EDITORIAL

GUIA DE LECTURA

JULIO 2011 Volumen 1 Numero 6

BOLETIN ALACE

Con alguna frecuencia me encuentro en los periódicos un aviso donde

se ofrece algún producto que cura definitivamente el asma o el cáncer.

En la radio un supuesto médico ofrece un oligoelemento que cura abso-

lutamente todo incluyendo los cálculos vesiculares, un “especialista”

ofrece unas cápsulas para bajar de peso cuyo contenido no puede decir por tratarse de una “fórmula secreta” seguramente milenaria.

Mi actitud frente a esto ha sido tradicionalmente de indiferencia.

En algunos casos me he preguntado: ¿dónde están las autoridades com-

petentes, los mecanismos reguladores?

Cada vez me convenzo más, que estos individuos proliferan justamente

por nuestra indiferencia.

Somos nosotros los médicos los que tenemos que detenerlos.

Yó no podré opinar mucho frente al asma pero sé positivamente que

una persona no debe tomar ningún medicamento cuyo contenido ignore,

también sé que no hay ninguna pastilla que cure TODOS los cánceres. Propongo no perder nuestra capacidad de indignación y protesta.

Dr. José De Vinatea De Cárdenas

SECCION VIDEOS

SECCION IRRE-

VERENTE

SECCION

GALERIA

SECCION EDITORIAL

SECCION CASOS

CURIOSOS

SECCION CON-

TROVERSIAS

SECCION ANALI-

SIS CRITICO

SECCION:LO QUE

NUNCA ME

ENSEÑARON

SECCION: CIRU-

GIA BASADA EN

EVIDENCIAS

2

3

4

5

6 Y 7

COMITÉ

EDITORIAL

Si desea recibir el BOLETIN ALACE, escriba a: boletinalace@gmail.com, en caso contrario

escriba al correo poniendo en asunto: NO DESEO

DR: JOSE DE VINATEA

DR: CARLOS BENAVIDES

DR: AURELIO GAMBIRA-

ZIO

DR: EDGAR GONZALES

ING. MIGUEL PRADA

DR: GUSTAVO REAÑO

DRA: MONICA URIBE

DR: DAVID ORTEGA

PUBLICACION OFICIAL DE LA

ASOCIACION LATINOAMERICANA

DE CIRUGIA ENDOSCOPICA

SECCION CASOS CURIOSOS:

AUTOCESAREA

Página 2

Volumen 1 Numero 6

Inés Ramírez Pérez (1960, Oaxaca, México) Es una mujer mexicana originaria del estado de Oaxaca

quien logró fama mundial de manera notoria al practicarse una cesarea ella misma.

Inés Ramírez es una mujer campesina que vive en una zona rural de Méxi-

co. Sólo habla zapoteco -lengua materna- (no habla español), y nunca reci-

bió entrenamiento médico alguno. No obstante se practicó ella misma una

cesárea de manera exitosa. Ambos, ella y su bebé sobrevivieron.

Ramírez se encontraba sola en su choza cercana a Río Talea, México, cuan-

do la labor de parto comenzó, la comadrona más cercana se hallaba a 80 km

de distancia, a lo largo de un terreno irregular y lleno de caminos difíciles,

su marido se encontraba bebiendo en una cantina. Río Talea tiene 500 habi-

tantes y solamente cuenta con una línea telefónica, pero muy lejana.

A la medianoche del 5 de marzo del año 2000 después de 12 horas de conti-

nuo dolor y un pequeño avance en la labor, Inés se sento en un banco y co-

menzó a beber una botella de alcohol para frotar, utilizó un cuchillo de coci-

na con el cual se practicó un corte para abrirse el abdomen. Ramírez cortó a

través de su piel en una línea diagonal por encima del estómago hacia el

ombligo (una típica Sección-C llega más abajo del ombligo). Después de

operarse ella misma por espacio de una hora consiguió llegar al útero y ex-

traer a su bebé.

Después cortó el cordón umbilical con unas tijeras, y cayó inconsciente al poco tiempo. Cuando recuperó el

conocimiento, se envolvió el abdomen herido y le pidió a su hijo de 6 años de edad, Benito, que consiguie-

se auxilio. Horas más tarde, el médico de la aldea encontró a Inés yaciendo al lado de su bebé, despierta y

consciente. El médico suturó la incisión de 17 cm de largo con una aguja e hilo disponibles. Finalmente fue

llevada al hospital más cercano, en donde dos obstetras la examinaron a ella y a su bebé encontrándolos en

perfectas condiciones, sin explicarse por qué.

Al narrar su experiencia en su lengua natal (zapoteco) Ramírez, dijo: “Ya no podía pararme el dolor, si mi

bebé moriría, entonces decidí que yo tendría que morir también. Pero si el crecería, yo lo vería crecer, pen-

sé que Dios salvaría ambas vidas”

Se cree que Ramírez es la única mujer en haber practicado una cesárea a sí misma, también se estima que

fue enormemente afortunada en colocarse en la posición elegida ya que ello colocó su útero -en lugar de

sus intestinos- por debajo del área de la incisión. También tuvo mucha suerte al ingerir solamente una dosis

sub-letal de alcohol isopropílico. Dijo después que no aconsejaba hacer lo mismo a otras mujeres.

” Esta historia inverosímil demuestra un gran valor humano y da un sentido a la vida extraordinario. De ella

se puede extraer el gran amor de una madre a un hijo, al sacrificio de una madre por un hijo, hasta donde

somos capaces de llegar los humanos por nuestro instinto de supervivencia y además añadir hasta donde se

puede llegar con la fe. A nuestro mundo desarrollado occidental, a las prisas diarias del trabajo, a los desai-

res por el mal humor, por vivir frenéticamente sin saborear la vida, creo que un pellizco de esta fe, la que

lleva a Inés Ramírez a practicarse la cesárea a ella misma, harian de nuestro mundo un poco mejor.”

SECCION CONTROVERSIAS: ADRENALECTOMIA RETRO PERITONEOSCÓPICA POSTERIOR DR. Aurelio Gambirazio Keller FACS

Página 3

Volumen 1 Numero 6

En los Archivos Adjuntos, podrá leer el articulo completo: 01 ADRENALECTOMIA RETROPERITONEOSCOPICA POSTERIOR Les invitamos a enviar su opinión , comentarios o las críticas que crean convenientes.

