Robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access: technical feasibility and preliminary results.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy (PRA) has several benefits compared with transperitoneal adrenalectomy in that it is safe and has a short learning curve. In addition, it provides direct short access to the target organ, prevents irritation to the intraperitoneal space, and does not require retraction of adjacent organs.1 (-) 3 We have performed several cases of robot-assisted PRA using single-port access for small adrenal tumors. This multimedia article introduces the detailed methods and preliminary results of this procedure. METHODS: Five patients underwent single-port robot-assisted PRA between March 2010 and June 2011 at our institution. During the procedure, patients were placed in a prone jackknife position with their hip joints bent at a right angle (Fig. 1). A 3 cm transverse skin incision was made just below the lowest tip of the 12th rib (Fig. 2), and the Glove port (Nelis, Kyung-gi, Korea) was placed through the skin incision while maintaining pneumoretroperitoneum (Fig. 3). CO2 was then insufflated to a pressure of 18 mm Hg to create an adequate working space. A 10 mm robotic camera with a 30-degree up view was placed at the center of the incision through the most cephalic portion of the Glove port. A Maryland dissector or Prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA) was placed on the medial side of the incision, and Harmonic curved shears (Intuitive Surgical) were placed on the lateral side of the incision (Fig. 4). Using the Maryland dissector and the harmonic curved shears, the Gerota fascia is opened, perinephric fat is dissected, and the kidney upper pole is mobilized to expose the adrenal gland (Fig. 5). Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction (Fig. 6). After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is ligated with a 5 mm hemolock clip (Fig. 7). Patient clinicopathologic data were analyzed retrospectively. RESULTS: The mean patient age was 56.6 ± 8.7 (range, 47-69) years. Right and left side approaches were used in two and three patients, respectively. All cases were adrenal cortical adenoma. The mean tumor size was 1.48 ± 0.28 (range, 1.0-1.7) cm. The mean surgery duration (skin to skin) was 159.4 ± 57.6 (range, 103-245) minutes, and the mean estimated blood loss was 46.0 ± 56.8 (range, 5-120) ml. The average time to oral intake and postoperative hospital stay were 0.65 ± 0.11 (range, 0.54-0.79) days and 4.0 ± 2.23 (range, 3-8) days, respectively. There were no conversions to open surgery or postoperative compli- cations. DISCUSSION: Some trials of minimally invasive single-access surgery of the adrenal gland have recently been performed.4 (,) 5 However, these new techniques have several limitations as a result of restrictions on instrumentation movement because of the small access ports used and relatively low-quality images produced. The recent introduction of the da Vinci S surgical robot system (Intuitive Surgical) to endoscopic surgery has improved instrumental dexterity and provided the surgeon with an ergonomically designed operating system. This system is also potentially safer and more meticulous in performing operations than endoscopic procedures as a result of a 3-D, magnified, stable operative view.6 (,) 7 The advantages of the da Vinci S surgical robot system and the numerous benefits of the posterior retroperitoneal approach motivated us to utilize single-port robot-assisted PRA. The primary selection criteria were small tumor size and a minimal amount of periadrenal fatty tissue because robot-assisted PRA using single-port access provides a small operative space, which causes manipulation problems when tumors are large. To ensure the safe application of these new techniques, we recommend that novice surgeons begin using single-port robot-assisted PRA for smaller tumors < 2 cm in patients with a body mass index of < 30 kg/m(2), gradually extending the size and body mass index as they accumulate experience. Although robot-assisted PRA using single-port access could not be compared with the other robotic adrenalectomy techniques in this study, the potential advantages of this approach compared to conventional robot-assisted transperitoneal adrenalectomy include a reduction in postoperative ileus, bacterial contamination, and intestinal complications because the peritoneal cavity is not opened, in addition to a reduction in postoperative pain because of its minimally invasive nature. CONCLUSIONS: Our initial experiences with robot-assisted PRA using single-port access assured us of its safety and feasibility for the resection of small adrenal tumors. Although single-port robot-assisted PRA appears to be safe and feasible, further experience and research is required to optimize patient selection criteria and verify its advantages over the traditional three-incision PRA technique.

Differentiated thyroid carcinoma of children and adolescents: 27-year experience in the yonsei university health system.

