Discussion on the Application of Transperitoneal Laparoscopic Surgery in the Treatment of Adrenal Tumors

The results of the study group in table 3.20 mainly showed signs of compression of the liver and spleen.

Related to the pancreas : because the adrenal gland is located far from the pancreas, this sign is only seen when the tumor is large (>50mm). Our study results show that only 5.54% have compression of the tail of the pancreas.

Computed tomography is a highly regarded imaging method, with

The diagnostic sensitivity is 96.8%, capable of detecting tumors <10mm in size, showing the vascular distribution in the tumor, especially it allows measuring the density of the tumor to help clinicians initially diagnose the nature of the tumor. Currently, it is the ideal method in diagnosing adrenal tumors.

Nowadays, with the strong development of science and technology applied in medicine, thanks to ultrasound diagnosis and computed tomography with high sensitivity (>90%), the diagnosis of adrenal tumors has become more convenient. SA is an effective and reasonable initial examination, with advantages

The point of seeing the moving image on the screen helps us to differentiate between different organs (in the research group, there were 2 cases where CT scan misdiagnosed liver cysts in segment VI, but SA confirmed

determined to be an adrenal cyst because on the ultrasound, the tumor moves in the opposite direction to the liver). Computed tomography has a higher sensitivity, especially the advantage of detecting small tumors (<10mm). While clinically, biochemical tests help us have a preliminary diagnosis of the disease caused by adrenal tumors, ultrasound and CT are decisive factors in confirming the presence of adrenal tumors. Ultrasound and CT are capable of providing some information to guide towards the nature of the tumor. However, according to Portnoi, both of these methods only show signs to guide towards the diagnosis of cancer, it does not allow a definitive diagnosis of the nature of the tumor unless it shows signs of metastasis to another organ[136]

4.4. Discussion on the application of transperitoneal laparoscopic surgery in the treatment of adrenal tumors

4.4.1. Endoscopic surgery in the treatment of adrenal tumors

Classic surgery to remove adrenal tumors is still a difficult surgery. The choice of surgical methods with different incisions aims to reduce mortality and complications, helping patients quickly return to normal life. Each method has its own advantages [2], [3], [5], [25], [29], [33], [61], [65], - [147]. Because the adrenal gland is located in a deep and difficult to access position, open surgery methods require large incisions, causing a lot of damage to the abdominal wall, and when operating, it also affects the increased secretion of hormones from the gland, leading to difficult recovery during and after surgery and severe postoperative complications. The newly developed laparoscopic surgery has been quickly accepted and developed strongly in many countries. The research topic wants to discuss the following two issues: Choosing laparoscopic surgery or open surgery . Choosing laparoscopic surgery through the peritoneum or retroperitoneum.

4.4.1.1. Choosing between laparoscopic or open surgery.

After the first announcement by Gagner. M, in 1997 Smith. C. D announced that there were 600 cases [147] of adrenal tumors operated laparoscopically in the world and in 2006 Brunt. L. M counted the results of 6 years (1977-2003) of 10 authors as 1080 cases [43]. The authors all found that the success in laparoscopic adrenal tumor resection is similar to the transfer of technical superiority between laparoscopic and open cholecystectomy, which is recognized by the surgical community. Technically, laparoscopic surgery inherits the advantage of shape.

The magnification of the camera helps the surgeon have a clear field of view, accurately identify the lesion and avoid dangerous anatomical areas, especially proactively clamping the TMTTC early to avoid the risk of increased catecholamine secretion during surgery. Good indications for benign pathology, small lesions [37],[56],[96],[105],-[106],[120],[123],[141]. Compared with open surgery,

Laparoscopic surgery for TTT tumors has clear advantages: minimal invasion of the abdominal wall, reduced intraoperative blood loss, reduced complication rate, fast postoperative recovery time, short hospital stay and aesthetic.

Table 4.4: Comparison of open and laparoscopic surgery for TTT tumors by Imai. T [96]

Surgical results

Endoscopy	Open surgery	p
Surgery time (minutes)	180	127	< 0.0001.
Blood loss (ml)	40	162	< 0.0001
Postoperative pain (days)	2.9	5.8	< 0.0001.
Hospital stay (days)	12	18	< 0.0001
Hospital fees (US dollars)	7,000	8,000.
Complications during surgery	1	2
Early postoperative complications	0	0
Late postoperative complications	0	47.5%	< 0.0001

Maybe you are interested!

Imai. T et al. [96] retrospectively studied the two groups and found differences in intraoperative blood loss, postoperative complications, postoperative pain duration, and hospital stay with p<0.0001 (Table 4.4). Hallffeldt [89] also showed that the difference between the two groups of open surgery and laparoscopic surgery was statistically significant with p<0.05 (Table 4.5).