Email : boletinalace@gmail.com

ADRENALECTOMIA RETRO PERITONEOSCÓPICA POSTERIOR: Una experiencia americana contemporánea. Dickson P., Jimenez C. et al. J. Am Coll. Surg. Vol 212, No. 4 abril 2011 Este interesante trabajo de los Departamentos de Oncología Quirúrgica y de Neoplasias Endocrinas del MD Ander-son Cancer Center de Houston, Texas se enfoca en la técnica de Adrenalectomía Retro Peritoneoscópica Posterior ( PRA), descrita a mediados de los noventa. El entusiasmo inicial por ésta fue escaso por la exposición limitada ob-tenida con las presiones de insuflación estándar (12 a 15 mm Hg). Investigaciones posteriores (Gebler y Walz) de-mostraron que presiones mayores (20 a 24 mm Hg) permitían mejorar la exposición sin afectar la hemodinámica. La técnica empleada, descrita por Walz y colaboradores se practica con el paciente en posición prona. Las ventajas incluyen el acceso directo a la glándula sin la necesidad de movilización visceral o lisis de adherencias de cirugías previas. Además, se puede practicar PRA bilateral sin reposicionar al paciente. La cirugía más ampliamente practicada en todo el mundo es la Adrenalectomía Anterior o Lateral Transabdominal Laparoscópica. Este grupo comenzó a practicar la PRA en el 2005, luego de viajar a Essen, Alemania para obser-var a Walz y su equipo y desde entonces es su abordaje preferido para la adrenalectomía mínimamente invasiva. Se revisó la base de datos de cirugía endocrina del Departamento de Oncología Quirúrgica del MDACC para colec-tar la data de pacientes sometidos a PRA entre octubre del 2005 y mayo del 2010; dividiéndolos en dos grupos: el primero representando la experiencia inicial, previamente reportada, y el más reciente. Cuatro cirujanos realizaron 118 PRAs (100 unilateral y 9 bilateral) que fueron el 94% de todas las adrenalectomías mínimamente invasivas de ese período. Sesenta y ocho pacientes tuvieron un tumor adrenal primario funcional, 19 un tumor no funcional y 28 una metástasis. Ninguno tuvo sospecha previa de carcinoma adrenal. El tamaño tumoral promedio fue de 2.7+/- 1.7 cm. El tiempo operatorio promedio fue de 114 +/- 37 minutos. Identificaron el sexo masculino, los procedimien-tos en el lado derecho y la obesidad como factores de tiempos más prolongados. La PRA requiere una reorientación cognitiva ya que la anatomía es, desde esta perspectiva, no familiar. Los puntos clave son el riñón, la musculatura para espinosa y la proyección de la cara posterior del hígado y el bazo. Con la experiencia adquirida es la aproximación preferida para las lesiones menores a 6 cms. y las metástasis aisladas. La tasa global de complicaciones de 11.2% fue similar a la encontrada en otros reportes. La más común fue la vio-lación inadvertida de la cavidad torácica con disrupción de la pleura parietal y neumotórax. El tratamiento fue el re-conocimiento precoz y la colocación de un tubo de tórax delgado por 24 horas. Recomiendan evitar el procedimien-to en pacientes con tumores mayores a 7 u 8 centímetros, por el alto riesgo de malignidad y la dificultad de manipu-larlos con alta posibilidad de ruptura capsular al trabajar en un espacio de disección pequeño. No ofrecen adrena-lectomía mínimamente invasiva ante la sospecha de carcinoma adrenal por la alta tasa de recurrencia local. La curva de aprendizaje fue corta y optimizada por la visita del equipo a un centro con experiencia y, finalmente, consideran la PRA como el abordaje preferido para la mayor parte de pacientes candidatos a adrenalectomía míni-mamente invasiva.

SECCION:

LO QUE NUNCA ME ENSEÑARON

TEMA: LA MEDIOCRIDAD

DR. José De Vinatea De Cardenas

SECCION: CIRUGIA BASADA EN EVIDENCIAS: ¿La esplenectomía laparoscópica tiene

menos complicaciones que la esplenectomía abierta?

Página 4

Volumen 1 Numero 6

Si Ud. Desea participar en esta seccion podrá enviarnos sus

aportes personales originales que le impactaron al siguiente

correo: boletínalace@gmail.com

En los Archivos Adjuntos, podrá leer el articulo completo con el título: 02 ESPLENECTOMIA

La esplenectomía laparoscópica es preferible a la esplenectomía abierta porque reduce complicaciones y el período de recupera-

ción es más corto. GRADO DE RECOMENDACIÓN B

Para esplenectomía en esplenomegalia ( pero no para esplenomegalia masiva ), el manejo laparoscópico es aún preferible a la

esplenectomía abierta. GRADO DE RECOMENDACIÓN B

HALS debe ser considerado para evitar conversión a cirugía abierta y como procedimiento primario para esplenomegalia masiva

GRADO DE RECOMENDACIÓN B

La Esplenectomía Laparoscópica esta recomendada tanto para enfer-

medades benignas como malignas.

GRADO DE RECOMENDACIÓN B

Si el bazo tiene que ser retirado integro se recomienda utilizar un puer-

to HALS o una incisión adicional

GRADO DE RECOMENDACIÓN C

CONCLUSIONES

La esplenectomía laparoscópica produce menos complicaciones

que la abierta en pacientes con bazo de tamaño normal independien-

temente de que el paciente sea portador de patología benigna o maligna

Nivel de Evidencia 3a

Grado de Recomendación B

El manejo laparoscópico también esta indicado en esplenomegalia, pero no en esplenomegalia masiva

Nivel de Evidencia 1b

Grado de Recomendación B Dr. David Ortega

Mediocridad:

Detrás de todo gran mediocre hay una gran mediocridad

El mediocre es un individuo de tibio color y gris temperatura

La incompetencia es semejante a la muerte, la mediocridad

a la agonía.

Le tengo mas miedo a la agonía que a la muerte.

SECCION: ANALISIS CRITICO:

Volumen 1 Numero 6

Estimados colegas y lectores del Boletín Alace, en este mes de Julio celebramos en Perú el Centenario del descubrimiento de

Macchu Picchu, coincidiendo fechas con el 1° curso descentralizado de la Sociedad de Cirujanos endoscópicos de Perú, tenien-

do el auspicio de ALACE, les presentamos esta pequeña crónica visual celebrando ambos eventos.

