperitoneal adrenalectomy (LTA). However, for many endocrine surgeons it is unclear if, when, and how to transition from LTA to PRA. Although the length of the learning curve for both approaches is comparable, the LTA is a technically more challenging procedure whilst PRA demands an orientation in a new environment in a patient that is positioned upside down. Visiting a proctor is crucial for successfully adopting the PRA procedure, and continued mentorship in a surgeon’s own hospital during the first procedures is preferable. There are several other aspects related to the decision to transition to PRA; the caseload of adrenal patients, learning aspects of other members of the team, technical considerations, case selection and a well-developed emergency plan in case of complications during surgery. In a dedicated endocrine centre with a considerable annual caseload of approximately 30 procedures, we recommend to transition to PRA in order to provide the highest quality of care to adrenal patients.
5 INTRODUCTION
Despite the enormous progress of the posterior retroperitoneoscopic adrenalectomy (PRA) in the last twenty years, many adrenal surgeons still prefer the laparoscopic transperitoneal adrenalectomy (LTA). Although operating via the “backdoor” goes along with major advantages such as shorter surgeries, minimal blood loss and minimal postoperative pain, the unfamiliar and small anatomic space and reluctance for yet another learning curve forms a threshold for transition. Therefore, the question many adrenal surgeons would like to have answered is; should I change my technique to posterior and is it worth the learning curve?
History of open surgery
The adrenal gland is one of the most inaccessible abdominal organs, which explains the various number of different surgical approaches that have been described in the past. Adrenal surgery has a long history, with the first planned adrenalectomy performed in 1914 by Sargent.1 In 1927 Charles Mayo performed the first flank approach for pheochromocytoma, though at the time he was probably unaware of the risks of operating on patients with this complex disease. As anatomically the adrenal gland is a dorsal retroperitoneal organ it can surgically be approached via an anterior or a posterior route. Therefore, since the early to mid 1900s several open posterior and anterior approaches have been developed to resect the adrenal gland safely. The anterior approach offered the advantages of being well known to all surgeons and allowing a bilateral exploration. However, a longer recovery time and higher ileus rate were seen and the procedure might be challenging especially when operating on obese patients. For the open posterior approach the incision is made posteriorly over the 11th or 12th rib, with or without a “hockey stick” cephalic extension. A great downside of this open posterior procedure is nerve damage of the twelfth subcostal nerve and musculoskeletal pain as quite often for exposure the 11th and 12th rib needs to be resected.
Although in the last decades laparoscopic surgery became the treatment of choice for the majority of adrenal masses, in an excellent adrenal centre, open adrenalectomy remains to play an important role for radical treatment of adrenal cortical cancer (ACC) or other large lesions of unknown origin (>7-10 cm). Even in the present day, being competent in performing a safe and radical open adrenal operation remains an important tool in the armamentarium of a good adrenal or endocrine surgeon.
History of LTA
During the mid-twentieth century, for decades little changes to adrenal surgical strategies were seen, until the first laparoscopic adrenalectomy was described by Gagner in 1992.2 This innovation at the beginning of the surgical minimally invasive evolution marked a new era for adrenal treatment. For smaller tumours, anterior laparoscopic surgery became the golden standard being associated with less blood loss and shorter hospital stay.3,4 Later, even for larger benign tumours and also for pheochromocytoma the LTA has proven to be effective and safe.4 The retroperitoneoscopy had already been performed by Bartel in 1969, however at that time the endoscopic camera and instrumentation was of low quality which formed an extra hurdle when operating dorsally in comparison with the anterior approach which was performed in the spacious abdominal environment where surgeons knew their way.5 In the early nineties, while the LTA technique was concurring the world, frontline endocrine surgeons such as Delbridge and later Walz already tried to develop a posterior retroperitoneal adrenalectomy (PRA) aiming to combine the privileges of minimal access with the ease of a more direct and safe approach to the adrenal gland.5,6 Although these endoscopic surgeries were successful, the minimal vision of the first generation endoscopic cameras of those days made it just a bit too early for a definite breakthrough for the PRA. But this would not last for long.
