Original Article

Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India Mrinal Pahwa1, Archna Rautela Pahwa3, Radhika Batra2, Rtika Ryfka Abraham4, Arun Chawla5, Sachin Kathuria1, Ajay Sharma1 Department of Urology, Sir Ganga Ram Hospital, 2Department of Radiology, Maulana Azad Medical College, 3Department of Pathology, Lady Hardinge Medical College, New Delhi, India, 4Department of Endocrinology, University of Arkansas Medical Sciences, 5Department of Nephrology, South Kidney Specialist, Hofstra, USA 1

Address for Correspondence: Dr. Mrinal Pahwa, 78-C, Mianwali Colony, Gurgaon - 122 001, Haryana, India. E-mail: [email protected]

Abstract

Key words: Laparoscopic adrenalectomy, laparoscopy, myelolipoma, phaeochromocytoma, robotic adrenalectomy

INTRODUCTION: Laparoscopic adrenalectomy (LA) is now considered the standard for treatment of surgically correctable adrenal disorders. Robotic adrenalectomy has been performed worldwide and has established itself as safe, feasible and effective approach. We hereby present the first study in robotic transperitoneal LA from Indian subcontinent. MATERIALS AND METHODS: We conducted a retrospective evaluation of 25 patients who had undergone robotic assisted LA at a tertiary health centre by a single surgeon. Demographic, clinical, histopathological and perioperative outcome data were collected and analysed. RESULTS: Mean age of the patients was 45 years (range: 27-65 years). Eleven male and 14 female patients were operated. Mean operative time was 139 min ± 30 min (range: 110-232 min) and mean blood loss was 85 ml ± 12 ml (range: 34-313 ml). Mean hospital stay was 2.5 ± 1.05 days (range: 2-6 days). Mean visual analogue scale score was 3.2 (range: 1-6) mean analgesic requirement was 50 mg diclofenac daily (range: 0-150 mg). Histopathological evaluation revealed 11 adenomas, eight phaeochromocytomas, two adrenocortical carcinomas, and four myelolipomas. According to Clavien-Dindo classification, three patients developed Grade I post-operative complications namely hypotension and pleural effusion. CONCLUSION: Robotic adrenalectomy is safe, technically feasible and comfortable to the surgeon. It is easier to perform with a short learning curve. Access this article online Quick Response Code:

Website: www.journalofmas.com

DOI: 10.4103/0972-9941.147704

INTRODUCTION In recent times, laparoscopic adrenalectomy (LA) has been regarded as the preferred surgical approach for the treatment of most surgically correctable benign adrenal disorders and certain malignant tumours. LA has replaced the conventional open procedure and is accepted as the treatment of choice for patients with benign adrenal lesions.[1] Recently, robotic technology has been introduced into laparoscopic clinical practice. In 2001, Horgan and Vanuno reported on the first robotic adrenalectomy.[2] The robotic system offers certain advantages over traditional laparoscopic surgery such as threedimensional optics, magnified view with excellent resolution and depth perception, 7° of freedom at wrists for operating instruments, filtering out tremors, and allowing precise movements. In addition, the surgeon has control of a steady camera, two operating robotic arms, and an optional fourth arm, which can be used as a retractor. Last but not the least; it enables the surgeon to operate in a comfortably seated position. These advantages could theoretically improve LA procedure and then lead to improved peri- and post-operative outcomes. We hereby describe our initial experience of robot assisted LA at our institute including functional and oncological outcomes.

MATERIALS AND METHODS We conducted a retrospective evaluation of patients who underwent adrenalectomy at our institute. In total, 25 robot assisted laparoscopic adrenalectomies were carried out in our department from February 2012 to April 2013 by a single