La sección de análisis critico, perteneciente a este mes por motivos de fuerza mayor, nos ha sido imposible editar, por consi-

guiente les pedimos mil disculpas y presentamos la galería fotográfica del evento quirúrgico de Perú que tubo dilectos amigos cirujanos extranjeros invitados.

El otro modo de acceder es

colocar el título del video en el

BUSCADOR DE YOUTUBE

Si Ud. está interesado en com-

partir su video, cuélguelo en

YOUTUBE y envíenos el

LINK a:

boletinalace@gmail.com.

Acompañe el título del video,

nombre del autor, nacionalidad

y un breve resumen del caso

presentado.

Estimados lectores, en esta sec-

ción podrán ver los videos a tra-

vés de los Archivos Adjuntos.

Encontrará un archivo en Word

03 VIDEO donde estarán los

links de los videos colgados en la

cuenta de ALACE en YOUTU-

BE. Deberá utilizar las teclas:

CONTROL+CLICK

El título del video de este número

es: Pancreatectomia distal con

esplenectomía parcial

SECCION:

LOS VIDEOS DEL BOLETIN ALACE

Página 6

Volumen 1 Numero 6

SECCION:

IRREVERENTE

Si desea colaborar: envií tu artículo a: boletínalace@gmail.com

CALENDARIO

EROTICO

SI DESEAS VERLO ACUDIR

A LOS ARCHIVOS ADJUN-

TOS Y ENTRAR EN LA PRE-

SENTACION PDF TITU-

LADA:

04 CALENDARIO EROTICO

GALERIA FOTOGRAFIAS MEDICAS: SERVICIO DE CIRUGIA DE PANCRAS BAZO Y RETOPERITONEO HOSP. ALMENARA. LIMA. PERU

DR JOSE DE VINATEA DE CARDENAS

Volumen 1 Numero 6

SI DESEA COMPARTIR SUS FOTOGRAFIAS, ENVIARLAS AL CORREO:

boletínalace@gmail.com

DEBE INCLUIR TITULO DE LA SERIE, BREVE RESEÑA DEL CASO, NOMBRE DEL AUTOR, NACIONALIDAD

MIELOLIPOMA ADRENAL BILATERAL

Paciente varon de 74 años

Asintomático

Calcificación adrenal izq.

probablemente post- trau-

mática

PIEZA O

P.

CERRADA

PIEZA OP. ABIERTA

TUBERCULOSIS ADRENAL BILATERAL

SCWUANOMA BENIGNO ADRENAL IZQUIERDO

Volumen 1 Numero 6

GALERIA FOTOGRAFIAS NO MEDICAS

CAMPAÑAS INGENIOSAS PARA LA SALUD

SI DESEA COMPARTIR SUS FOTOGRAFIAS, ENVIARLAS AL CORREO:

boletínalace@gmail.com

DEBE INCLUIR TITULO DE LA SERIE, NOMBRE DEL AUTOR Y NACIONALIDAD

Dr Carlos Benavides Zúñiga

CUERPOS PINTADOS CONTRA EL CANCER DE MAMA SINGAPUR)

CONTRA EL TABACO

Volumen 1 Numero 6

COMENTARIOS, CASOS, OPINIONES Y CRITICAS

CURSOS Y CONGRESOS

SI DESEA COMPARTIR SUS FOTOGRAFIAS, ENVIARLAS AL CORREO:

boletínalace@gmail.com

DEBE INCLUIR TITULO DE LA SERIE, NOMBRE DEL AUTOR Y NACIONALIDAD

COMENTARIO: DR GUILLERMO DOMINGUEZ BS. AS. ARGENTINA

En relación a la Colecistectomía por un solo puerto en el cáncer de vesicula.

Lo felicito por el articulo, por que nosotros trabajamos hace mucho tiempo para que el cirujano ….. Ver comentario total en el ARCHIVO ADJUNTO denominado: 07 COMENTARIO DR DOMINGUEZ

FELICITACIONES AL DR. EDUARDO TARGARONA SOLER

EL DR TARGARONA NACIDO EN BARCELONA ESPAÑA, ES EL JEFE DE LA UNIDAD

DE CIRUGIA GASTROINTESTINAL Y HEMATOLOGICA DEL HOSPITAL SANT PAU

DE BARCELONA ESPAÑA.

LE FELICITAMOS POR HABER SIDO NOMBRADO COMO SECRETA-

RIO GENERAL DE LA EAES (ASOCIACION EUROPEA DE CIRUGIA

ENDOSCOPIPA), PARA EL PERIODO 2011-2013, AUGURANDOLE EXI-

TOS EN SU GESTION . EL DR TARGARONA ES UN GRAN COLABORA-

DOR PARA LATINOAMERICA EN CURSOS Y CONGRESOS

EN ARCHIVOS ADJUNTOS VEA SU CURRICULUM VITAE CON EL

NOMBRE DE 08 DR. TARGARONA

El Profesor Ricardo Torres de la Universidad Nacional del Nordeste, (Centro de Entrenamiento

e investigación en Cirugía Laparoscópica—Corrientes-Argentina), invita a suscribirse al curso

“HANDS ON” DE URODINAMIA Y PISO PELVIANO, a desarrollarse entre el 10 y 13 de

Agosto 2011.

Ver afiche del Curso en el ARCHIVO ADJUNTO denominado: 05 “HANDS ON…………..”

En PUERTO VALLARTA MEXICO, se desarrollara el XIII WORLD CONGRESS OF EN-

DOSCOPIC SURGERY, XXI INTERNATIONAL CONGRESS MEXICAL ASSOCIA-

TION OF ENDOSCOPIC SURGERY,X LATIN AMERICAN CONGRESS OF ENDOS-

COPIC SURGERY en el mes de abril 2012 entre el 24 y 28.

