Minimally invasive surgery of the adrenal gland : laparoscopic versus robotic approach : an observational retrospective case-control study on 141 cases

Abstract

BACKGROUND. Since Gagner performed the first Laparoscopic Adrenalectomy in 1992 [1], laparoscopy has quickly become the gold standard for benign adrenal masses removal [5], providing lower complication rates, reduced operative blood loss (EBL), less perioperative pain and shorter hospital stay (LOS). However, some of the technical limitations of laparoscopy, such as the two dimensional vision, the instability of the camera, and the limitation of movements through the laparoscopic rigid instruments, makes laparoscopic adrenalectomy (LA) a chellenging procedure, affected by a steep learning curve. In the past decade robotic adrenalectomy (RA) as been described as an alternative to the laparoscopic approach, the intrinsic advantages of the robotic platform, as the three-dimensional and stable vision[6], tremor filtering, and endowristed instruments with 7 degrees of freedom, may overcome some of the the technical limitations of laparoscopy and eventually shorten the learning curve [7]. Criticism still exists towards robotic surgery; most controversial issues being related to operative times and high costs. To date, the indication to perform an adrenalectomy with a minimally invasive technique is still limited to benign pathology [8]. The aim of the study is to compare laparoscopic and robotic adrenalectomy in terms of surgical technique and short term post-operative outcomes. In this study, we will analyse a series of patients who underwent laparoscopic and robotic adrenalectomy over a period of 11 years, in which the laparoscopic surgeons gradually learned and performed robotic adrenalectomy, also we will compare both surgical technique in terms of the periopetative outcomes. MATERIALS AND METHODS. This is a retrospective observational study on 141 patients undergoing minimally invasive adrenalectomy, laparoscopic and robotic, from January 2006 to December 2017. Perioperative and postoperative outcomes included operative time, length of hospital stay, blood loss, complications, and conversions to open Operative time was analized in relation of BMI, tumor side and tumor size for both techniques. RESULTS: 80 LA and 61 RA were performed. Operative times were longer in the robotic group, this difference reached statistical significance only for right adrenalectomy. Tumor size influenced operative time in LA, but not RA. BMI did not influence operative times in both techniques. Length of hospital stay was significantly shorter in the RA group. No conversion to open was registered. No difference in post-operative complications was registered between the two techniques. CONCLUSIONS: In relation to the experience of the surgical team and the technology available, RA and LA are both safe and do not change the clinical outcomes in patients with benign adrenal lesions. RA may offer an advantage in length of hospital stay and in the treatment of large adrenal masses, expanding the indications of minimally invasive surgery. Randomized multicenter studies with larger samples are needed to further evaluate the impact of the robotic platform in adrenal surgery.