Median arcuate ligament syndrome noticed during pancreaticoduodenectomy.

Median arcuate ligament syndrome (MALS) occurs as a result of compression of the celiac artery by a fibrous band called the median ligament, which originates from the diaphragmatic crus. The prevalence of MALS has been reported as 10-24% among patients. The etiology is not clear. The components of the clinical triad are a chronic post-prandial pain, epigastric murmur and weight loss. Diagnosis is based on clinical and radiological findings. MALS has been reported in a small portion of patients undergoing pancreaticoduodenectomy. Most of the patients have been diagnosed prior to surgery.

Rhabdomyolysis as a rare complication of bariatric surgery.

Rhabdomyolysis after bariatric surgery is a quite rare occurrence with low recognition. Due to the breakdown of striated muscle fibers, creatine kinase and myoglobin are released into systemic circulation with variable effects on renal filtering functions. Herein, it was aimed to present a patient who de- veloped rhabdomyolysis following revision bariatric surgery. This 34-year-old male patient was admitted for bariatric surgery. He had had a gastric band surgery approximately six years ago, with regain of weight starting one year after surgery gradually reaching the previous weight level. Consequently, the gastric band had been removed with open surgery three years ago. The patient had a body mass index of 69 kg/m2 as well as an incisional hernia due to previous surgery. Although initially laparoscopic sleeve gastrectomy was planned, a switch to open surgery was made due to the presence of diffuse intra-abdominal adhesions and giant incisional hernia precluding laparoscopic intervention. The total duration of surgery was 420 minutes. Postoperative laboratory work-up showed elevated blood creatine kinase (25837 U/L). Upon the failure of fluid replacement and diuretics, hemodialy- sis was initiated at postoperative day 1. Despite daily sessions of hemodialysis, acidosis did not improve, his general status worsened and the patient died on postoperative day 14. Rhabdomyolysis is a severe and potentially life-threatening complication of bariatric surgery. Its severity may vary from asymptomatic elevations of creatine kinase to death. Postoperative creatine kinase levels should be routinely checked in high-risk patients as a practical and inexpensive laboratory modality for early diagnosis.

Non-operative management of perforated peptic ulcer: A single-center experience.

BACKGROUND: Perforation is a rare complication of peptic ulcer. Although the most widely accepted treatment for peptic ulcer perforation is surgery, non-operative treatment can be an option in selected patients. In this study, we aimed to present our non-surgical treatment experience in peptic ulcer perforation. METHODS: In this study, the data of the patients who were treated due to peptic ulcer perforation between January 2012 and September 2017 in our clinic were retrospectively reviewed. The diagnosis was reached by physical examination and radiologic findings. After obtaining the informed consent from the patients, non-operative treatment was performed to the selected patients who had normal vital parameters and did not have findings of generalized peritonitis in the abdominal examination. Oral food and fluid intake were stopped and intravenous fluid, antibiotics and pantoprazole were administered to all patients in this study. RESULTS: A total of 41 patients were treated due to the diagnosis of peptic ulcer perforation in our clinic during the study period. Out of 41 patients, while 35 of the patients were operated, six of them were treated non-operatively. There were peritoneal irritation signs and symptoms in the upper quadrants on physical examination in all of the patients. None of them had generalized peritonitis. Abdominal X-ray and computed tomography were obtained from all of the patients. None of the patients in the non-operative group underwent any interventional procedure or surgery during the follow-up period. The median length of hospital stay was four days in this group. All of the patients were discharged uneventfully. CONCLUSION: Standard treatment of peptic ulcer perforation in most of the patients is still surgical repair. Non-surgical treatment should be kept in mind as an option in the selected patients who had normal vital parameters and did not have any findings of generalized peritonitis in the abdominal examination. In this way, it may be possible to avoid unnecessary surgery and reduce the possible morbidity and mortality associated with the operation.

Median arcuate ligament syndrome during pancreaticoduodenectomy.