Extendemos la invitación a participar de él. Ver afiche del Congreso en el ARCHIVO ADJUNTO denominado: 06 “XIII CON-

GRESS……”

C

Posterior Retroperitoneoscopic Adrenalectomy: AContemporary American ExperiencePaxton V Dickson, MD, Camilo Jimenez, MD, Gary B Chisholm, MS, Debra L Kennamer, MD,

haan Ng, MD, Elizabeth G Grubbs, MD, FACS, Douglas B Evans, MD, FACS, Jeffrey E Lee, MD, FACS,Nancy D Perrier, MD, FACS

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy (PRA) is an excellent surgical option for adrenalgland removal. The operation requires that surgeons learn a new approach with few similaritiesto anterior adrenalectomy. This study reports a large series of PRAs incorporated into surgicalcare using a team-model approach.

STUDY DESIGN: The prospective endocrine surgery database was queried to identify patients who underwentPRA during a recent 4-year period. Demographic, operative, and pathologic data were re-corded. The authors’ initial experiences with PRA (group 1) are compared with our contem-porary experience (group 2).

RESULTS: One hundred and eighteen PRAs were successfully performed (100 unilateral and 9 bilateral).Indications were pheochromocytoma in 21 patients, Cushing’s syndrome or Cushing’s disease in 22patients, aldosteronoma in 22 patients, virilizing tumor in 3 patients, isolated metastasis in 28patients, and nonfunctional mass in 19 patients. Forty-eight percent of patients had undergoneearlier abdominal surgery. Forty-eight percent were obese (body mass index [calculated as kg/m2]�30). No significant differences were found in operative time (110 versus 118 minutes, p � 0.30),tumor size (2.59 versus 2.85 cm, p � 0.44), or body mass index (29.63 versus 29.93, p � 0.82)between groups 1 and 2. Both complications (15.9% versus 7.7%, p � 0.29) and conversion rates(9.5% versus 1.9%, p � 0.19) were lower in group 2, although this was not statistically significant.

CONCLUSIONS: PRA is a technique safely performed for a variety of adrenal lesions, is ideal for patients who haveundergone earlier abdominal surgery, and is feasible in obese patients. Proficiency can beobtained during a short period, leading to low conversion and complication rates. This tech-nique should be incorporated into the armamentarium of the endocrine surgeon. A teamapproach to learning new surgical techniques is effective. ( J Am Coll Surg 2011;212:659–667.

© 2011 by the American College of Surgeons)

ewrtopsncsa

Since the first description of laparoscopic adrenalec-tomy in 1992,1 a minimally invasive approach for re-moval of benign adrenal masses has become the standardof care. The most widely practiced minimally invasiveoperation for adrenalectomy is an anterior or lateraltransabdominal laparoscopic approach, which affords

Disclosure Information: Nothing to disclose.Presented at Southern Surgical Association 122nd Annual Meeting, PalmBeach, FL, December 2010.

Received December 14, 2010; Accepted December 15, 2010.From the Departments of Surgical Oncology (Dickson, Grubbs, Lee, Perrier),Endocrine Neoplasia and Hormonal Disorders (Jimenez), Biostatistics (Ch-isholm), Radiology (Ng), and Anesthesiology and Perioperative Medicine(Kennamer), MD Anderson Cancer Center, Houston, TX, and Medical Col-lege of Wisconsin (Evans), Milwaukee, WI.Correspondence address: Nancy D Perrier, MD, FACS, Department of Sur-

gical Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit444, Houston, TX 77030.

659© 2011 by the American College of SurgeonsPublished by Elsevier Inc.

familiar anatomic orientation and uses techniques sim-ilar to other traditional laparoscopic procedures. Poste-rior retroperitoneoscopic adrenalectomy (PRA) was firstdescribed in the mid 1990s2; however, initial widespreadnthusiasm was hampered primarily by limited exposureithin the retroperitoneum when using standard lapa-

oscopic insufflation pressures (12 to 15 mmHg). Inves-igations by Giebler and Walz and their colleagues dem-nstrated that higher retroperitoneal insufflationressures (20 to 24 mmHg) permitted improved expo-ure and working space without resulting in hemody-amic insult.3-5 Subsequently, Walz and colleagues havehampioned this technique and reported on its safety,hort operative time, rapid patient recovery, and use forvariety of adrenal lesions.6-10

The technique endorsed in this report, as described by

Walz and colleagues,7 is performed with the patient in the

ISSN 1072-7515/11/$36.00doi:10.1016/j.jamcollsurg.2010.12.023

pSeirpp

660 Dickson et al Posterior Retroperitoneoscopic Adrenalectomy J Am Coll Surg

prone position. Advantages of PRA include direct access tothe adrenal gland without the need for visceral mobiliza-tion or lysis of adhesions from earlier abdominal opera-tions. In addition, bilateral PRA can be performed withoutrepositioning the patient. However, most surgeons do notuse this approach. We began performing PRA for benignadrenal neoplasms and isolated metastases in 2005, aftertraveling to Essen, Germany to observe Walz and his sur-gical team. Since then, PRA has become our preferred ap-proach for minimally invasive adrenalectomy.11,12 We re-

orted our initial experience with this technique in 2008.ince that time, we have doubled our series size and ournthusiasm for this approach continues. We believe it is thedeal operation for minimally invasive adrenalectomy andeport a substantial series demonstrating its safety and ap-licability. In addition, we encourage a surgical team ap-roach when incorporating this technique into practice.

METHODSThe prospectively maintained endocrine surgery databasein the Department of Surgical Oncology at The Universityof Texas MD Anderson Cancer Center was retrospectivelyreviewed to collect data on patients who underwent PRAbetween October 2005 and May 2010. Institutional reviewboard approval was obtained before data retrieval and anal-ysis. Patient’s charts were reviewed to collect demographicdata, clinical diagnoses, patient and tumor characteristics,operative data, and short and long-term postoperativeoutcomes.

Body mass index (BMI; calculated as kg/m2), estimatedblood loss, and operative times (defined as the time fromskin incision to application of dressing) were determinedfrom the anesthesia record. Date of operation was used todivide the patients into 2 groups; group 1 consisted ofpatients who underwent surgery between October 2005and February 2008 and group 2 consisted of patients whounderwent surgery between March 2008 and May 2010.This division was chosen such that patients in group 1 werethose included in our initial report on our experience withthis technique12 and group 2 included all patients operatedon since that data analysis, representing our more contem-porary experience. Statistical analysis was performed usingthe t-test and chi-square test for comparison betweengroups 1 and 2. To evaluate factors that can impact oper-ating time, general linear models methodology was used totest independent variables to determine which were statis-tically predictive of operative time. SAS version 9.2 (SASInstitute) was used for analysis. A p value of 0.05 was con-sidered statistically significant.