Evolution of the PRA
In 1996 Dr. Walz published his first series on the PRA procedure as he had operated a total of 30 procedures performed on 27 patients.7 The collection of patients consisted of seven Cushing adenomas, five Conn adenomas, seven pheochromocytomas, four hormonally inactive tumours and one cyst. All operations were carried out in the prone position. After balloon dilatation of the retroperitoneum and creation of a pneumoretroperitoneum, the preparation of the adrenal gland was performed via three trocar sites positioned below the 12th rib. At this stage of development, Walz had to perform five conversions, the average operating time was 124 minutes and the blood loss was minimal. This paper marked the beginning of the PRA evolution.7 Eleven years later, in 2006, his group published a large patient cohort of 520 patients.8 They concluded that although PRA still seemed less popular than LTA globally, the direct approach to the adrenal glands was much easier to use and offered major advantages for adrenalectomy. This was supported by the fact that in eleven years their mean operating time had declined to 67 minutes. At this stage, the PRA in Essen clinic had become a safe and fast procedure and in experienced hands seemed to be the ideal approach for adrenal surgery.8 However, there were still only a few other clinics performing the PRA procedure this way. In following years, Walz was invited several times in international meetings to present his data and to demonstrate his procedure in live surgery sessions. He also invited endocrine surgeons from all over the world to his clinic and organized adrenal surgery sessions where he shared his skills
5
and knowledge with his peers trying to convince them of the major advantages of the PRA procedure. During these days and during many of his presentations he claimed the PRA procedure to be fast, safe, pain free, with good cosmetics and easy to learn.
He showed his visitors the advantage of organizing regular adrenal days where he, by means of two operation rooms and two teams, operated nine patients per day performing PRA. The logistic process, the team cooperation, and the skill and patient outcome were impressive. Ninety percent of the operated patients were discharged the same day barely using any painkillers. These data and developments influenced endocrine surgeons around the world to increasingly move to the retroperitoneal environment.9-11 The lack of necessity to mobilize intra-abdominal organs such as liver, pancreatic tail or spleen with all the dangers involved made it increasingly attractive to move to the new PRA technique.
The fact that less harm can be done to the adjacent organs during the procedure was significantly reflected by lower complication rates. Other dominant advantages of the retroperitoneal approach are the avoidance of peritoneal adhesions in patients with a previous history of abdominal surgery, easier and more efficient bilateral adrenalectomy in one surgical session without the need for repositioning of the patient and lastly its feasibility in obese patients as the abdominal fat is located at the non-operative ventral side of the patient. Finally, as the peritoneum is not involved during this procedure there was a significant reduction of postoperative pain and admission days.12
The PRA learning curve
As most surgeons are unfamiliar with the anatomic environment of the retroperitoneal space since they are not exposed to it during their surgical training, the use of PRA requires a substantial learning time.13 Even for an experienced endoscopic skilled surgeon the learning curve will therefore demand an orientation in a new anatomical environment in a patient that is literally turned upside down. A comprehensive training can shorten the learning period; about 20-25 PRA’s would be necessary to apprehend the PRA procedure.14 Walz et al. showed that the retroperitoneal approach is difficult to perform in patients with large tumours (>7-8 cm) and in patients with a high BMI.8 Other concerns have been raised regarding the higher CO2 pressure needed for PRA (20-25 mmHg) to form the operation space instead of the earlier balloon, but in no study CO2 related complications, such as CO2 embolism were described for PRA.8,15 For LTA, approximately 20-40 cases are required to go through the learning curve.16 The length of the learning curve for PRA for second generation adrenal surgeons, a potential barrier for adaptation of the procedure, has never been well assessed. Recently, a group from Nijmegen published data of their own learning curve in a single centre environment.17 Although they reported significant advantages in operating times and hospital stay for PRA, it concerns only a single centre learning curve with a stabilization in operation time after a large amount of 70 procedures.
Recently, we therefore analysed the first consecutive PRA`s performed by four surgical
teams from four university centres in three different countries, with operation time as primary outcome measure. A total of 181 procedures performed by four surgical teams were analysed and the conclusion was that in specialized endocrine surgical centres a range of 12-42 procedures is required to fulfil the entire learning curve for the PRA.18
The length of a learning curve is related to knowledge, training, the complexity of a procedure, previous experience, proctorship and mentoring.19 To visit an institution with expertise in the technique is crucial for successfully adopting a procedure. Continued mentorship during the first phase is crucial. In case of lack of mentors a team can also choose for telementoring in which an experienced physician guides a surgical procedure by video monitoring.20 Of course this way of teaching will not be comparable with the quality of direct supervision by an experienced professional that stands in your own operation room and guides you through the procedure.
