Abstract
We read with interest the robot-assisted posterior adrenalectomy report by Ludwig and associates. We would like to congratulate the authors on their technique. Our endocrine surgery group at the Cleveland Clinic has also had a specific interest in the laparoscopic posterior retroperitoneal (PR) technique and would like to share our experience with the history and technique of this procedure.
Dr. Selcuk Mercan 1 from Istanbul, Turkey, was the first surgeon who described the laparoscopic PR adrenalectomy procedure in 1995. Initially, there was not much interest in performing this procedure across the world; the lateral transabdominal (LT) approach was easier to perform because of more easily recognized landmarks. After its initial description, our group modified the Mercan procedure by adding intraoperative ultrasonography and described the technique on 31 patients in 2000 as the first report from the United States. 2 Our modification involved the use of percutaneous ultrasonography before incision to guide trocar placement and subsequent laparoscopic ultrasound to identify the adrenal gland to facilitate the dissection, which sometimes can be difficult in obese patients and those with smaller tumors. In our subsequent report that compared 99 posterior retroperitoneal and 73 lateral transabdominal adrenalectomies, we demonstrated that both techniques have a similar perioperative outcome when patients are selected for each approach based on certain criteria. 3 Subsequently, Dr. Martin Walz 4 from Essen, Germany, was instrumental in popularizing the procedure by reporting large series of patients and introducing a modification to the technique by maintaining a higher insufflation procedure of 20 mm Hg to keep the space open.
The laparoscopic PR approach is still limited by the small space, rigid instrumentation, and patient's body habitus. Therefore, it is an ideal indication for robot-assisted surgery. After establishing our Robotic Endocrine Surgery program in 2008 and getting comfortable with the robotic LT approach, we started doing PR adrenalectomies robotically. We described our technique as a poster and video at the Scientific Session of the Society of the American Gastrointestinal and Endoscopic Surgeons at National Harbor, MD, held April 14 to 17, 2010. 5,6 Our robotic approach 7 has some differences compared with the current report by Ludwig and colleagues. After intubation on the gurney, we place the patient in a prone jackknife position using a Wilson frame. We do not tuck any of the arms: Both are placed on arm boards along the head of the table toward the anesthetist. We use 5-mm instruments to decrease collision. We keep the insufflation pressure at 15 mm Hg for most cases and increase it to 20 mm Hg only in cases with difficulty in establishing the space. We do the dissection using a 5-mm grasper and a Harmonic scalpel. We prefer to ligate the adrenal vein, either by using the Harmonic scalpel or a 5-mm endoscopic clip applier. As mentioned, we use intraoperative ultrasonography. For patient selection, our cutoff is 6 cm, and we look at the thickness of the soft tissues at the back, not necessarily the body mass index.
We agree with the authors that the main limitation of the technique is the inability to suction during dissection when all robotic instruments are in use. We overcome this by taking one of the robotic instruments out and inserting a laparoscopic suction irrigator through the same trocar. This prolongs the operation, especially with an inexperienced first assistant. We believe that it is important for the safety of the patient to have two experienced surgeons do this procedure. This might not always be possible, however, and there is a need to train the residents and fellows in robot-assisted surgery.
Footnotes
Disclosure Statement
Dr. Eren Berber is a consultant for Intuitive Surgical, Inc.