During the entire study period, operations were per-

formed by 1 of 4 faculty members in the Section of Surgical

Endocrinology within the Department of Surgical Oncol-ogy (DBE, EGG, JEL, NDP). To learn the procedure, 3senior surgeons initially participated in an instructionalprogram in Essen, Germany, including multiple, repeatedcase observations followed by hands-on instruction byWalz and his operating team. This was followed by a reversesite visit by Dr Walz to Houston, TX for observation, proc-toring, and critique of procedures performed at MD An-derson Cancer Center. The fourth surgeon to join thegroup underwent fellowship training in our program andinitial PRA proctoring under the direction of the 3 seniorsurgeons trained by Dr Walz.

The technical aspects of PRA have been described pre-viously.11,12 Briefly, the patient is placed in the prone jack-knife position on a Cloward Surgical Saddle (SurgicalEquipment International) (Fig. 1A). The retroperitonealspace is sharply entered through a 1.5-cm transverse inci-sion placed just beneath the tip of the 12th rib. Usingdigital palpation and direction with the surgeon’s index

Figure 1. Right-sided posterior retroperitoneoscopic adrenalec-tomy. The patient is positioned prone on the Cloward table and sitesfor port placement are marked (A). Once the working space iscreated within the retroperitoneum, the lower aspect of the adrenalgland is separated from the superior pole of the kidney, which isretracted caudally. The adrenal gland is dissected posteriorly andlaterally, leaving the superior and medial attachments of the glandto be dissected last. The dissection ensues medially and inferiorlyand the adrenal vein is identified (B).

finger inside the retroperitoneum, a medial 10-mm trocar

MS

MT

M

MMMC

BP

661Vol. 212, No. 4, April 2011 Dickson et al Posterior Retroperitoneoscopic Adrenalectomy

is placed along the lateral border of the paraspinus muscles.The trocar is directed cephalad toward the adrenal gland atan approximate 45-degree angle. A lateral 5-mm trocar isplaced in a similar fashion 4 to 5 cm lateral to the initialincision, beneath the 11th rib. A 12-mm blunt balloontrocar (Ethicon Endosurgery) is then introduced throughthe initial central incision. Pneumoretroperitoneum is es-tablished with CO2 insufflation, which is maintained at apressure of 20 to 24 mmHg throughout the procedure.After the creation of the working space, blunt dissection isperformed through the retroperitoneal areolar tissue andGerota fascia, allowing identification of the superior borderof the kidney. The lower aspect of the adrenal gland is thenseparated from the superior pole of the kidney, which isretracted caudally. The adrenal gland is dissected posteri-orly and laterally, largely with the use of the HarmonicScalpel (Ethicon Endosurgery), leaving the superior andmedial attachments of the gland to be dissected last. Thedissection ensues medially and inferiorly and the adrenalvein is identified (Fig. 1B), ligated, and divided betweenclips. The superior attachments of the gland are then re-leased and the adrenal gland is placed into an endocatchdevice and removed through the middle trocar site.

RESULTSFour surgeons at our institution successfully performed118 PRAs (100 unilateral and 9 bilateral) from October2005 through May 2010, representing 94% of all mini-mally invasive adrenalectomies by our endocrine surgerygroup during this period. Indications for PRA are listed in

Table 1. Tumor Characteristics for Patients undergoingPlanned Posterior Retroperitoneoscopic AdrenalectomyIndications

Functional primary adrenal tumor, n (%) 68 (59)Conn syndrome, n 22Pheochromocytoma, n 21Cushing’s syndrome, n 18Cushing’s disease, n 4Virilizing tumors, n 3

Nonfunctional primary adrenal tumor, n (%) 19 (17)Metastasis, n (%) 28 (24)

Lung, n 16Melanoma, n 6Breast, n 2Other, n 4

Planned operationUnilateral n (%) 105 (91)

Left, n 63Right, n 42

Bilateral, n (%) 10 (9)

Table 1. No patient with a clinical suspicion for adrenalcarcinoma was offered a minimally invasive approach,and there were no lesions removed that, on final pathol-ogy, were found to represent a primary adrenal malig-nancy. Of the lesions removed that were not suspiciousfor cancer or biochemical hyperfunction, the most com-mon indication was pain or concerns of subclinicalCushing’s disease. The mean tumor size was 2.7 � 1.7cm. Of patients offered PRA, 56 (48.7%) had a relativecontraindication to an anterior approach due to a his-tory of earlier abdominal surgery. Fifty-five (47.8%) pa-tients were obese (BMI �30), of these 17 (14.8%) weremorbidly obese (BMI �35).

PRA was successfully performed in 118 of the 125(94.4%) planned procedures. To evaluate development ofproficiency with the technique as we gained experience, wecompared perioperative outcomes between patients oper-ated during our initial experience12 (group 1) with thosewho underwent PRA since our first report (group 2) (Table2). For purposes of comparison, patients who underwentbilateral adrenalectomy, had concomitant procedures,and/or underwent conversion, were excluded. There were

Table 2. Comparisons between Groups 1 and 2 of Patientand Tumor Characteristics and Perioperative Outcomes forSuccessful Unilateral Posterior RetroperitoneoscopicAdrenalectomy

Group 1 Group 2 p Value

Sex 0.91Male 22 20Female 25 26ean age (y) 53.7 54.2 0.71

ide of PRA 0.93Left 30 28Right 17 18ean BMI* 29.6 29.9 0.82

umor functional status 0.47Functional 31 26Nonfunctional 16 20etastatic versus primary 0.95Metastatic 12 11Primary 35 35ean tumor size (cm) 2.59 2.85 0.44ean OR time (min) 110 118 0.30ean EBL (mL) 14 18 0.48omplications (%)Patients undergoing successful

PRA 17.2 7.8 0.23Overall 15.9 7.7 0.29

*Calculated as kg/m2.MI, body mass index; EBL, estimated blood loss; OR, operating room;RA, posterior retroperitoneoscopic adrenalectomy.

no differences in the demographics and tumor characteris-

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tics between these 2 groups. We detected no significantdifference in operative times (110 � 31.9 minutes versus118 � 41.8 minutes; p � 0.30) or blood loss (14 � 24.7mL versus 18 � 30.4 mL; p � 0.48) between these groups,indicating that basic adeptness with the technique of PRAcan take place during a relatively short period.

