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LAPAROSCOPIC SURGERY FOR ADRENAL TUMORS: results from 450 operations
C. Aggeli, A. Nixon, I. Perysinakis, A. Diamantopoulos, A. Koronaios, G.N. Zografos
Department of SurgeryAthens General Hospital ‘ G. Gennimatas’, Greece
EAES CONGRESS, AMSTERDAM JUNE 16-18, 2016
ADRENAL SURGERYThird Department of Surgery, Athens General Hospital
“G. Gennimatas” January 1998 – December 2015
450 Resection of adrenal tumors ( 439 patients)
361 Laparoscopic procedure
50 Open approach from the start
37 Conversion of laparoscopic approach to open
450 ProceduresJanuary 1998 – December 2015
ADRENAL SURGERYThird Department of Surgery, Athens General Hospital “G. Gennimatas” January 1998 – December 2015
121 Adenoma (72 autonomous cortizol+/- aldosterone)29 Potentially malignant tumors ( 24 medulla, 5 cortical)63 Cushing’ syndrome 11 Cushing’ disease65 Pheochromocytoma (5 ectopic, 4 ΜΕΝ ΙΙΑ)35 Malignant tumors6 Malignant pheochromocytoma1 Recurrent malignant pheochromocytoma13 Metastatic Ca (lung., colon, kidney )24 Primary cortical Ca 1 Αngiosarcoma66 Conn’ s syndrome12 Μyelolipoma11 Cysts, Cystic tumors3 Ganglioneuroma 1 hematoma 2 swannoma 1 Αngiolipoma
•Mean age: 53,6 years
PATIENT POSITIONING
65 Pheochromocytomas Hypervascular tumors, need laparoscopic
experience
G.N. Zografos, G. Piaditis et al. Laparoscopic resection of pheochromocytoma with delayed vein ligation
Surg Laparosc Endosc Percut Tech 2011;21(2):116
LAPAROSCOPIC ADRENALECTOMY IN CUSHING’S SYNDROME ( 63 +11 Cushing’s disease)
72 SUBCLINICAL CUSHING
LARGE ADRENAL TUMORS
• 121/450( 8 to 23 cm)
• 71 tumors 8 – 14 cm laparoscopically
• Tumors > 15cm can not be resected laparoscopically
• 3 Hand – assisted technique
Bresadola V et al Applicability of laparoscopic approach to the resection of large adrenal tumors: a retrospective cohort study of 200 patients Surg Endosc 2015; 5Zografos GN et al. Laparoscopic resection of large adrenal ganglioneuromaJ Surg Lap Soc 2007;11(4):487-492.
LAPAROSCOPIC SURGERY FOR MALIGNANT AND POTENTIALLY MALIGNANT
TUMORS
• Primary malignancy: 5/23 laparoscopic ( 1 pheo, 4 cortical)
• Potentially malignant: 25 laparoscopic ( 5/6 cortical, 2 paragagglioma, 18/23 pheochromocytoma)
• Solitary adrenal metastasis: 7 laparoscopic, 5 conversion, 6 open from the start
37 CONVERSION TO OPEN
• 12 Malignant tumors ( oncologic safety), • 9 large tumors• 16 previous surgery, in learning curve
ADRENAL SPARING SURGERY
• Bilateral benign pheochromocytoma inΜΕΝ ΙΙ ( 4 cases)
• Conn’ s syndrome (5/66)
Adrenal mass
CT, MRI Laboratory screen
Biochemically active Biochemically inactive
<12-14cm >12-14cm <4cm >12-14 cm
OpenAdrenalectomy Serial CT
<
OpenAdrenalectomy
LapAdrenalectomy
>4 cm,<12-14cm<4cm, <50yo
Laparoscopicadrenalectomy
Primary Malignancy cautious approachPossible invasion early conversion
CONCLUSION
Laparoscopic surgery is indicated in all benign adrenal tumors
Large tumors 8-14 cm necessitate laparoscopic experience
Solitary adrenal metastasis can be safely resected laparoscopically
G. Zografos et al . Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma. J.S.L.S 2007;11(2):261-265
CONCLUSIONS
• Primary adrenal tumors suspicious of malignancy < 10 cm must be approached by laparoscopy in specialized centres.
• Malignant tumors or potentially malignant tumors > 10 cm, with or without peri-adrenal invasion must be operated by open technique from the start
Ζografos G.N et al Laparoscopic surgery for malignant adrenal tumors Journal Surgical Oncology 2009;13(2):196-202Zografos G.N. et al Laparoscopic surgery for potentially malignant adrenal tumors: an
unresolved issue. Hormones 2015
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