Median arcuate ligament syndrome is caused by the compression of the celiac artery by a fibrous band called the median ligament, which originates from the crus of diaphragm. The prevalence of Median arcuate ligament syndrome has been reported as 10%-24% among patients; however, the etiology is unclear. The components of the clinical triad include a chronic post-prandial pain, epigastric murmur, and weight loss. Diagnosis is based on clinical and radiological findings. Median arcuate ligament syndrome has been reported in a small portion of patients undergoing pancreaticoduodenectomy. Most patients have been diagnosed prior to surgery.

Rhabdomyolysis as a rare but fatal complication of bariatric surgery: A case report.

Rhabdomyolysis after bariatric surgery is a quite rare occurrence with low recognition. Due to the breakdown of the striated muscle fibers, creatine kinase and myoglobin are released into the systemic circulation with variable effects on the renal filtration functions. Herein we present the case of a patient who developed rhabdomyolysis following revision bariatric surgery. A 34-year-old male patient was admitted for bariatric surgery. He had undergone a gastric band surgery approximately 6 years ago, with weight regain starting 1 year postoperatively gradually reaching the previous weight level. Consequently, the gastric band was removed with open surgery 3 years ago. The patient had a body mass index of 69 kg/m2 and an incisional hernia due to the previous surgery. Although initially, laparoscopic sleeve gastrectomy was planned, a switch to open surgery was made due to the presence of diffuse intra-abdominal adhesions and a giant incisional hernia precluding a laparoscopic intervention. The total duration of surgery was 420 min. Postoperative laboratory work-up showed elevated blood creatine kinase levels (25837 U/L). Upon the failure of fluid replacement and diuretics, hemodialysis was initiated on postoperative day 1. Despite daily sessions of hemodialysis, the patient's acidosis did not improve; his general status worsened, and he died on postoperative day 14. Rhabdomyolysis is a severe and potentially life-threatening complication of bariatric surgery. Its severity may vary from asymptomatic elevation in creatine kinase levels to death. Postoperative creatine kinase levels should be routinely monitored in high-risk patients as a practical and inexpensive laboratory modality for early diagnosis.

A Late Complication Occurring Due to Tacrolimus After Liver Transplant: Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome is a rare condition of the central nervous system that may occur in adults as well as in children. Clinically, it presents with mental status changes, visual loss, headaches, seizures, or coma. The diagnosis of posterior reversible encephalopathy syndrome is based on the typical appearance in occipital and parietal lobes in radiologic imaging studies, such as computed tomography or magnetic resonance imaging of the brain, which exhibit the typical appearance due to vasogenic edema. Causative factors include hypertensive encephalopathy, renal failure, preeclampsia, autoimmune conditions, and the use of cytotoxic or immunosuppressive agents. Rare cases of posterior reversible encephalopathy syndrome due to treatment with tacrolimus, an immunosuppressive agent commonly used after organ transplant, have been reported. In these patients, the tacrolimus dose is reduced or discontinued. In transplant patients with neurologic symptoms, the possibility of posterior reversible encephalopathy syndrome should be kept in mind.

Local recurrence after laparoscopic radiofrequency ablation of malignant liver tumors: Results of a contemporary series.

INTRODUCTION: The aims of this study were to determine the incidence of Local recurrence (LR) in patients at long-term follow-up after laparoscopic RFA (LRFA) and also to determine the risk factors for LR from a contemporary series. METHODS: Patients undergoing LRFA between 2005 and 2014 by a single surgeon were reviewed. Demographic and perioperative data were analyzed from a prospective database. RESULTS: LRFA was performed on 316 patients with 901 lesions. Median follow-up was 25 months, with 76% of whom completed at least one year of follow-up. The LR rate was 18.4%. The LR in patients followed for less than 12 months was 13.8%, 20.3% for 12 months, and 19.7% for 18 months (P = 0.02). One-fourth of the LRs developed after the 1st year. Morbidity was 8.9% and mortality 0.3%. Tumor type, size, ablation margin, and surgeon experience affected LR, with tumor type, size, and ablation margin being independent. CONCLUSIONS: This study shows that 14% of malignant liver tumors will develop LR within a year after LRFA. Additional 4% of the lesions will demonstrate recurrence within 1 cm of the ablation zone, mostly as part of a multifocal recurrence. Ablation margin is the only parameter that the surgeon can manipulate to decrease LR.

