Single-incision retroperitoneoscopic adrenalectomy: a North American experience

Background: Endoscopic adrenalectomy is currently performed using multiple ports placed either transabdominally or retroperitoneally. We report our initial experience with single-incision retroperitoneoscopic adrenalectomy (SIRA).

Methods: A prospective database of patients undergoing adrenalectomy from December 2013 through March 2016 was analyzed. We adopted conventional retroperitoneoscopic adrenalectomy (CORA) in December 2013 and transitioned to SIRA in March 2015. SIRA was performed using three trocars placed through a single 2-cm incision below the 12th rib. Clinical characteristics and outcomes were compared between patients undergoing SIRA and CORA.

Results: One hundred and five adrenalectomies were performed in 102 patients: 34 laparoscopic transperitoneal, 24 CORA, 37 SIRA and 7 open. The SIRA and CORA groups were similar with respect to clinical characteristics (SIRA vs. CORA: mean BMI 27.0 vs. 28.8 kg/m², maximum BMI 38.9 vs. 44.3 kg/m²; mean nodule size 3.2 vs. 3.2 cm, maximum nodule size 8.0 vs. 6.0 cm). One patient undergoing SIRA required placement of an additional 5-mm port because of extensive adhesions. No patients who underwent SIRA or CORA required conversion to open adrenalectomy. There were no deaths, and blood loss remained <10 mL for all cases. Operative length was similar between SIRA and CORA (105 vs. 92 min, P = 0.26). In multivariable linear regression analysis, nodule size > 5 cm (effect = 1.75, P < 0.001) and pheochromocytoma (effect = 1.30, P = 0.05) were significant predictors of increased operative length for SIRA. BMI and laterality (right vs. left) did not affect operative length. Rates of postoperative temporary abdominal wall relaxation, length of stay and postoperative pain medication use were similar between the two groups.

Conclusions: SIRA is safe and feasible to implement as a refinement of CORA and may be applied to technically challenging cases involving obese patients or large nodules. The use of three ports allows for two-handed dissection, which may shorten the learning curve for many surgeons.