Conversion was required for 7 adrenalectomies in 6 pa-tients, for an overall rate of 6.6%. Of patients who requiredconversion, 5 were in group 1 and 1 was in group 2 (Table2). Three patients underwent conversion to an open pos-terior approach and 3 to a transabdominal laparoscopicapproach. Conversions were required in patients withpheochromocytoma (n � 2), aldosteronoma (n � 1), met-astatic lung cancer (n � 1), a nonfunctional mass (n � 1),and in 1 patient with Cushing’s disease undergoing bilat-eral adrenalectomy. The mean tumor size for patients re-quiring conversion was 3.32 � 1.14 cm. Five of 6 patientshad a BMI �30. Reasons for conversion were predomi-nantly failure to maintain an adequate working space withCO2 insufflation. No conversion was made due to uncon-rollable bleeding or hemorrhage.

The perioperative complication rate for the entire co-ort of patients was 11.2%. There were 4 patients withneumothoraces. In 3 of these, violation of the thoracicavity was detected at the time of surgery and was managedntraoperatively with placement of a small-caliber chestube. In the fourth patient, a small pneumothorax wasetected on postoperative chest x-ray and resolved without

ntervention. Three patients demonstrated evidence ofostoperative bleeding; each appropriately responding toolume replacement and/or transfusion; none required re-peration. Additional complications included woundnfections (2 patients), postoperative urinary retention2 patients), symptomatic pleural effusion (1 patient),neumonia requiring readmission (1 patient), and a post-perative superior vena cava syndrome exacerbation (1 pa-ient). The complication rate for patients undergoing PRAn group 2 (7.7%) was lower by nearly 50% compared withhat for patients in group 1 (15.9%); however, this was nottatistically significant (p � 0.29) (Table 2). There was noerioperative mortality in either group.As proficiency with PRA was not demonstrably different

n our initial versus contemporary experience, we subse-uently evaluated factors that might predict longer opera-ive time among the entire cohort (Table 3). Independentariables tested included sex, laterality, diagnosis (Cush-ng’s syndrome, pheochromocytoma, metastases, andther), tumor size, and obesity (BMI �30). Mean opera-ive times were significantly longer in males versus females130.9 minutes versus 100.5 minutes; p � 0.0001), in

ight-sided versus left-sided PRAs (123.9 minutes versus s

08.1 minutes; p � 0.05), and in obese versus nonobeseatients (125.0 minutes versus 105.7 minutes; p � 0.01).iagnosis and tumor size were not major predictors of

rolonged operating time.

DISCUSSIONDuring the last 2 decades, minimally invasive adrenalec-tomy has become the preferred approach for surgical man-agement of benign, primary adrenal masses. In addition, aminimally invasive approach has proven effective for somepatients with isolated adrenal metastasis.13,14 Transabdom-nal laparoscopic adrenalectomy is by far the most com-

only used technique by surgeons in the United States,ikely because of familiarity with the anatomy and skillscquired through other laparoscopic operations. However,RA has been demonstrated to be a safe and effective min-

mally invasive technique for a variety of adrenal lesions,ith operative times and outcomes comparable with a

ransabdominal approach. In addition, PRA is ideal foratients who might have intra-abdominal adhesions result-ng from earlier operations. Despite certain advantages,RA remains a relatively unfamiliar operation for most USurgeons, with only a few centers in this country reporting

Table 3. Predictors of Operative Time in Patients Undergo-ing Unilateral Posterior Retroperitoneoscopic AdrenalectomyVariable Mean OR time (min) p Value

Sex �0.0001*Female 100.5Male 130.9

Side 0.05*Left 108.1Right 123.9

Tumor size (cm) 0.16*�2.35 120.5�2.35 109.0

Diagnosis 0.11†

Cushing’s 97.4Pheochromocytoma 103.2Metastases 115.7Other 127.2

BMI‡ 0.01*�30 105.7�30 125.0

General linear models methodology was used to test each independent vari-able to determine if it was statistically predictive of surgery time. Pair-wisecomparisons were performed for the levels of the variable diagnosis. Statisticaltest performed in each case was either*Tukey’s t-test or†Snedecor’s F-test.‡Calculated as kg/m2.

MI, body mass index; OR, operating room.

ubstantial experience with the technique.12,15,16 We believe

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663Vol. 212, No. 4, April 2011 Dickson et al Posterior Retroperitoneoscopic Adrenalectomy

that the approach might be preferable in many patientsbecause of the ability to direct the dissection to the adrenalgland without mobilization of other organs (ie, spleen,liver, pancreas, and colon). Here we report the results of alarge consecutive series of PRAs performed in a tertiary caresetting by an experienced group of endocrine surgeons.

Initial experiences with posterior endoscopic approacheswere met with some frustration because of difficulty increating an adequate working space and obtaining accept-able visibility within the confines of the retroperito-neum.2,17,18 These challenges were overcome with the real-ization that retroperitoneal insufflation pressures in therange of 20 to 24 mmHg greatly facilitate exposure, and donot result in the adverse hemodynamic sequelae that thesepressures would cause if achieved within the peritonealcavity.3-5 Additionally, the higher CO2 pressures tend totamponade bleeding from small vessels, further improvingvisibility.

PRA does require a cognitive “reorientation” for the sur-geon, as the anatomy from this perspective is, at first, un-familiar. Once familiarity with the critical landmarks (kid-ney, paraspinous musculature, and the hue of the posteriorsurface of the liver or spleen) necessary to perform theoperation is acquired, surgeons with the laparoscopic skillset used for transabdominal operations can become facilewith the posterior approach. Paramount to our early pro-ficiency with this technique was participation by 3 seniorsurgeons and a fellow in an organized educational programthat involved observing and assisting an expert with thetechnique, followed by a reverse site visit in which theexpert proctored and critiqued our early experience. In ad-dition, for the majority of our initial cases, at least 2 seniorsurgeons participated. We also created a dedicated operat-ing room team (at all levels), which has remained largelyintact throughout our experience. The team consists of thesurgeon, a dedicated anesthesiologist (DK), circulatingnurse, and surgical assistant. As a result, we quickly gainedcompetence with this technique and it has become ourpreferred approach for resection of benign lesions �6 cmor isolated metastases. In addition, we submit that ourteam approach and on-site observation of experts perform-ing the operation, as well as a reverse site visit by a proctor-ing surgeon, represents an excellent model for incorporat-ing new surgical techniques and technologies. We havesince used this strategy when learning other newprocedures.19