Thyroid carcinomas are uncommon in childhood and adolescence. The aim of this study was to analyze clinical features and clinical outcomes of thyroid cancer in the pediatric population treated in the Yonsei University Health System. From September 1982 to June 2009, 90 patients (75 females, 15 males; female:male ratio of 5:1) with differentiated thyroid carcinoma were identified in our institute. The mean age at diagnosis was 15.8 yr old (range 4.8-19.9 yr). Cervical masses were most common clinical manifestations at diagnosis in 65 patients (72.2%). Forty-two patients underwent less than total thyroidectomy and 18 patients underwent total thyroidectomy. Thirty patients (33.3%) had lateral neck lymph node metastasis and seven patients (7.8%) had lung metastasis at the time of surgery. Among the 90 patients, recurrence occurred in 14 patients (15.5%). Mean follow-up period for patients with differentiated thyroid carcinoma was 81.6 months (13-324 months). No patients died of differentiated thyroid carcinoma. Patients with differentiated thyroid carcinoma who were < 20-yr-of-age were present with aggressive local disease and a high frequency of lymph node and distant metastasis. It is recommended that pediatric thyroid cancer should be managed mostly using proper surgical approach with thyroidectomy and lymph node dissection when indicated.

A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors.

BACKGROUND: Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of small adrenal tumors. However, several approach routes, such as the transperitoneal (TP), lateral retroperitoneal, and the posterior retroperitoneal (PR) approaches are being used based on surgeon's preference. The PR approach has several benefits compared with the others. Recently, the authors used the PR approach to treat several adrenal tumors and here describe the methods used in detail and the preliminary results obtained. METHODS: From January 2009 to July 2010, 58 patients underwent adrenalectomy. Open adrenalectomy and robotic adrenalectomy were performed in 5 and 10 patients. Also, 43 patients underwent laparoscopic adrenalectomy, and the TP and PR approaches were used in 26 and 17 patients, respectively. Clinicopathologic data and surgical outcomes were evaluated and compared retrospectively. RESULTS: There were no significant differences between the TP and PR groups in terms of age, sex, BMI, lesion side, volume of blood loss, or tumor size (3.86 ± 3.83 in TP approach, 2.64 ± 1.61 in PR approach). Mean operative time and average oral intake time using the PR approach were shorter than for the TP approach. Less analgesia use was required in patients who underwent PR approach. CONCLUSIONS: This study shows that posterior retroperitoneoscopic adrenalectomy is a safe procedure and the operative time is comparable to transperitoneoscopic adrenalectomy. The use of the PR approach for small adrenal tumor can provide very favorable surgical outcomes compared with the TP approach.

A comparative study of the surgical outcomes of robotic and conventional open modified radical neck dissection for papillary thyroid carcinoma with lateral neck node metastasis.

BACKGROUND: Several endoscopic modified radical neck dissections (MRND) have been conducted since the introduction of the endoscopic technique to thyroid surgery with the aim of avoiding a long cervical scar. Furthermore, the recent introduction of surgical robotic systems has increased the precision of endoscopic techniques. The aim of this study was to evaluate and compare the early surgical outcomes of robotic and conventional open MRND for papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM). METHODS: From January 2009 to May 2010, 165 patients with PTC underwent bilateral total thyroidectomy with central compartment neck dissection and ipsilateral MRND. Of these patients, 56 formed the robotic procedure group (RG) and 109 the conventional open procedure group. These two groups were retrospectively compared with respect to their clinicopathological characteristics, early surgical outcomes, and surgical completeness. RESULTS: The operative time was longer, mean tumor size was smaller, mean age was lower, and disease stage was earlier in the RG. However, mean numbers of retrieved lymph nodes were similar in the two groups, and mean hospital stay after surgery was shorter in the RG. Furthermore, complication rates were similar in the two groups, and there was no statistical difference in postoperative Tg levels between the groups. CONCLUSIONS: Robotic MRND was found to be similar to conventional open MRND in terms of early surgical outcomes and surgical completeness but leaves no scar on the neck area. Robotic MRND can be viewed as an acceptable alternative method in low-risk PTC with LNM.

Role of prophylactic ipsilateral central compartment lymph node dissection in papillary thyroid microcarcinoma.