Table 4.5: Comparison of open and laparoscopic surgery for adrenal tumors by Hallffeldt [89]

Surgical results

Endoscopy	Open surgery	p
Surgery time (minutes)	135 ± 39	106 ±31	<0.05
Blood loss (ml)	260 ±105	380±220	<0.05
Convert to open surgery	2
Complications during surgery	1	1
Early postoperative complications	4	7	<0.05
Time to use pain relief after surgery	2.9±1.8	6.4±5.9	<0.05
Hospital stay (days)	7±3	10±3	<0.05

In 2005, Brunt. L. M reported the rate of complications and mortality in 527 laparoscopic surgery patients and 645 open surgery patients. The complication rate of the laparoscopic surgery group was 12% and mortality was 0.3%, the complication rate of the open surgery group was 41.9% and mortality was 0.9% with a reliability of p<0.001[43].

Research by domestic authors [2],[8],[12],[14],-[25],[28] also gave similar results. According to table 4.6, we can see that the number of days in hospital is clearly different: the laparoscopic surgery group has a number of days in hospital of 5 days compared to the open surgery group of 16.03 days with a reliability of p < 0.05, hemodynamic disorders during and after surgery are also different, especially the time in hospital, the amount of blood loss, the number of patients requiring blood transfusions have a very clear difference with a reliability of p < 0.05 and the mortality rate of the laparoscopic surgery group is 0%.

Table 4.6: Comparison of open surgery and laparoscopic surgery by domestic authors

Surgical results

Laparoscopy [2,7]	Open surgery [12,14]	p
Surgery time (minutes)	100	107
Blood loss (mml)	120	487	<0.05
Blood transfusion	16%	70%	<0.05
Hemodynamic disturbances during surgery	20%	36.6%
Postoperative hemodynamic disorders	11.4%	16.7%
Bleeding during surgery	8.5%	20%
Hospital stay (days)	5	16.03	<0.05
suicide	0%	1.9%

The above research results show that laparoscopic surgery has brought about

superior in the treatment of adrenal gland tumors. It was quickly accepted by endocrine surgeons and confirmed as a safe and feasible surgery, with convincing advantages: Early proactive clamping of the adrenal gland reduces hemodynamic disorders during and after surgery, quick postoperative recovery time, short treatment days, low complication rate and no mortality.

4.4.1.2. Choice of intraperitoneal or retroperitoneal incision

Access to the adrenal gland includes the intraperitoneal and retroperitoneal routes, which is superior. Some authors agree with both techniques [53],[56],[71],[99],[139] but the vast majority are convinced by the intraperitoneal route [43], [51], [64], [66], [75], [78], [109], [119], [129] on the grounds that

Because: the transperitoneal approach creates a spacious surgical field, allowing for perfect endoscopic operations, it also facilitates easy dissection as well as control and treatment of bleeding, especially treatment of associated injuries, the rate of subcutaneous emphysema is lower; According to Fang [34], subcutaneous emphysema after retroperitoneal laparoscopic surgery is 45% compared to the study group.

rescue was 8.4%, ¸ p pressure was slightly lower (10-12mmHg vs 15-20mmHg) and manipulation

Inflating is simpler.

Several studies have confirmed a clear difference in operating time between the two techniques. In the study of Lezoche. E and Salomon. L [109], the operating time of the intraperitoneal approach was 97 minutes and the retroperitoneal approach was 240 minutes, and in the study of Gockel. I, table 4. 7, this difference is also clearly shown.

The research team's results showed that the intraperitoneal surgical time was 86 minutes. In our opinion, this is a good surgical approach with the following advantages: wide field of view, unobstructed operation, convenient dissection, and easy treatment of associated injuries.

Table 4.7: Gockel. I study comparing two incisions [75]

Incision

Result

Retroperitoneal		Intraperitoneal
Right	Left	Right	Left
Surgery time	60	102	96	39
Amount of blood loss	0-500	0-1100	0-1000	0-2000
Complications during surgery	1	1	1	1
Postoperative complications	4	5	3	2
Convert to open surgery	1	3	1	1
Days in hospital	5	6	6	7

4.4.2. Indications and contraindications

4.4.2.1. Indication

Table 4.8 shows that laparoscopic surgery can be applied to most benign adrenal tumors, especially pheochomocytoma and Conn's syndrome, avoiding the high risk of hemodynamic disorders during and after surgery. The surgical indications in the study group are completely consistent with other authors.

Table 4.8: Indications for endoscopic surgery for adrenal tumors

U TTT

Author

n	Conn	PhÐo	Cushing (adenomes)	No. moderation	cushing	U other*
Gagner [78]	97	21	25	13	20	8	10
Terachi [158]	100	41	8	0	22	21	8
Rutherford [146]	60	48	3	1	7	0	1
Guazzoni [80]	20	10	7	3	0	0	0
Brunt [48]	24	6	11	1	0	2	4
Steven [148]	50	15	7	3	11	10	4
Smith [153]	28	9	3	0	6	4	6
Miccoli [177]	238	82	37	3	74	26	16
Maccabees [120]	64	18	11	16	11	2	6
Gockel [75]	223	40	44	17	80	30	12
Martin [118]	325	106	83	46	60	30	0
Research Group	95	17	40	0	12	15	11

* Other adrenal tumors: cysts, myolymphomas, angiolymphomas, ganglioneuromas, bilateral adrenal cortex and medulla hyperplasia.

