| Background:The traditional surgery is open adrenalectomy(OA).But the adrenal surgery is a tricky operation.Surgical exposure is difficult due to the retroperitoneal site of adrenal gland,and the high incision site is easy to damage the pleura,the low incision site has the bad view of the operation,making difficult to look for adrenal gland.With the advent of minimally invasive surgical techniques,traditional treatment of adrenal tumors has changed.Since the laparoscopic adrenalectomy(LA)was applicated by Gagner in 1992,following that many scholars have carried out a comprehensive and in-depth study on the indications and surgical methods,repeating comparison with open surgery(OA)after decades of development at home and abroad,it became the gold standard for the surgical treatment of adrenal tumors.Compared with open adrenalectomy(OA),laparoscopic adrenalectomy(LA)takes the virtue of good vision,less bleeding,quick recovery and short operation time,especially for the deep tumors.It includes two kinds of methods:transperitoneal and retroperitoneal.They have their own advantages and disadvantages:The transperitoneal one has good vision,the abundant exposure,but the abdominal organs were interfered by some degree.The retroperitoneal surgery has the advantages of less interference to the abdominal organs,the quick recovery after operation,but the exposure was more difficult and the working space is small.The focus of the research was to explore the most appropriate surgical routes under various conditions by comparing transperitoneal and retroperitoneal laparoscopic adrenalectomy.ObjectiveTo evaluate the clinical value of transperitoneal laparoscopic adrenalectomy(TLA)and retroperitoneal laparoscopic adrenalectomy(RLA)through analysis of the clinical datas of 494 cases of laparoscopic adrenalectomy.Methods:1.Subjects A retrospective research of clinical datas of 494 cases of adrenal tumors and undergoing laparoscopic adrenalectomy in Qilu Hospital of Shandong University from 2012.5.1 to 2016.12.31.2 Methods(1)Statistical analysis of the overall data,comparison of TLA and RLA in tumor size,operative time,blood loss,converted to open surgery,complications,time to anal exsufflation,postoperative hospital stay,postoperative analgesics requirement and postoperative pathological differences to evaluate the clinical value.(2)The subgroup analysis of the clinical data,494 patients were divided into:1.the left and right group,2.tumor size group,3.pheochromocytoma group and non-pheochromocytoma group,4.BMI group.To provide the basis choice of surgical approach by the comparison of tumor size,operative time,blood loss,converted to open surgery,complications,time to anal exsufflation,postoperative hospital stay,postoperative analgesics requirement and postoperative pathological differences.Results:1 For transperitoneal group and retroperitoneal group,there had significant difference in tumor size(31.30mmvs24.67mm),operative time(93.94minvs104.84min),intraoperative blood loss(48.31mlvs85.87ml),time to anal exsufflation(2.29dvs2.01d)and the postoperative hospital time(7.50dvs6.05d)(P<0.01).It had no difference in complications,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences.(P>0.05).2 Subgroup Analysis2.1 Left and right groups2.1.1 The left side group For transperitoneal group and retroperitoneal group,there had significant difference in tumor size(32.58mmvs22.08mm),blood loss(49.36mlvs83.83m1),time to anal exsufflation(2.32dvs1.91d)and postoperative hospital time(7.56dvs6.11d)(P<0.01).It had no difference in operative time,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.1.2 The right side group For transperitoneal group and retroperitoneal group,It had significant difference in operative time(86.67minvs107,43min),blood loss(47.32mlvs75.49ml),postoperative hospital time(7.45dvs5.99d),BMI(21.12 Kg/m2vs22.14Kg/m2)(P<0.01).It had no difference in time to anal exsufflation,tumor size,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.1.3 Transperitoneal group 132 cases of left,139 cases of right,there had significant difference in operative time(101.55minvs86.67min)(P<0.01).It had no difference in blood loss,tumor size,postoperative hospital time,time to anal exsufflation,complications,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.1.4 Retroperitoneal group 110 cases of left,113 cases of right.there had significant difference in tumor size(22.08mmvs27.19mm)and time to anal exsufflation(1.91dvs2.11d)(P<0.05).It had no difference in operative time,blood loss,converted to open surgery,postoperative hospital time,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.2 Tumor size group2.2.1 Tumor size<6cm group For transperitoneal group and retroperitoneal group,there had significant difference in blood loss(39.98mlvs79.49m1),operative time(86.60minvs104.14min).time to anal exsufflation(2.27dvsl.98d)and postoperative hospital