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surgeon. The operating surgeon had an adequate experience of open and laparoscopic adrenalectomies. Demographic, perioperative, pathologic, and oncological outcome data were collected and analysed. Visual analogue scale (VAS) was used to assess the pain in the postoperative period. Pain score was obtained once daily until the patients got discharged from the hospital before the administration of analgesics. 50 mg diclofenac was given to the patient if the VAS score was above 2. A surgeon fatigue index (SFI) was calculated according to the numerological rating scale. It is not a validated tool, but just a rough estimate of surgeon’s fatigue. The operating surgeon was asked to rate the discomfort after completion of the surgery on a scale of 1-10. Five patients had undergone open adrenalectomy during this period. The reasons for performing open adrenalectomy were increased size (>10 cm), infiltrative tumours and financial issues. Patients with suspicion of phaeochromocytoma underwent the same pre-operative pharmacological management with alphablocker as in open surgery. The surgical technique is essentially similar to laparoscopic surgery. The patient is placed in modified flank position with table break at the level of the 12th rib. The Da Vinci (DV) robot surgery system is docked over the ipsilateral shoulder. Initially, the table’s position was changed according to the robot, but now we prefer to move around the robot according to the position of the patient as we observed faster docking with this technique. Pneumoperitoneum is made by veress needle at the lateral margin of rectus muscle two-finger breadth above umbilicus. We normally use only 30° down scope for dissection and two robotic arms for two instruments namely fenestrated bipolar forceps and the cautery hook. Four ports are used on either side with an additional fifth port used occasionally on the right side for retracting liver. The port position is as shown in Figures 1 and 2. The key steps involved in right adrenalectomy include division of the triangular ligament, division of gerotas fascia, early identification and division of adrenal vein at its junction with inferior vena cava, mobilisation of the adrenal gland posteriorly,

Figure 1: Port placement on left side

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laterally and from kidney inferiorly. The same techniques apply on left side also except for mobilisation of spleen and division of splenocolic ligament and identification of adrenal vein at its junction with renal vein. Meticulous care is taken to avoid manipulation of tumour, and periadrenal tissues are used for grasping the adrenal gland. According to the operating surgeon, use of robot is especially advantageous in dissecting and clipping adrenal vein with minimal manipulation of the adrenal gland.

RESULTS The various demographic data and patient profile is shown in Table 1. Mean age of the patients was 45 years. Eleven patients were male, and 14 were female. Fifteen patients were operated for left side tumours, and ten had right side tumours. Two patients developed intra-operative hypertension that was controlled easily with intravenous nitoglycerine drip. There was no incidence of any arrhythmias intra-operatively or postoperatively. The mean console time was 139 min ± 30 min which was considerably lesser than reported for laparoscopic cases in the literature. Initially, the mean docking time for first 15 cases was roughly 35 min that got reduced to 22 min for next 10 cases. Table 1: Patient profile Patient characteristics Number of patients Male/female Age Tumour size BMI Intraoperative spikes in BP Tumour side (right/left) Conversion to open Histology Adenomas Phaeochromocytomas Myelolipoma Adrenocortical carcinoma Margin positivity

Parameters 25 11/14 45±12.67 (27-65) 4.5±1.63 27.3 2 10/15 0/25 11 8 4 2 0

BMI: Body mass index, BP: Blood pressure

Figure 2: Port placement on right side

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Pahwa, et al.: Robotic assisted laparoscopic adrenalectomy

The mean intraoperative blood loss was 85 ml ± 12 ml. Only one adrenocortical cancer patient had significant bleeding that needed blood transfusion. The mean hospital stay was 2.5 ± 1.05 days. Patients were mostly pain-free during the hospital stay. Pain score was calculated daily until the patient was discharged from the hospital using numerical rating scale. Mean VAS score was 3.2 (range: 1-6). The daily analgesic requirement was approximately 50 mg of diclofenac. According to Clavien-Dindo classification, three patients developed Grade I post-operative complications namely hypotension and pleural effusion. No Grade 2 or higher complications were present. Hypotension occurred in the immediate post-operative period in patients harbouring phaeochromocytoma and was managed with intravenous fluids. Pleural effusion was mild and mostly reactive. It was observed in patients with upper polar tumours. There was no respiratory distress and effusion resolved on its own. There was no mortality. The mean SFI based on a numerological rating scale was found to be a low 2.4 (range: 1.5-6). We compared these patients with another cohort of patients who underwent LA over the last 5 years. Table 2 depicts a comparison between laparoscopic and robotic group in terms of demographic and operative parameters.