Conditions needed when considering PRA implementation Volume
The implementation of PRA into clinical practice is a complex process requiring extensive preparation and time. However, if prepared well, the implementation will eventually benefit adrenal patient outcome. When a team wants to implement PRA, the annual caseload should be substantial. If the annual caseload is too low, it will be hard to overcome the learning curve. When combined with an earlier mentioned
“adrenal day” structure an optimum of time efficiency, individual learning and team learning occurs. As the procedure requires complex positioning it is very efficient to be able to perform the PRA procedure four times a day as it facilitates routine and repetition. Therefore, implementing the PRA procedure seems to fit best in large endocrine clinical environments where between 30 and 40 adrenalectomies per year are performed.
Team
Excellent team cooperation is needed to implement PRA, especially during the first procedures an excellent collaboration is mandatory. The involved anaesthesiologist, theatre personnel and the other members of the surgical team are often unfamiliar with correctly positioning the patient in the prone position. During the introductory phase, positioning of the patient will take substantial more time and attention and therefore practice sessions with a fake patient are recommended. Another important consideration is that the prone position in combination with high retroperitoneal CO2 pressures can cause the serum pCO2 to rise. The first PRA procedures often take long, demanding adequate pCO2 management. Therefore, an anaesthesiologist with experience in ‘‘prone’’
positioning, such as spinal procedures, is preferred.
5
Technical aspects of the PRA procedure
Although resecting the same organ as LTA, the PRA procedure is anatomically as well as technically a completely different operation. For PRA, the correct placement of incisions and the precise positioning of the patient aiming to create a good exposure to the intended surgical area are of vital importance. Only when the patient is positioned in a correct way, the area between the ileum and the lower dorsal ribs is well enough exposed to have sufficient access during the entire operation. After incision and opening of the dorsal wall in a blunt fashion with scissors, the index finger is inserted in the retroperitoneal space after which the second incision and 5 mm trocart is inserted laterally on the index finger in a controlled manner. Hereafter, the 10 mm trocart is inserted and the pneumoretroperitoneum is created using 25 mmHg. Now the camera is introduced and with the left hand Gerota’s fascia is opened by making pulling and dissecting movements. The manipulation combined with the high CO2 pressures forms the surgical operating field. The anatomical landmarks are the psoas muscle, diaphragm, peritoneum and kidney. When the kidney is found, the upper pole is dissected and surgically exposed. After identification of the adrenal vein, the adrenal gland can be dissected from between the diaphragm and peritoneum. In contrast with the LTA, the PRA is merely a dissecting operation where the above described anatomical area have to be cleared of tissue. In the ideal PRA operation, the adrenal gland is only identified in the specimen.
Case selection during the learning curve
After starting the implementation process it is recommendable to preoperatively select easy patient cases in order to prevent too challenging cases, aiming to build team confidence. The criteria for expected difficulty are retroperitoneal fat on preoperative CT scan, male sex (difficult dissection on the kidney), pheochromocytoma or adrenal metastases of other malignancies. Pheochromocytoma in the first cases can create hemodynamically stressful situations that prevent the surgeon from focusing on the technical aspects. Adrenal metastases of various malignancies (melanoma, lung cancer, colon cancer and breast cancer) are usually stuck in the environment, are complicated to dissect and can be involved with pancreas, liver or kidney. Also, adrenal cases of the external obese and patients with adhesions should be reserved for later. The ideal “starting patients” for the first series are females with Conns disease or adrenal incidentalomas smaller than five centimetres.
Conversion and complications
When first starting PRA, a long operation with rising pCO2 pressures can be a reason for converting if for instance the adrenal gland or the kidney cannot be found.
Complications such as renal vein, renal artery or ureter injury are described and usually
are the result of a disorientated surgical team lost in an unfamiliar environment. If this is the case, the team should move back to the old strategy or call for help by an experienced surgeon that is comfortable in this area.
Furthermore, there should be an emergency plan in case of a major venous bleeding from for instance the caval vein. If a bleeding occurs the pCO2 should be elevated and a gauze can be inserted to give pressure on the vein to control the situation. Eventually, the cava should be repaired preferentially by means of an endoscopically placed suture. If this is technically not feasible, during the first procedures a second table can be reserved in the next room to be able to flip and turn over the patient quickly and convert to an open anterior approach. Another option can be to convert to posterior although this is not an attractive option as even after a rib resection exposure can be very disappointing especially in an emergency situation.
5 CONCLUSION
When considering what procedure to perform for minimally invasive adrenal surgery, the PRA procedure seems to have become the new golden standard mainly because the approach is focused on the actual anatomical home of the adrenal gland: the retroperitoneal space.