Unusual presentation; seeding of tumor after biopsy for hepatocellular carcinoma.

Hepatocellular cancer is one of the most common and fatal cancer tumor worldwide. However, the obtained results are questionable in terms of medical treatment of hepatocellular cancer. The muscle, soft tissue and cutaneous metastases of hepatocellular cancer, for instance, are rare and may result from interventional procedures. Seeding of tumor along the biopsy needle upon percutaneous biopsy is a very rare phenomenon. We report a very rare case of a 79 -year- old man, known to be hepatitis C virus carrier with a metastatic tumor in abdominal wall caused by seeding of tumor after three years following a percutaneous biopsy procedure. Even years later, after a biopsy procedure for diagnostic purposes and may be soft tissue metastases. This complication is a very rare condition that should not be ignored but can be observed. The biopsy requirement should be questioned closely and avoided unnecessary biopsy procedures.

Barriers Against Mammographic Screening in a Socioeconomically Underdeveloped Population: A Population-based, Cross-sectional Study.

OBJECTIVE: Mammography-screening (MS) rates remain low in underdeveloped populations. We aimed to find the barriers against MS in a low socioeconomic population. MATERIALS AND METHODS: Women aged 40-69 years who lived in the least developed city in Turkey (Mus), were targeted. A survey was used to question breast cancer (BC) knowledge and health practices. RESULTS: In total, 2054 women were surveyed (participation rate: 85%). The MS rate was 35%. Women aged 50-59 years (42%, p<0.001), having annual Obstetric-Gynecology (OB-GYN) visits (42%, p<0.001), reading daily newspaper (44%, p=0.003), having Social Security (39%, p=0.006) had increased MS rates. The most common source of information about BC was TV/radio (36%). Having doctors as main source of information (42%, p<0.001), knowing BC as the most common cancer in females (36%, p=0.024), knowing that BC is curable if detected early (36%, p=0.016), knowing that MS is free (42%, p<0.001) and agreeing to the phrase "I would get mammography (MG), if my doctor referred me" (36%, p=0.015) increased MS rates. Agreeing that MG exposes women to unnecessary radiation decreased MS rate (32%, p=0.002). CONCLUSION: To increase the MS rate in low socioeconomic populations, clear messages about BC being the most common cancer in women, MS after 40 years of age not causing unnecessary radiation but saving lives through enabling early detection, and MS being free of charge should be given frequently on audiovisual media. Uninsured women and women aged 40-49 years should be especially targeted. Physicians from all specialties should inform their patients about BC.

What approach should we take for the incidental finding of increased 18F-FDG uptake foci in the colon on PET/CT?

INTRODUCTION: F-Fluorodeoxyglucose (F-FDG) PET/CT represents an imaging modality that is gaining increasingly more prominence in screening, staging, and therapeutic monitoring of malignant diseases. An incidental focus of uptake in different regions of the body is not an uncommon finding during PET/CT imaging. Patients with incidental gastrointestinal tract findings comprise ∼3% of the overall patient group. The aim of the current study was to provide contributory information in relation to the answer on the most appropriate approach in cases with incidental colonic F-FDG uptake. PATIENTS AND METHODS: A retrospective examination was performed on PET/CT results of 5258 patients. Of these, 152 were recommended to undergo colonoscopy because of the presence of suspicious foci and 31 underwent colonoscopy within 60 days with biopsy from all visible lesions. These dates were also examined. RESULTS: Of the 24 patients undergoing colonoscopy with a suspicion of malignancy, five (20.83%) had no pathological findings. Of the 19 (79.17%) cases with a pathological finding in endoscopy, histopathology showed a benign lesion in five (20.83%), premalignant lesion in seven (29.17%), and a malignant lesion in seven (29.17%). Among seven patients undergoing colonoscopy because of a suspicion of inflammatory bowel disease, five were free of pathological signs and two patients with pathological endoscopy findings had nonspecific inflammation as documented by histopathological examination. CONCLUSION: Colonoscopic and histopathological examination of the increased foci of colonic F-FDG uptake incidentally detected at PET/CT seems to be a plausible approach.