DISCUSSION In the last decade, LA has been established as standard of care for benign adrenal disease[1,3-6] and increasingly considered for selected malignant lesions.[7-10] First described in 1992,[11] LA has been shown to be well-tolerated, reduce patient morbidity, decrease costs, and shorten convalescence compared with open surgery.[4,5,12-14] However, surgeons need to confront some disadvantages during traditional laparoscopy, including an unstable operating field, orientation error due to camera Table 2: Comparison of the patients undergoing laparoscopic and robotic adrenalectomy Perioperative and postoperative parameters Operative time Blood loss Hospital stay Complications

Mean pain score (VAS) Surgeon fatigue index Daily analgesic requirement

Laparoscopic group

Robotic group

174±33 min 139±30 min 78±8 ml 85±12 ml 3.0±1.4 days 2.5±1.05 days Clavien Grade 1-3 Clavien Grade (bleeding, ileus, 1-3 patients hypotension) (pleural effusion-2, hypotension-1) 3.4 3.2

P value

0.03 NS NS NA

NS

6.3

2.4

6 cm (two out of four), or pheochromocytoma (two out of four). Studies on robotic adrenalectomy have all demonstrated reasonably low complication rates and morbidity. Morino et al. described two cases of severe intra-operative hypertension in their series of 10 patients.[22] The basic principles of surgery for phaeochromocytoma remain the same and apply as well in robotic surgery. The tumour should be minimally manipulated, and adrenal should be grasped by periadrenal tissues. Proper identification of planes and upward traction by bipolar forceps is equally important to avoid inadvertent manipulation. We also experienced two cases of intra-operative rise in blood pressure that were adequately controlled by intravenous nitroglycerine drip and fluid management. The pharmacological pre-operative preparation of phaeochromocytoma remains the same irrespective of the approach used. Length of hospital stay has been shown to be equivalent between robotic and LA.[16,19] It has mainly ranged from 2 to 6 days. The mean hospital stay in our series was also similar to that

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reported in the literature. Besides hospital stay, we observed that the patient had considerably lesser post-operative analgesic requirement as compared with open surgery. In comparison to pure laparoscopic approach, robotic adrenalectomy has longer operative time. In 2006, the median operative time was reported to be 185 min by Winter et al. on a series of 30 RAs performed by 3 surgeons at a single institution.[17] In another study by Brunaud,[16] mean operative time decreased significantly (P = 0.03) from 101 min in the first 50 cases to 88 min for the last 45 cases (five conversions were excluded). Nordenstrom et al.[21] showed that the median skin-to-skin time for all 100 patients was 113 min (25 and 75 percentiles, 92-159 min), and 106 (range: 58-343) for the last 50 patients. The skin-to-skin time decreased significantly with the number of patients (P = 0.0001). The median console operation time for the whole series was 88 min (range: 39-397 min). In a recent study, Giulianotti et al.[20] showed that mean operative time was 118 min. Interestingly, the difference in operative times between the latest robot version (DVs system with four arms) and the previous one (DV system) was not significant (115 vs. 122 min; P = 0.65). Robotic adrenalectomy may though confer a time advantage for obese patients; Brunaud et al. in two papers[16,19] noted positive correlation between patient’s BMI (>30 kg/m2) and duration of LA, but no correlation in patients having the robotic procedure. In one study, larger tumour size (>55 mm) increased operative time for LA compared with robotic adrenalectomy, but this difference did not exist with smaller tumours. Other factors that might improve operative times for robotic adrenalectomy are side (right > left), experience of the side surgeon, and laparoscopic experience of the primary surgeon.[18] We observed that docking time and the overall time decreased with increasing experience of the operation theatre personnel and operating surgeon.

CONCLUSION

REFERENCES

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Robotic adrenalectomy is feasible, well-tolerated and produces the desirous result along with ease to the surgeon based on shorter operative time, lesser blood loss, and lesser pain score, lesser SFI and shorter hospital stay. This is the first series of robotic adrenalectomy from Indian subcontinent. Limitations of our study include a small number of patients, short follow-up and lack of cost analysis. The start-up costs, cost of maintenance of the robot, and cost of disposables that are used in each robotic case compared to similar laparoscopic procedures in addition to the marketing value of the robot are not evaluated in this study.

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Cite this article as: Pahwa M, Pahwa AR, Batra R, Abraham RR, Chawla A, Kathuria S, et al. Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India. J Min Access Surg 2015;11:83-6.

Schell SR, Talamini MA, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: Improved safety, morbidity, and cost-effectiveness. Surg Endosc 1999;13:30-4.

Date of submission: 14/04/2014, Date of acceptance: 14/06/2014 Source of Support: Nil, Conflict of Interest: None declared.

Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1

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Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India.

Laparoscopic adrenalectomy (LA) is now considered the standard for treatment of surgically correctable adrenal disorders. Robotic adrenalectomy has be...
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