Robot-assisted laparoscopic adrenalectomy: step-by-step technique and comparative outcomes.
BACKGROUND
Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses.


OBJECTIVE
To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA).


METHODS
We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group.


METHODS
The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure.


METHODS
Demographic parameters and main surgical outcomes were assessed.


CONCLUSIONS
A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3cm [interquartile range (IQR): 3] vs 4cm [IQR: 3]; p=0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50ml [IQR: 50] vs 100ml [IQR: 288]; p=0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p=0.66) and positive margin rate (p=0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p=0.02).


CONCLUSIONS
The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy.


RESULTS
In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Luis Felipe
LF
Brandao
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Riccardo
R
Autorino
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Homayoun
H
Zargar
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Jayram
J
Krishnan
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Humberto
H
Laydner
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Oktay
O
Akca
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Maria Carmen
MC
Mir
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Dinesh
D
Samarasekera
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Robert
R
Stein
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: kaoukj@ccf.org.
Jihad
J
Kaouk
D000310:Adrenal Gland Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D020706:Laparoscopes; D010535:Laparoscopy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D010673:Pheochromocytoma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D047368:Tumor Burden
Adrenalectomy; Laparoscopy; Robotic surgery; Surgical technique