The effect of laser epilation on recurrence and satisfaction in patients with sacrococcygeal pilonidal disease: a prospective randomized controlled trial.

BACKGROUND: The primary aim of this prospective study was to investigate the effects of laser epilation on patient satisfaction and recurrence in patients who underwent pilonidal sinus surgery. METHOD: Sixty patients scheduled for pilonidal sinus surgery in our clinic between 2011 and 2012 were enrolled in this prospective randomized controlled study. Patients were divided in two groups of 30 patients each. Only the Karydakis flap reconstruction technique was performed in the first group. Two sessions of laser epilation were applied in the second group in addition to Karydakis flap reconstruction. The patients in the second group underwent laser epilation 2 weeks before and 3 weeks after the surgery for a total of 2 times in a private office. RESULTS: There were no statistically significant differences between the groups in terms of age, gender, smoking usage, ASA Score, duration of patient's complaints, BMI and hospital stay. There were no statistically significant differences between the groups in terms of surgical site infection, wound separation, abscess formation at the any time postoperatively. There were statistically significant differences between the two groups in the first week post operation considering the VAS pain score (P<0.03) and VAS satisfaction score (P<0.01). While there were statistically significant differences between the two groups in the first month post operation considering the VAS pain score (P<0.0001), there were no statistically significant differences between the groups in terms of VAS satisfaction score in the first and three month postoperatively. In the telephone interviews done 1 year after the surgery, recurrence were detected in 4% of first group and in 20% of second group. Recurrence rates were significantly higher in the second group (P=0.045). CONCLUSION: Our results show that laser epilation does not reduce the relapse rates in pilonidal sinus surgery, as expected. It is obvious that prospective randomized studies need to be held on this subject.

A critical analysis of postoperative morbidity and mortality after laparoscopic radiofrequency ablation of liver tumors.

BACKGROUND: Although the laparoscopic approach provides certain advantages over the percutaneous radiofrequency thermal ablation (RFA), the morbidity needs to be defined. The aim of this study is to analyze the morbidity and underlying risk factors after laparoscopic RFA of liver tumors. METHODS: Between 1996 and 2012, 910 patients underwent 1,207 RFA procedures for malignant liver tumors in a tertiary academic center. The 90-day morbidity and mortality were extracted from a prospective IRB-approved database. Statistical analyses were performed using regression, t, and χ (2) tests. RESULTS: Complications occurred in 50 patients (4 %) and were gastrointestinal in 13 patients (1.1 %), infections in 10 (0.8 %), hemorrhagic in 9 (0.7 %), urinary in 7 (0.6 %), cardiac in 4 (0.3 %), pulmonary in 3 (0.3 %), hematologic in 2 (0.2 %), and neurologic in 2 (0.2 %). The complication rates for an RFA done alone (5 %) versus concomitantly with ancillary procedure (6 %) were similar (p = .6). In all patients who developed postoperative bleeding from the liver, the ablations had been performed on lesions located in the right posterior sector. Of 9 patients with bleeding, 5 (55 %) required a laparotomy. Also, 60 % of liver abscesses occurred in patients with a prior bilioenteric anastomosis (BEA). The 90-day mortality was 0.4 % (n = 5). Hospital stay was 1.2 ± 0.1 days and was prolonged to 4.4 ± 0.3 days in case of complications. CONCLUSIONS: This study describes the morbidity and mortality to be expected after a laparoscopic RFA procedure. Our results show that additional caution should be used to prevent bleeding complications in patients with tumors located in the right posterior sector and infections in patients with a history of BEA.

Robotic versus laparoscopic adrenalectomy for pheochromocytoma.