Endoscopic surgery is advantageous for small-sized TTT tumors. Some opinions suggest that endoscopic surgery should only be performed for tumors < 60mm in size [71],[79],[139],[148], while most other opinions suggest limiting the standard for endoscopic surgery for TTT tumors to 70mm.

up to 90 mm [64],[66],[75],[78]-[137]-[153], [120],[177].[171]. In general

The authors all believe that large tumors (>50mm) often have symptoms.

currently invasive, pushing around, narrowing the surgical field, limiting endoscopic manipulation, difficult dissection, easy bleeding, especially high cancer rate, so the surgical efficiency is not high. Our study showed that the average size was only

The laparoscopic surgery was 40.25mm, the smallest tumor was 10mm and the largest was 100mm.

There are also authors who believe that tumors >100mm that are not malignant in nature can still be performed endoscopically, ensuring high safety and effectiveness, especially when using hand-assisted laparoscopic surgery for better results [43],[95],[150].[152], Gager. M successfully operated on an adrenal adenoma measuring 150mm [78].

Most surgeons agree with the indication of laparoscopic surgery for TTT tumors with a size of ≤ 90mm, they believe that this is the possible border of TTT cancer [47]. Research by Aso. Y and Homan through 210 TTT tumors discovered by chance, there were 14 cases of cancer, all 14/14 tumors had a size > 60mm [35].

For non-secretory adrenal tumors: surgery is indicated when the tumor size is > 30-60mm. For tumors ≤ 30mm in size, surgery is not indicated but must be closely monitored by ultrasound and CT scan every 3 months, 6 months,

up to once a year, if during the monitoring period the tumor size increases by 20-30% in volume, laparoscopic surgery is indicated.

4.4.2.2. Contraindications

According to the experience of Smith. C. D [147], Gagner M[79], Benjamin N.

J. [50] and Brunt. L. M. Contraindications to laparoscopic surgery for adrenal tumors depend on the nature, size of the tumor and the patient's condition.

+ Due to the nature of the tumor (malignancy): In reality, current clinical and paraclinical signs are only suggestive of the nature of the malignant tumor. According to many authors [47],[84],[87],[95],[135],[144],[149],[155],[163],-

[175], adrenal cancers that have invasion of surrounding tissues or metastasis are absolute contraindications. Because surgical intervention for malignant tumors requires extensive resection, lymph node dissection, and periadrenal fat, it is sometimes necessary to remove the invaded adjacent organs (spleen, kidney,

liver, TMCD … ), laparoscopic surgery has not proven to be more favorable than open surgery. Adrenal medullary carcinoma with metastasis to neighboring organs such as the liver and spine are absolute contraindications.

+ Tumor size: the above authors also agree that tumors with a size >100mm are contraindicated, they believe that: With tumors larger than 100mm, the risk of cancer is high. Statistics by Peix. L. J [186], in 114 TTT tumors, there were 105 cases (92%) of malignant adrenal cortical tumors with a size >60mm. Research by Terzolo. M [157] also showed similar results. Smith. C. D believes that with large tumors, the surgical field will be narrowed, limiting visibility, hindering endoscopic operations, and the tumor will proliferate and bleed easily, causing more difficulty during dissection than the risk of cancer [147].

+ Due to systemic diseases and surgical history: Diseases related to blood clotting disorders, heart failure, respiratory failure, severe liver and kidney dysfunction. Previous surgery history related to the adrenal gland area (nephrectomy, spleen removal). A left adrenal tumor with a left diaphragmatic hernia causes a lot of difficulty in releasing the spleen, tail of the pancreas and splenic flexure of the colon.

The indication for surgery in the study group was consistent with the opinions of other authors, with 95 adrenal tumors ≤ 100mm in size: including 40 pheochromocytomas, 17 Conn's syndrome, 15 Cushing's syndrome, 12 non-secretory tumors and 10 adrenal cysts. Pathology was 100% benign.

4.4.3. Conditions to ensure the success of laparoscopic adrenal tumor surgery:

4.4.3.1. Patient preparation

Medical treatment is an indispensable principle in the general strategy of surgical treatment of adrenal tumors. Good endocrine preparation will limit the negative effects of hormone hypersecretion on the target organ. Preoperative patient assessment and classification is necessary.

* For pheochromocytoma: limit the vasoconstrictor effect and the consequence of reduced circulating volume (after TMTTC coupling) caused by the effect of

Comment