Mean operative time for unilateral PRA in the entiregroup of patients studied was 114 � 37.2 minutes, whichis comparable with that reported in other series,15,20,21 as

ell as operative times reported in large series of transab-

ominal laparoscopic adrenalectomy.15,22 Interestingly, 1

ven after performing a considerable number of cases, weid not see a decrease in operating time. As there were noubstantial differences in patient and tumor characteristicsetween those operated on during our earlier series versusur more contemporary experience, this finding might, inart, reflect the increasing participation of trainees overime. Rarely in our current practice does any single caseave more than one faculty member scrubbed at the bed-ide. As surgical fellows are routinely involved in the pro-edure, graduated participation occurs in the key steps ofhe operation. After observing multiple cases and learningo operate the endoscope within the retroperitoneum, therainee then learns to perform the dissection. Appropriateort placement is critical to success of the operation; how-ver, it is initially more difficult than port placement forraditional laparoscopic procedures and is unfamiliar tohose first introduced to the technique. Although this cru-ial step occurs at the beginning of the procedure, it is theast step of the operation turned over from the trainer to therainee.

Although average operative times were unchangedhroughout the entire study period, we identified that maleex, right-sided procedures, and obesity predicted longerperative times. During right-sided procedures, the moreeticulous dissection required to safely isolate the short

ight adrenal vein as it enters the inferior vena cava mightccount, in part, for the difference observed. In addition, inight-sided PRA, the vena cava forms one of the boundariesf dissection. It is likely that prudent initial dissection todentify and avoid injury to this structure also contributeso longer dissection times on this side. In men, it has beenur observation that the paraspinous muscles are oftenider and thicker than in women. We also appreciate that

ngulation of trocars and instruments require more preci-ion and planning because of the pronounced musculaturend increased girth of the flank in men. Medial port place-ent can be more difficult because of this, and a greater

mount of dissection is necessary because of increased bodyavity size (not reflected by BMI). However, it is unlikely toccount entirely for the 30-minute difference in mean op-rative times observed between male and female patients.

Historically, there has been reservation about recom-ending PRA in obese patients. We found that increasingMI does result in longer operative times. Even in therone position and using high insufflation pressures, it cane difficult to create an effective working space in obeseatients. In addition, the adrenal gland is often nestledithin copious amounts of retroperitoneal fat, which can

reate a more challenging dissection. In our series, nearlyalf (47.8%) of the patients were obese (BMI �30) and

4.8% were morbidly obese (BMI �35). Of the 6 patients

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664 Dickson et al Posterior Retroperitoneoscopic Adrenalectomy J Am Coll Surg

requiring conversion, respective BMIs were 20.9, 31.9,32.2, 32.6, 34.0, and 37.5 (bilateral conversion in a patientwith Cushing’s disease). However, obesity alone is not pro-hibitive, as we were successful in performing 9 PRAs in 8patients with a BMI �40. Recently, Alesina and Walz andheir colleagues reported on the feasibility of PRA in pa-ients with Cushing’s disease in which a substantial propor-ion of patients had a BMI �35.6 They advocated usingnsufflation pressures as high as 30 mmHg to acquire ade-uate exposure. Although these results indicate that PRAan be performed safely in obese and morbidly obese pa-ients, these cases can be technically challenging and it isecommended that they not be among the first patientselected when learning to perform the operation.

The overall complication rate of 11.2% in our series isimilar to other groups reporting experience with PRA.23

The most common complication encountered was inad-vertent violation of the thoracic cavity with disruption ofthe parietal pleura, resulting in pneumothorax. This di-lemma has been encountered by others7,9,23 and is likely theesult of either a small tear in the diaphragm when a trocars placed too cephalad, or from tracking of CO2 through

the diaphragm. Early recognition and management with asmall-caliber chest tube for 24 hours was sufficient treat-ment in our patients. We now obtain a portable chest x-rayfor each patient on arrival to the recovery room. Of the 4pneumothoraces in our series, 3 occurred during the first50 cases. Proper trocar placement is necessary not only toavoid this complication, but also to permit adequate rangeof motion of instruments within a relatively small workingspace. It has been our practice to use a direct cut-downtechnique to access the retroperitoneum just below the tipof the 12th rib, as determined by palpation. The medialand lateral trocars are then placed under direct palpationwith the surgeon’s index finger within the retroperitonealspace (through the central cut-down site). An alternativetechnique is the use of percutaneous ultrasound, once thepatient is properly positioned, to identify key structuressuch as the 12th rib, kidney, and adrenal to help guide andorient port placement. In addition, Siperstein and col-leagues have also used intraoperative laparoscopic ultra-sound for adrenal gland localization, in their hands facili-tating orientation and initial dissection.16

Walz and colleagues have recommended avoiding theposterior approach in patients with tumors �7 to 8 cm.7

We agree with this recommendation. In addition to bear-ing a greater risk of malignancy, larger tumors can be diffi-cult to manipulate and are at an increased risk of capsulartear when working in the relatively small working space.The mean tumor size of patients offered PRA in our series

was 2.7 � 1.7 cm. We do not offer minimally invasive

adrenalectomy to any patient suspected of having adrenalcortical carcinoma based on either tumor size or imagingcharacteristics, as this is associated with unacceptable ratesof recurrence.24 Importantly, in our series, no patient wasdiscovered to have a primary adrenal malignancy.

From a technical standpoint, proficiency with PRA islargely dependent on becoming oriented with the anatomyfrom this “backdoor” view. Dissection does not require anymore technical prowess than is needed for traditional lapa-roscopic operations. Working endoscopically in the retro-peritoneum does, however, have inherent challenges. It isthe responsibility of the assistant running the endoscope tokeep the dissecting surgeon in the correct plane, parallelto the paraspinous musculature. If the dissection begins toolateral, the orientation is lost and can account for dissectionmisadventure. We have found this more so than with trans-abdominal laparoscopic surgery, where orientation andlandmarks are generally more familiar. Compared with thetransperitoneal approach, the overall working space issmaller, instruments are placed closer together, and therigidity of standard laparoscopic tools can present an ergo-nomic challenge, with less room for error if instruments aremalpositioned or dissection is started in the wrong plane.In an effort to improve technique and overcome these chal-lenges, use of robotic surgical technology is being pursued,as the angulations and articulation afforded by the currentrobotic instruments seem to make dissection easier.25,26 We

ave recently begun to incorporate this technology into ourractice (data not included) and, as with our initial expe-ience with PRA, are using a team approach to optimizeroficiency.