BACKGROUND: Although initial reports demonstrated the safety and feasibility of robotic adrenalectomy (RA), there are scant data on the use of this approach for pheochromocytoma. The aim of this study is to compare perioperative outcomes and efficacy of RA versus laparoscopic adrenalectomy (LA) for pheochromocytoma. METHODS: Within 3 years, 25 patients underwent 26 RA procedures for pheochromocytoma. These patients were compared with 40 patients who underwent 42 LA procedures before the start of the robotic program. Data were retrospectively reviewed from a prospectively maintained, IRB-approved adrenal database. RESULTS: Demographic and clinical parameters at presentation were similar between the groups, except for a larger tumor size in the robotic group. In both groups, skin-to-skin operative time, estimated blood loss less, and intraoperative hemodynamic parameters were similar. The conversion to open rate was 3.9 % in the robotic and 7.5 % in the laparoscopic group (p = .532). There was no morbidity or mortality in the robotic group; morbidity was 10 % (p = .041) and mortality 2.5 % in the laparoscopic group. The pain score on postoperative day 1 was lower, and the length of hospital stay shorter in the robotic group (1.2 ± .1 vs. 1.7 ± .1 days, p = .036). CONCLUSIONS: To our knowledge, this is the first study comparing robotic versus laparoscopic resection of pheochromocytoma. Our results show that the robotic approach is similar to the laparoscopic regarding safety and efficacy. The lower morbidity, less immediate postoperative pain, and shorter hospital stay observed in the robotic approach warrant further investigation in future larger studies.

Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain.

BACKGROUND: Unnecessary hospital admissions and negative appendectomies increase healthcare costs of patients with right lower quadrant (RLQ) pain. This study aimed to evaluate the impact on the cost of treatment of appendicitis scoring systems. METHODS: Charts were reviewed of patients admitted to the general surgery ward of our hospital with RLQ pain within a year. Alvarado and Lintula scores were calculated, and a simulation was performed to determine the treatment charges that would have been generated had the scoring recommendations been used for admission and surgical decision-making. RESULTS: Of the 114 admitted patients, 64 (56%) underwent appendectomy. The rate of negative appendectomy was 17.2%. The overall accuracy rates of the Alvarado and Lintula scores for both 'admit' and 'operate' decision-making were 82.7% and 91.9%, respectively (p=0.102). Total charges for the 114 patients were $39,655. If the Alvarado or Lintula score had been used, the total treatment charges would have been $34,087 and $25,772 (p=0.015 and p=0.000), with negative appendectomy rates of 18.5% and 3.6%, respectively. CONCLUSION: The implementation of Alvarado and Lintula scores for the decision of hospital admission and appendectomy would have reduced overall treatment charges for acute RLQ pain.

Effect of autotransfusion system on tumor recurrence and survival in hepatocellular carcinoma patients.

AIM: To investigate the therapeutic efficacy and safety of continuous autotransfusion system (CATS) during liver transplantation of hepatocellular carcinoma patients. METHODS: Eighty-three hepatocellular carcinoma (HCC) patients who underwent liver transplantation with intraoperative CATS (n = 24, CATS group) and without (n = 59, non-CATS group) between April 2006 and November 2011 at the Liver Transplant Institute of Inonu University were analyzed retrospectively. Postoperative HCC recurrence was monitored by measuring alpha-fetoprotein (AFP) levels at 3-mo intervals and performing imaging analysis by thoracoabdominal multidetector computed tomography at 6-month intervals. Inter-group differences in recurrence and correlations between demographic, clinical, and pathological data were assessed by ANOVA and χ(2) tests. Overall and disease-free survivals were calculated by the univariate Kaplan-Meier method. RESULTS: Of the 83 liver transplanted HCC patients, 89.2% were male and the overall mean age was 51.3 ± 8.9 years (range: 18-69 years). The CATS and non-CATS groups showed no statistically significant differences in age, sex ratio, body mass index, underlying disease, donor type, graft-to-recipient weight ratio, Child-Pugh and Model for End-Stage Liver Disease scores, number of tumors, tumor size, AFP level, Milan and University of California San Francisco selection criteria, tumor differentiation, macrovascular invasion, median hospital stay, recurrence rate, recurrence site, or mortality rate. The mean follow-up time of the non-CATS group was 17.9 ± 12.8 mo, during which systemic metastasis and/or locoregional recurrence developed in 25.4% of the patients. The mean follow-up time for the CATS group was 25.8 ± 15.1 mo, during which systemic metastasis and/or locoregional recurrence was detected in 29.2% of the patients. There was no significant difference between the CATS and non-CATS groups in recurrence rate or site. Additionally, no significant differences existed between the groups in overall or disease-free survival. CONCLUSION: CATS is a safe procedure and may decrease the risk of tumor recurrence in HCC patients.