Indeed, the PRA is a direct approach where the surgeon does not lose time dissecting on other organs such as liver, pancreas, colon or spleen. When going through the learning curve, eventually it becomes a fast procedure and once the surgeon is well orientated the procedure is very safe. As the peritoneum is left untouched in general, postoperatively the PRA is almost pain free demanding barely any painkillers on the first postoperative days. The learning curve of PRA is comparable with that for LTA but is more directly related to the three-dimensional orientation than the actual technical endoscopic skills. The amount of procedures to master is defined somewhere between 12 and 40 procedures depending on how well the implementation process is organised.14,18 The PRA is an entirely different procedure with a different positioning, different understanding of the environment and different technique, and it is only worthwhile going through the learning curve if a clinic performs between 30 and 40 procedures per year. If in a clinic with a low volume the LTA approach is performed satisfactory, we would therefore not recommend a PRA transition. On the other hand, with an annual caseload of more than 30 not making the PRA transition would be a lost opportunity in saving medical means for healthcare and providing the highest quality for adrenal patients.
Article information
This is a postprint version of the article published in Minerva Chirurgica. This version is free to view and download to private research and study only. Not for redistribution or re- use. ©Edizioni Minerva Medica. The final published article is available online on Minerva Medica website at https:doi.org[10.23736/S0026-473317.07465-X].
REFERENCES
1. Prager G, Heinz-Peer G, Passler C, Kaczirek K, Schindl M, Scheuba C, et al. Surgical strategy in adrenal masses. Eur J Radiol. 2002;41(1):70-77.
2. Gagner M, Lacroix A, Prinz RA, Bolté E, Albala D, Potvin C, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery. 1993;114(6):1120-1124; discussion 1124-1125.
3. Bulus H, Uslu HY, Karakoyun R, Kocak S. Comparison of laparoscopic and open adrenalectomy.
Acta Chir Belg. 2013;113(3):203-207.
4. Elfenbein DM, Scarborough JE, Speicher PJ, Scheri RP. Comparison of laparoscopic versus open adrenalectomy: Results from american college of surgeons-national surgery quality improvement project. J Surg Res. 2013;184(1):216-220.
5. Bartel M. Retroperitoneoscopy. an endoscopic method for inspection and bioptic examination of the retroperitoneal space. Zentralblatt für Chirurgie. 1969-3-22;94(12):377-383.
6. Walz MK, Peitgen K, Krause U, Eigler FW. Dorsal retroperitoneoscopic adrenalectomy--a new surgical technique. Zentralblatt für Chirurgie. 1995;120(1):53-58.
7. Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eigler FW. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: Results of 30 adrenalectomies in 27 patients. World J Surg. 1996-9;20(7):769-774.
8. Walz MK, Alesina PF, Wenger FA, Deligiannis A, Szuczik E, Petersenn S, et al. Posterior retroperitoneoscopic adrenalectomy--results of 560 procedures in 520 patients. Surgery. 2006- 12;140(6):943-948.
9. Vrielink OM, Wevers KP, Kist JW, Borel Rinkes IHM, Hemmer PHJ, Vriens MR, et al. Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy: A shift to a new golden standard? Langenbecks Arch Surg. 2017;402(5):767-773.
10. Perrier ND, Kennamer DL, Bao R, Jimenez C, Grubbs EG, Lee JE, et al. Posterior retroperitoneoscopic adrenalectomy: Preferred technique for removal of benign tumors and isolated metastases. Ann Surg. 2008-10;248(4):666-674.
11. Barczynski M, Konturek A, Nowak W. Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow- up. Ann Surg. 2014;260(5):740-747; discussion 747-748.
12. Kiriakopoulos A, Economopoulos KP, Poulios E, Linos D. Impact of posterior retroperitoneoscopic adrenalectomy in a tertiary care center: A paradigm shift. Surg Endosc. 2011-11;25(11):3584-3589.
13. Schreinemakers JM, Kiela GJ, Valk GD, Vriens MR, Rinkes IH. Retroperitoneal endoscopic adrenalectomy is safe and effective. Br J Surg. 2010-11;97(11):1667-1672.
14. Barczynski M, Konturek A, Golkowski F, Cichon S, Huszno B, Peitgen K, et al. Posterior retroperitoneoscopic adrenalectomy: A comparison between the initial experience in the invention phase and introductory phase of the new surgical technique. World J Surg.
2007;31(1):65-71.
15. Dickson PV, Alex GC, Grubbs EG, Ayala-Ramirez M, Jimenez C, Evans DB, et al. Posterior retroperitoneoscopic adrenalectomy is a safe and effective alternative to transabdominal laparoscopic adrenalectomy for pheochromocytoma. Surgery. 2011-9;150(3):452-458.