CONCLUSIONSIn conclusion, PRA is a technique safely performed for avariety of adrenal lesions, is ideal for patients with earlierabdominal operations, and is feasible in obese patients.Proficiency can be obtained during a short period, leadingto low conversion and complication rates. We believe theopportunity to visit a center with expertise in the techniqueis critical for successfully adopting this method of adrenal-ectomy. In addition, we submit that a team approach inwhich more than one experienced surgeon is participatingduring the learning phase and a dedicated operating roomteam are ideal for incorporating this technique. Because ofthe potential advantages it offers over transabdominal ap-proaches, PRA should be incorporated into the armamen-tarium of the endocrine surgeon. The benefits of this tech-nique with regard to operative time, ease and quality of thedissection, and perioperative outcomes will likely be user-dependent and based on the experience of the surgeon. In

our practice, PRA has become the preferred approach for

665Vol. 212, No. 4, April 2011 Dickson et al Discussion

the majority of patients undergoing unilateral or bilateralminimally invasive adrenalectomy.

Author ContributionsDrafting of manuscript: Perrier, DicksonCritical revision: Perrier

REFERENCES

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2. Mercan S, Seven R, Ozarmagan S, Tezelman S. Endoscopic ret-roperitoneal adrenalectomy. Surgery 1995;118:1071–1075; dis-cussion 1075–1076.

3. Giebler RM, Behrends M, Steffens T, et al. Intraperitoneal andretroperitoneal carbon dioxide insufflation evoke different ef-fects on caval vein pressure gradients in humans: evidence for thestarling resistor concept of abdominal venous return. Anesthe-siology 2000;92:1568–1580.

4. Giebler RM, Kabatnik M, Stegen BH, et al. Retroperitoneal andintraperitoneal CO2 insufflation have markedly different car-diovascular effects. J Surg Res 1997;68:153–160.

5. Giebler RM, Walz MK, Peitgen K, Scherer RU. Hemodynamicchanges after retroperitoneal CO2 insufflation for posterior ret-roperitoneoscopic adrenalectomy. Anesth Analg 1996;82:827–831.

6. Alesina PF, Hommeltenberg S, Meier B, et al. Posterior retro-peritoneoscopic adrenalectomy for clinical and subclinicalCushing’s syndrome. World J Surg 2010;34:1391–1397.

7. Walz MK, Alesina PF, Wenger FA, et al. Posterior retroperito-neoscopic adrenalectomy—results of 560 procedures in 520 pa-tients. Surgery 2006;140:943–948; discussion 948–950.

8. Walz MK, Gwosdz R, Levin SL, et al. Retroperitoneoscopicadrenalectomy in Conn’s syndrome caused by adrenal adeno-mas or nodular hyperplasia. World J Surg 2008;32:847–853.

9. Walz MK, Peitgen K, Diesing D, et al. Partial versus total adre-nalectomy by the posterior retroperitoneoscopic approach: earlyand long-term results of 325 consecutive procedures in primaryadrenal neoplasias. World J Surg 2004;28:1323–1329.

10. Walz MK, Peitgen K, Hoermann R, et al. Posterior retroperito-neoscopy as a new minimally invasive approach for adrenalec-tomy: results of 30 adrenalectomies in 27 patients. World J Surg1996;20:769–774.

11. Callender GG, Kennamer DL, Grubbs EG, et al. Posterior ret-roperitoneoscopic adrenalectomy. Adv Surg 2009;43:147–57.

12. Perrier ND, Kennamer DL, Bao R, et al. Posterior retroperito-neoscopic adrenalectomy: preferred technique for removal ofbenign tumors and isolated metastases. Ann Surg 2008;248:666–674.

13. Lenert JT, Barnett CC Jr, Kudelka AP, et al. Evaluation andsurgical resection of adrenal masses in patients with a history ofextra-adrenal malignancy. Surgery 2001;130:1060–1067.

14. Mittendorf EA, Lim SJ, Schacherer CW, et al. Melanoma adre-nal metastasis: natural history and surgical management. Am JSurg 2008;195:363–368; discussion 368–369.

15. Berber E, Tellioglu G, Harvey A, et al. Comparison of laparo-scopic transabdominal lateral versus posterior retroperitonealadrenalectomy. Surgery 2009;146:621–625; discussion 625–

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17. Walz MK, Peitgen K, Krause U, Eigler FW. [Dorsal retroperito-neoscopic adrenalectomy—a new surgical technique]. ZentralblChir 1995;120:53–58.

18. Walz MK, Peitgen K, Walz MV, et al. Posterior retroperitoneo-scopic adrenalectomy: lessons learned within five years. WorldJ Surg 2001;25:728–734.

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Discussion

DR GERARD M DOHERTY (Ann Arbor, MI): It’s my pleasure tocomment on this paper from Dr Perrier’s group at MD Anderson,detailing her experience with posterior endoscopic approach to ad-renalectomy. In surgery, there does seem to be a cyclical nature to theimprovements to our craft.

Fifteen years ago, at this meeting, our group at Washington Uni-versity in St Louis presented our initial experience with a new ap-proach to adrenalectomy at that time, the transperitoneal endoscopicadrenalectomy from a lateral or anterior approach. The main com-parison group for patients with small benign tumors then was theposterior open approach through the bed of the 12th rib, whichmany of you may be familiar with. The current new approach isessentially a marriage of those 2 that we compared 15 years ago, anendoscopic approach from just inferior to the 12th rib posteriorly.

The take-home messages of this manuscript, in my opinion, arethat this approach is clinically safe, learnable by surgeons who havelaparoscopic skills and adrenalectomy experience, and is a helpfultool to have in the armamentarium of the endocrine surgeon. I have3 questions.

First, Dr Perrier, your series included 19 patients who had non-

CALENDARIO

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