Complementary use of resection and radiofrequency ablation for the treatment of colorectal liver metastases: an analysis of 395 patients.

BACKGROUND: Liver resection and radiofrequency ablation (RFA) are two surgical options in the treatment of patients with colorectal liver metastases (CLM). The aim of this study was to analyze patient characteristics and outcomes after resection and RFA for CLM from a single center. METHODS: Between 2000 and 2010, 395 patients with CLM undergoing RFA (n = 295), liver resection (n = 94) or both (n = 6) were identified from a prospective IRB-approved database. Demographic, clinical and survival data were analyzed using univariate and multivariate analyses. RESULTS: RFA patients had more comorbidities, number of liver tumors and a higher incidence of extrahepatic disease compared to the Resection patients. The 5-year overall actual survival was 17 % in the RFA, 58 % in the Resection group (p = 0.001). On multivariate analysis, multiple liver tumors, dominant lesion >3 cm, and CEA >10 ng/ml were independent predictors of overall survival. Patients were followed for a median of 20 ± 1 months. Liver and extrahepatic recurrences were seen in 69 %, and 29 % of the patients in the RFA, and 40 %, and 19 % of the patients in the Resection group, respectively. CONCLUSIONS: In this large surgical series, we described the characteristics and oncologic outcomes of patients undergoing resection or RFA for CLM. By having both options available, we were able to surgically treat a large number of patients presenting with different degrees of liver tumor burden and co-morbidities, and also manage liver recurrences in follow-up.

Reuse of a pediatric liver graft: a case report.

We report the reuse of a liver graft after brain death of the first recipient. The liver donor was an 8-year-old male who died as a result of head injury. The graft was implanted first to a 4-year-old girl for fulminant hepatic failure. Unfortunately she developed progressive coma and brain death on fifth day of transplantation. The graft functions were normal, and reuse of the liver graft was planned. After informed consent, the graft was transplanted to a 31-year-old female recipient who has hepatocellular carcinoma with an underlying cryptogenic liver cirrhosis. The patient was discharged to home on 9th day after an uneventful postoperative period. However, she was readmitted to hospital with an acute abdominal pain 30 days after the operation. Hepatic artery thrombosis was diagnosed, and the attempt to open the artery by interventional radiology was unsuccessful. She died of sepsis and multiorgan failure on 37th posttransplant day.

The diagnostic value of D-dimer, procalcitonin and CRP in acute appendicitis.

BACKGROUND: The early diagnosis of acute abdomen is of great importance. To date, several inflammatory markers have been used for the diagnosis of acute abdominal conditions, including acute appendicitis. The aim of this study was to evaluate the diagnostic utility of D-dimer, Procalcitonin (PCT) and C-reactive protein (CRP) measurements in the acute appendicitis. METHODS: This prospective study was conducted between March 1(st), 2010 and July 1(st), 2011. In this period, seventy-eight patients were operated with the diagnosis of acute appendicitis, and D-dimer, PCT and CRP levels of the patients were measured. The patients were grouped as phlegmonous appendicitis (Group 1), gangrenous appendicitis (Group 2), perforated appendicitis (Group 3) and negative appendectomy (Group 4) according to the surgical findings and histopathological results. RESULTS: Of 78 patients, 54 (69.2 %) were male and 24 (30.8 %) were female, and the mean age was 25.4 ± 11.1 years (range, 18 to 69 years). 66 (84.6 %) patients had increased leukocyte count (white blood cell count). The PCT values were higher than the upper normal limit in 20 (25.6%) patients, followed by D-dimer in 22 (28.2 %) patients and CRP in 54 (69.2 %) patients. The diagnostic value of leukocyte count and CRP in acute appendicitis was higher than that of the other markers, whereas leukocyte count showed very low specificity. CRP values were higher in perforated appendicitis when compared with the phlegmonous appendicitis (p < 0.05). However, PCT and D-dimer showed lower diagnostic values (26% and 31%, respectively). CONCLUSION: An increase in CRP levels alone is not sufficient to make the diagnosis of acute appendicitis. However, CRP levels may differentiate between phlegmonous appendicitis and perforated appendicitis. Due to their low sensitivity and diagnostic value, PCT and D-dimer are not better markers than CRP for the diagnosis of acute appendicitis.