16. Sommerey S, Foroghi Y, Chiapponi C, Baumbach SF, Hallfeldt KK, Ladumer R, et al.
Laparoscopic adrenalectomy--10-year experience at a teaching hospital. Langenbecks Arch Surg. 2015;400(3):341-347.
5
17. van Uitert A, d’Ancona FC, Deinum J, Timmers HJ, Langenhuijsen JF. Evaluating the learning curve for retroperitoneoscopic adrenalectomy in a high-volume center for laparoscopic adrenal surgery. Surg Endosc. 2016.
18. Vrielink OM, Engelsman AF, Hemmer PHJ, de Vries J, Vorselaars WMCM, Vriens MR, et al.
A multicenter evaluation of the surgical learning curve for posterior retroperitoneosocpic adrenalectomy. AAES Annual Meeting 2016 Poster presentation.
19. Goitein D, Mintz Y, Gross D, Reissman P. Laparoscopic adrenalectomy: Ascending the learning curve. Surg Endosc. 2004;18(5):771-773.
20. Treter S, Perrier N, Sosa JA, Roman S. Telementoring: A multi-institutional experience with the introduction of a novel surgical approach for adrenalectomy. Ann Surg Oncol. 2013;20(8):2754- 2758.
21. Kelly M, Jorgensen J, Magarey C, Delbridge L. Extraperitoneal ‘laparoscopic’ adrenalectomy.
Aust N Z J Surg. 1994;64(7):498-500.
22. Sasagawa I, Suzuki H, Izumi T, Suzuki Y, Tateno T, Nakada T. Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma. J Endourol.
2000;14(7):573-576.
23. Walz MK, Peitgen K, Walz MV, Hoermann R, Saller B, Giebler RM, et al. Posterior retroperitoneoscopic adrenalectomy: Lessons learned within five years. World J Surg. 2001- 6;25(6):728-734.
24. Sasagawa I, Suzuki Y, Itoh K, Izumi T, Miura M, Suzuki H, et al. Posterior retroperitoneoscopic partial adrenalectomy: Clinical experience in 47 procedures. Eur Urol. 2003;43(4):381-385.
25. Alesina PF, Hommeltenberg S, Meier B, Petersenn S, Lahner H, Schmid KW, et al. Posterior retroperitoneoscopic adrenalectomy for clinical and subclinical cushing’s syndrome. World J Surg. 2010;34(6):1391-1397.
26. Dickson PV, Jimenez C, Chisholm GB, Kennamer DL, Ng C, Grubbs EG, et al. Posterior retroperitoneoscopic adrenalectomy: A contemporary american experience. J Am Coll Surg.
2011;212(4):659-665; discussion 665-667.
27. Epelboym I, Digesu CS, Johnston MG, Chabot JA, Inabnet WB, Allendorf JD, et al. Expanding the indications for laparoscopic retroperitoneal adrenalectomy: Experience with 81 resections.
J Surg Res. 2014;187(2):496-501.
28. Cabalag MS, Mann GB, Gorelik A, Miller JA. Posterior retroperitoneoscopic adrenalectomy:
Outcomes and lessons learned from initial 50 cases. ANZ J Surg. 2015;85(6):478-482.
SUPPLEMENTARY INFORMATION
Table S1 Important publications on the posterior retroperitoneal adrenalectomy in the prone position
Author Year Number of
procedures
Operation time, min Conversion, n (%)
Kelly et al.21 1994 2 218.5 (197 - 240) 0 (0.0)
Walz et al.6 1995
Walz et al.7 1996 30 124 (45 - 225) 5 (16.7)
Sasagawa et al.22 2000 10 154 (110 - 231) 0 (0.0)
Walz et al.23 2001 142 101 (35 - 285) 7 (5.0)
Sasagawa et al.24 2003 47 198 (71 - 420) 1 (2.1)
Walz et al.8 2006 560 55 9 (1.7)
Barzcynski et al.14 2007 100 100 8 (8.0)
Perrier et al.10 2008 68 121 (28 - 226) 6 (8.8)
Schreinemakers et al.13 2010 112 100 (90 - 130) 2 (1.8)
Alesina et al.25 2010 183 58 (20 - 230) 1 (0.5)
Dickson et al.26 2011 128 114 7 (6.6)
Epelboym et al.27 2014 81 80 (+/- 30) 0 (0.0)
Cabalag et al.28 2015 50 70.5 (54 - 85) 0 (0.0)
