Urology & Kidney Disease News Fall 2009 - Cleveland Clinic

34 Urology & Kidney Disease News
Robotics and Laparoscopy
Application of 2-mm Needlescopic Instruments
in Urological Laparoscopic Surgery
Shih-Chieh Jeff Chueh, MD, PhD
Dr. Chueh recently joined the staff of the Glickman
Urological & Kidney Institute. Prior to his appointment
at Cleveland Clinic, Dr. Chueh practiced at National
Taiwan University Hospital in Taipei. He now offers
this care as part of the Glickman program at
Charleston Area Medical Center in Charleston, W.Va.
Our endeavor to perform transperitoneal laparoscopic adrenalectomy
solely with needlescopic working instruments
(Figure 1) for presumptively benign adrenal tumors < 5 cm
started in 2000, after Gagner, Yu, and Soble, et al reported
some initial experience in a variety of surgery. Only one
umbilical 12mm port for the telescope and 2 (for left adenomas)
or 3 (for right adenomas) subcostal 2mm working
ports were used (Figure 2). Control of the adrenal vessels
and hemostasis were achieved by a 2mm bipolar coagulator
without any clipping.
Our initial 12 consecutive successful cases revealed the
benefits of less pain, better cosmesis and faster recovery
compared with those done by the conventional 5~12mm
laparoscopic instruments. We continued to accumulate
more cases and a larger series (112 patients) to further
examine the safety and efficacy for most adrenal tumors < 5
cm. All 112 operations were completed without any mortality
or re-operation. Mean operative time was 151 minutes,
and mean blood loss was 30 mL. Only one patient required
a blood transfusion and application of a hand-assisted device.
Conversion to conventional laparoscopic instruments
was necessary in another five patients (4.5%). The operative
time of the latter 100 cases (mean 147 min) was significant-
Figure 1.
Left: Comparison of the
diameters of the needlescopic
trocars and instruments.
Key Point:
scarless wounds, excellent postoperative cosmetic effect,
less pain and faster convalescence, although it is more challenging
to master their proper usage. Needlescopic techniques
have been successfully employed for adrenalectomy
-
fenestration.
ly shorter than that of the initial 12 cases (183 min). Larger
tumors, previous abdominal surgery, and pheochromocytoma
were independent risk factors of a longer operative
time. Except for one leiomyosarcoma, all the others were
benign adrenal pathologies (57 aldosterone-producing
adenomas, 23 Cushing’s adenomas, 12 pheochromocytomas,
and 20 incidentalomas). Our experience indicates that
the safety and effectiveness of laparoscopic adrenalectomy
employing only needlescopic instruments for most adrenal
tumors < 5 cm was feasible with acceptable operative time.
The patients with previous upper midline or ipsilateral upper
quadrant open surgery may not be suitable candidates
for such a technique.
Experience of laparoscopic total adrenalectomy with only
mini-instruments prompted interest in its application in
laparoscopic partial adrenalectomy. For the treatment of
aldosterone-producing adrenal adenomas (APAs) partial
adrenalectomy offers definite benefits to patients with
suspected bilateral APAs or an APA in a solitary adrenal
gland. We described the feasibility of this novel technique