Robotic vs laparoscopic posterior retroperitoneal adrenalectomy.

OBJECTIVE: To compare robotic vs laparoscopic posterior retroperitoneal adrenalectomy with regard to perioperative outcomes. DESIGN: Prospectively study. SETTING: Tertiary academic center. PATIENTS: Thirty-one patients who underwent robotic posterior retroperitoneal adrenalectomy and 31 consecutive patients who underwent laparoscopic posterior retroperitoneal adrenalectomy from a prospective institutional review board-approved database. MAIN OUTCOME MEASURES: Demographic and clinical parameters, operative time, presence of complications, length of hospital stay, and pain score on postoperative days 1 and 14. RESULTS: The mean (SEM) tumor sizes for the robotic and laparoscopic groups were similar (3.1 [0.2] and 3.0 [0.2] cm, respectively; P = .48). For all patients, the mean (SEM) skin-to-skin operative times were similar in both groups (163.2 [10.1] and 165.7 [9.5] minutes, respectively; P = .43). When the last 21 patients who underwent robotic posterior retroperitoneal adrenalectomy were compared with the 31 patients from the laparoscopic series, it was seen that the mean (SEM) operative time was shorter for the robotic group than for the laparoscopic group (139.1 [10.9] vs 166.9 [8.2] minutes; P = .046). The mean (SEM) estimated blood losses and hospital stays were similar between groups. The mean (SEM) pain score on postoperative day 1 was lower in the robotic group than in the laparoscopic group (2.5 [0.3] vs 4.2 [0.4]; P = .008); however, the mean (SEM) pain scores for the groups were similar on postoperative day 14 (P = .53). There were no deaths or cases of morbidity in either group. CONCLUSIONS: Our study shows that, beyond the learning curve for experienced laparoscopic surgeons, robotic posterior retroperitoneal adrenalectomy shortens the skin-to-skin operative time compared with the laparoscopic approach. Our results also suggest that the immediate postoperative pain may be less severe for patients who undergo robotic posterior retroperitoneal adrenalectomy.

Robotic versus laparoscopic resection of large adrenal tumors.

BACKGROUND: Although recent studies have shown the feasibility and safety of robotic adrenalectomy, an advantage over the laparoscopic approach has not been demonstrated. Our hypothesis was that the use of the robot would facilitate minimally invasive resection of large adrenal tumors. METHODS: Adrenal tumors≥5 cm resected robotically were compared with those removed laparoscopically from a prospective institutional review board-approved adrenal database. Clinical and perioperative parameters were analyzed using t and chi-square tests. All data are expressed as mean±standard error of mean. RESULTS: There were 24 patients with 25 tumors in the robotic group and 38 patients with 38 tumors in the laparoscopic group. Tumor size was similar in both groups (6.5±0.4 [robotic] vs 6.2±0.3 cm [laparoscopic], P=.661). Operative time was shorter for the robotic versus laparoscopic group (159.4±13.4 vs 187.2±8.3 min, respectively, P=.043), while estimated blood loss was similar (P=.147). The conversion to open rate was less in the robotic (4%) versus the laparoscopic (11%) group; P=.043. Hospital stay was shorter for the robotic group (1.4±0.2 vs 1.9±0.1 days, respectively, P=.009). The 30-day morbidity was 0 in robotic and 2.7% in laparoscopic group. Pathology was similar between groups. CONCLUSIONS: Our study shows that the use of the robot could shorten operative time and decrease the rate of conversion to open for adrenal tumors larger than 5 cm. Based on our favorable experience, robotic adrenalectomy has become our preferred minimally invasive surgical approach for removing large adrenal tumors.