time(7.35dvs5.97d)(P<0.01).It had no difference in converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.2.2 Tumor size>6cm group For transperitoneal and retroperitoneal group,it had no difference in blood loss,operative time,time to anal exsufflation,converted to open surgery,postoperative hospital time,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.2.3 Tumor size<6cm and tumor size>6cm group 450 cases of tumor size<6cm group and 44 cases of tumor size>6cm group,two groups in transperitoneal route was obvious difference(52.22%vs81.82%)(P<0.01),and it had significant difference in blood loss(58.86mlvs130.68mtl),operative time(94.98minvs137.73min),time to anal exsufflation(2.13dvs2.48d)and postoperative hospital time(6.69dvs8.43d)(P<0.01).2 cases were converted to OA in tumor size<6cm group,2 cases in tumor size ≥6cm group(0.44%vs4.54%)(P<0.01).There is no obvious difference in other aspects(P>0.05).2.3 Pheochromocytoma and non-pheochromocytoma group2.3.1 The pheochromocytoma group For transperitoneal group and retroperitoneal group,there had difference in blood loss(126.89mlvs220.00ml)and postoperative hospital time(8.05dvs6.44d)(P<0.01).It had no difference in operative time,time to anal exsufflation,tumor size,converted to open surgery and postoperative analgesics requirement(P>0.05).2.3.2 The non-pheochromocytoma group For transperitoneal group and retroperitoneal group,there had difference in operative time(88.00minvs102.54min),blood loss(35.84mlvs70.10ml),time to anal exsufflation(2.28dvs1.97d)and postoperative hospital time(7.42dvs6.02d)(P<0.01).It had no-difference in tumor size,complications,converted to open surgery and postoperative analgesics requirement(P>0.05).2.3.3 Pheochromocytoma and non-pheochromocytoma group 53 cases of pheochromocytoma group,441 cases of non-pheochromocytoma group.There had 37 in the pheochromocytoma group in transperitoneal route,while 235 in the non-pheochromocytoma group,there were obvious differences(P=0.021).There had significant difference in operative time(132.36minvs94.84min),blood loss(176.13mlvs51.95ml),tumor size(47.06mmvs26.04mm),time to anal exsufflation(2.40dvs2.14d)and postoperative hospital time(7.57dvs6.76d)(P<0.01).3 cases were converted to OA in pheochromocytoma group,1 case was converted to OA in non-pheochromocytoma group(P<0.01).2.4 BMI group2.4.1 BMI<24Kg/m2 group For transperitoneal group and retroperitoneal group,there had difference in operative time(84.80minvs93.47min),blood loss(41.91mlvs71.56ml),time to anal exsufflation(2.33dvs1.99d)and postoperative hospital time(7.41dvs5.87d)(P<0.01).It had no difference in tumor size,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.4.2 BMI ≥ 24Kg/m2 group For transperitoneal group and retroperitoneal group,there had significant difference in tumor size(38.83mmvs24.75mm),blood loss(68.11mlvs117.83ml)and postoperative hospital time(7.79dvs6.45d)(P<0.01)It had no difference in operative time,time to anal exsufflation,converted to open surgery,postoperative analgesics requirement and postoperative pathological differences(P>0.05).2.4.3 BMI group 359 cases in the BMI<24Kg/m2 group,135 cases in the BMI>24Kg/m2 group.There had 89 males in the BMI<24Kg/m2 group,110cases in the BMI>24Kg/m2 group,and there were obvious differences(P<0.01).It had difference in tumor size(27.04mmvs31.64mm),blood loss(54.66mlvs93.52ml)and operative time(88.53minvs126.30min)and postoperative pathological differences(P<0.05).None cases were converted to OA in BMI<24Kg/m2 group,while 4 cases were converted to OA in BMI ≥ 24Kg/m2 group,the difference between the two is obvious(P<0.01).It had no difference in the location of lesions,time to anal exsufflation and postoperative analgesics requirement(P>0.05).Conclusion:1 Two kinds of laparoscopic surgery have a good effect in surgical treatment of adrenal tumors,the transperitoneal one has the virtue of short operation time,less bleeding,suitable for the surgical treatment of large adrenal tumors.And the retroperitoneal one has less postoperative hospital time.2 The transperitoneal one is suitable for surgical treatment of large left tumors,having less bleeding,but retroperitoneal approach has rapid postoperative recovery.Transperitoneal surgery is obviously better than the retroperitoneal approach in operative time and blood loss in the right tumors.3 If the tumor is less than 6cm,transperitoneal approach has short operative time,less bleeding,if the tumor is more than 6cm,it is more likely to be operated via the transperitoneal approach.4 if the tumor was pheochromocytoma,transperitoneal approach is more effective for it due to the good vision,the abundant exposure,less bleeding and less irritation.The time of the two kinds of operation was not significantly different.5 Body mass index(BMI)had little effect on the choice of surgical approach. |
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