In 2015 in CHUC-HG (Covões), I performed the first posterior retroperitoneoscopic adrenalectomy (PRA) in Coimbra, Portugal. After learning this technique from Professor Dr. Martin Walz (Essen, Germany) it was obvious to me this was the best approach to benign adrenal tumors up to 6-8 cm. PRA has clear advantages over transperitoneal approach, namely a fast and direct access to the gland, no incursion into intraperitoneal space avoiding incidental trauma to viscera, less operative time, less pain, faster recovery and is feasible in obese patients. Because surgeons are not familiarized with the retroperitoneal space and the transperitoneal approach offers the usual wider space of peritoneal cavity, PRA is still not the preferred technique. But it should be…
Our global mean operative time was 38,9 min.
No postoperative complications occurred.
Having myself experience in several fields of laparoscopic surgery, following Prof. Walz teaching and tips, and being supported by older surgeons of my department, it was easy to start performing this technique. After performing 10 cases we had similar results comparing to more experienced surgeons (a publication of these first results is available in International Journal of Surgery Case Reports). We concluded that this technique has a small learning curve if the surgeon has gained experience in other fields of minimally invasive surgery.
Operative time (p = 0,036) and in-hospital days (p = 0.01) were influenced by surgeon’s experience, but there were no differences in the outcomes.
After performing ten (10) more cases, we wanted to know if there was any difference comparing to the first group of ten (10) patients. In that setting we published this month "An update of posterior retroperitoneoscopic adrenalectomy - Case series", which is available in the International Journal of Surgery Case Reports. The objective was to analyze the second group of 10 cases, to compare with the results of the first 10 cases, to analyze the results of all 20 cases, and take conclusions about the feasibility, safety and learning curve. Results are clear. A lower operative time was found in the second group (p=0.036), with a global mean operative time of 38.9 min. A mean in-hospital days of 2.2 and 1.1 was found for the first group and second group, respectively (p=0.01). Conversion rate was 10%. There were neither complications nor mortality in both groups. These results show that only operative time (p = 0,036) and in-hospital days (p = 0.01) were influenced by surgeon’s experience. There were no differences in the outcomes between the two groups and our overall results match more experienced surgeons, supporting the idea of a small learning curve for PRA. Our results contradict the idea of other authors who state that up to 40 procedures are necessary in order to achieve good results and complete the learning curve.
Having experience in other fields of minimally invasive surgery is what allowed us to achieve such results. Knowledge is never too much.
Feel free to read to full article (open access).
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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