Central compartment lymph node (CCLN) management in patients without clinical or radiologic evidence of CCLN metastasis is debatable. The aim of the present study was to evaluate outcomes of surgery for papillary thyroid microcarcinoma (PTMC) with prophylactic ipsilateral CCLN dissection (PI-CCND) in a large cohort of patients treated at one single institution in a 5-year follow-up. Between January 2000 and December 2005, 2192 patients with papillary thyroid carcinoma underwent thyroid surgery. Inclusion criteria were patients with PTMC, absence of clinical or radiologic evidence of CCLN metastasis, and a follow-up for a period ≥60 months. Data from 842 patients were retrieved in the current retrospective cohort study. PI-CCND was routinely performed in addition to thyroid surgery in all cases. Ipsilateral CCLN metastasis was found in 218 patients (25.9%). Postoperative complications included 76 cases of transient hypoparathyroidism (9%), 11 cases of permanent hypoparathyroidism (2.6%), four cases of vocal cord palsy (0.5%), and one case of bleeding (0.1%). Univariate analysis and multivariate logistic regression analysis revealed that CCLN metastasis was statistically significantly correlated with tumor size and extracapsular invasion. Recurrence has been observed to date in 19 patients (2.26%). No CCLN site recurrence occured in patients who underwent PI-CCND. This study demonstrates the technical feasibility and safety of PI- CCND, which is a better way to determine lymph node status for a more accurate staging of disease and risk stratification. PI-CCND should be considered even if clinical or radiological exams are negative for CCLN metastasis.

Coexistence of chronic lymphocytic thyroiditis with papillary thyroid carcinoma: clinical manifestation and prognostic outcome.

The study aimed to identify the clinical characteristics of coexisting chronic lymphocytic thyroiditis (CLT) in papillary thyroid carcinoma (PTC) and to evaluate the influence on prognosis. A total of 1,357 patients who underwent thyroid surgery for PTC were included. The clinicopathological characteristics were identified. Patients who underwent total thyroidectomy (n = 597) were studied to evaluate the influence of coexistent CLT on prognosis. Among the total 1,357 patients, 359 (26.5%) had coexistent CLT. In the CLT group, the prevalence of females was higher than in the control group without CLT (P < 0.001). Mean tumor size and mean age in the patients with CLT were smaller than without CLT (P = 0.040, P = 0.047, respectively). Extrathyroidal extension in the patients with CLT was significantly lower than without CLT (P = 0.016). Among the subset of 597 patients, disease-free survival rate in the patients with CLT was significantly higher than without CLT (P = 0.042). However, the multivariate analysis did not reveal a negative association between CLT coexistence and recurrence. Patients with CLT display a greater female preponderance, smaller size, younger and lower extrathyroidal extension. CLT is not a significant independent negative predictive factor for recurrence, although presence of CLT indicates a reduced risk of recurrence.

Initial experience with robotic gasless transaxillary thyroidectomy for the management of graves disease: comparison of conventional open versus robotic thyroidectomy.

PURPOSE: The aim of this study was to report on our initial experiences with robotic gasless transaxillary thyroidectomy for the management of Graves disease (GD). METHODS: Among 257 patients with benign thyroid diseases who underwent thyroidectomy, 16 patients who underwent thyroidectomy for GD were analyzed from January 2009 to December 2010. These patients included 7 individuals who underwent robotic gasless transaxillary thyroidectomy (robot group; RG) and 9 who underwent conventional open thyroidectomy (open group; OG). Regardless of the type of surgery, all patients underwent subtotal thyroidectomy. The clinical characteristics and surgical outcomes of the 2 groups were compared. RESULTS: Patients in the RG were significantly younger at the time of surgery compared with those in the OG (P=0.028). The mean operative time was 171.29±18.88 minutes for the RG and 89.44±7.08 minutes for the OG (P=0.001). The mean weight of the resected glands was 77.43±12.29 g for the RG and 85.56±20.37 g for the OG (P=0.896). The RG had a significantly shorter mean hospitalization period of 3.0±0 days compared with 3.78±0.22 days of the OG. The mean number of times analgesics were used for pain control were 2.43±0.29 for the RG and 4.0±0.52 for the OG (P=0.039). No cases in the RG were converted to open thyroidectomy. During a mean follow-up period of 14.43±1.49 months for the RG, no patients continued antithyroid drugs or developed recurrent GD. CONCLUSIONS: Robotic gasless transaxillary thyroidectomy is a technically feasible and safe procedure for the patients with GD that results in a scarless outcome on the neck. This procedure can be a promising alternative for endoscopic or conventional open thyroidectomy for the management of GD.

Laparoscopic appendectomy is a safe and beneficial procedure in pregnant women.

BACKGROUND: Appendectomy is the most common nongynecologic surgery performed during pregnancy. Pregnancy is no longer considered an absolute contraindication for laparoscopic procedures. Laparoscopic appendectomy (LA) is a safe, effective, and beneficial procedure for the treatment of acute appendicitis. However, limited data are available regarding the safety and feasibility of LA during pregnancy. METHODS: Between May 2005 and May 2009, 20 patients with clinically suspected appendicitis in pregnancy underwent LA at Chungbuk National University Hospital. Clinical data collected retrospectively included demographic information. We compared maternal age, gestational age, operation time, anesthetic time, surgical complications, length of hospitalization, and final outcome of pregnancy. RESULTS: All the 20 patients who underwent LA did not need a conversion. Mean maternal age was 28.1 years (range, approximately 20 to 35 y), gestational age was 15.4 weeks (range, approximately 6 to 30 wk), mean operation time was 45.5 minutes (range, approximately 25 to 90 min), mean length of hospital stay was 4.7 days (range, approximately 2 to 11 d). Fifteen of 20 pregnant women delivered healthy term infants and 5 women have kept a healthy pregnancy. CONCLUSIONS: Our data support the accumulating evidence that LA is a safe and feasible procedure for the treatment of acute appendicitis in all trimesters of pregnancy. Close maternal and fetal monitoring is essential during and after the operation.

Prospects of robotic thyroidectomy using a gasless, transaxillary approach for the management of thyroid carcinoma.

PURPOSE: Robotic surgical systems are among the most innovative surgical developments and have radically promoted the use of minimally invasive techniques. Robotic technologies using different approaches have also been applied to thyroid surgery. Recently, the authors described a novel robotic surgical method for thyroid surgery based on a gasless, transaxillary approach (TAA), and have since serially reported on its technical feasibility and safety. Here, the authors report their experience of a consecutive series of 1000 cases treated using robotic thyroidectomy, and demonstrate its use for the surgical management of thyroid cancer. PATIENTS AND METHODS: From October 2007 to November 2009, 1000 patients with thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless TAA. All patients were selected using predetermined inclusion criteria after considering surgical risk, and all procedures were completed successfully using the da Vinci S or Si surgical system (Intuitive Surgical, Sunnyvale, CA). Patient's clinicopathologic characteristics, operation types, operation times, numbers of retrieved lymph nodes (LNs), postoperative hospital stays, complications, and short-term follow-up results were analyzed. RESULTS: Mean patient age was 39.1 ± 9.6 years and the male-to-female ratio was 1:12.6 (73:927). Six hundred twenty-seven patients underwent less than total and 373 patients underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all 1000 cases and additional lateral neck node dissection was conducted in 36 of the 1000 patients. Mean operation time was 136.7 ± 44.4 minutes and mean postoperative hospital stay was 3.0 ± 0.45 days. No serious postoperative complication occurred, except 3 cases of recurrent laryngeal nerve injury, and 1 case of Horner syndrome. Mean tumor size was 0.79 ± 0.6 cm and papillary thyroid microcarcinoma was in 752 cases (75.5%). The mean number of retrieved central LNs per patient was 4.62 ± 3.14. Central neck LN metastasis occurred in 361(36.1%) and lateral neck LN metastasis in 36 cases (3.6%). According to tumor nodes metastasis staging, 847 patients (84.7%) were of stage I, 144 patients (14.4%) were of stage III, and 9 patients (0.9%) were of stage IVA. CONCLUSIONS: The authors conclude that robotic thyroidectomy using a gasless TAA is a feasible, safe, and promising surgical alternative for selected patients with low-risk thyroid cancer, and recommend that the inclusion criteria of this technique be gradually extended to advanced thyroid cancer given suitable operator experience and future developments in robotic systems and instrumentation.