Dougald C. MacGillivray

A comparison of open vs laparoscopic adrenalectomy

AbstractBackground: To compare the outcome of patients who underwent laparoscopic transabdominal adrenalectomy (LA) with those who had open adrenalectomy (OA). Methods: A retrospective review of consecutive adrenalectomies performed by a single surgical team at a university hospital. Outcome measurements were operative time, operative blood loss, procedure-related complications, postoperative stay, and return to regular activity. Results: Twenty-nine adrenalectomies were done in 23 patients during a 54-month period. There were 12 OAs performed in nine patients and 17 LAs were done in 14 patients. Both groups were similar in their demographics and their indications for operation. All attempted LAs were successfully completed. The mean operative time was longer for LA than for OA (289 vs 201 min; p= 0.042). Resumption of oral intake (1.0 vs 3.0 days; p= 0.002), postoperative hospital stay (3.0 vs 7.9 days; p= 0.002), and return to regular activity (8.9 vs 14.6 days; p= 0.002) were significantly shorter after LA than after OA. There were no postoperative deaths and there was no difference in operative blood loss between the two groups. Procedure-related complications occurred in three patients having LA and in five patients having OA. Conclusions: Patients having LA had longer operative procedures but shorter hospital stays and faster return to normal activity than patients having OA. Procedure-related complications for LA were due to bleeding into the retroperitoneum or abdominal wall. Significant postoperative cardiac and respiratory complications occurred only in the OA group.

Fracture incidence in postmenopausal women with primary hyperparathyroidism

BACKGROUND The association of bone loss and increased fractures in postmenopausal women with minimally symptomatic hyperparathyroidism has not been clearly defined. This study was done to determine the frequency of fractures in postmenopausal women with hyperparathyroidism. METHODS Forty-six postmenopausal women who had undergone parathyroidectomy for hyperparathyroidism during a 5-year period (1986 to 1991) were interviewed, and their medical records were examined to determine their fracture history. Forty-four postmenopausal women without hyperparathyroidism were contacted by random digit dialing and interviewed as controls. RESULTS The groups were comparable with regard to age, weight, height, race, and age at menopause. Medical conditions and medication use were also similar, except for more reports of hypothyroidism in the hyperparathyroidism group (p = 0.05). Only 13% of women presented for treatment because of bone concerns, either fractures (9%) or low bone density (4%). However, on interview, 48% of the patients with hyperparathyroidism reported fractures compared with 25% of the controls (p = 0.02), a difference that remained even when those presenting with bone disease were excluded (p = 0.05). Of those with fractures, multiple fractures occurred in 36% of patients with hyperparathyroidism compared with 9% of controls and generally occurred after minor rather than major trauma (92% versus 45%, p = 0.002). Appendicular skeletal sites were reported for 86% of hyperparathyroidism groups and 92% of control groups fractures. Moreover, 50% of patients with hyperparathyroidism reported height loss compared with 27% of the control group (p = 0.05). CONCLUSIONS This study shows that postmenopausal women with hyperparathyroidism reported more fractures and height loss than the control group, even when patients with hyperparathyroidism who presented because of bone disease were excluded.

Laparoscopic resection of large adrenal tumors

BackgroundThe maximum size of adrenal tumors that should be removed with a laparoscopic approach is controversial. It has been suggested that laparoscopic adrenalectomy is appropriate only for adrenal tumors <6 cm in size. We report our experience with laparoscopic adrenalectomy in patients with adrenal tumors of ≥6 cm compared with patients with smaller tumors.MethodsWe retrospectively reviewed a consecutive series of patients who had a laparoscopic adrenalectomy. Patients were considered candidates for laparoscopic adrenalectomy if their computed tomography (CT) scan showed a well-encapsulated tumor confined to the adrenal gland.ResultsSixty laparoscopic adrenalectomies were performed in 53 patients. Twelve of the adrenalectomies (20%) were for tumors that were ≥6 cm (median, 8 cm; range, 6 to 12 cm). There have been no local or regional recurrences but one patient with adrenocortical carcinoma developed pulmonary metastases. When the 12 patients with large tumors were compared with the 36 patients with tumors <6 cm, the median operative time (190 vs. 180 minutes;P=.32), operative blood loss (100 vs. 50 mL;P=.53), and postoperative hospital stay (2 vs. 2 days;P=1.0) were similar.ConclusionsThe size of an adrenal tumor should not be the primary factor in determining whether a laparoscopic adrenalectomy should be performed. Large adrenal tumors that are confined to the adrenal gland on CT can be removed with a laparoscopic approach.

Lateral transperitoneal laparoscopic adrenalectomy

Abstract Several laparoscopic approaches to the adrenal gland have been described. The lateral transperitoneal approach has several distinct advantages when contrasted with other techniques for laparoscopic adrenalectomy (LA). We present our technique and results obtained in 50 consecutive transperitoneal LAs. We review 50 consecutive laparoscopic adrenalectomies (28 female, 19 male) performed from 1993 to 1998. S.J. Shichman or R.E. Sosa was either the primary surgeon or the first assistant for all cases. The lateral transperitoneal approach described below was used in all cases. Indications for adrenalectomy included Cushings syndrome (13), aldosteronoma (15), pheochromocytoma (7), nonfunctioning adenoma (11), hyperplasia (2), and 1 case each of Carneys syndrome and metastasis to the adrenal gland. We performed 5 bilateral, 22 left, and 18 right laparoscopic adrenalectomies. The average time needed for bilateral adrenalectomy was 503 min (range 298–690 min); for left adrenalectomy, 227 min (range 121–337 min); and for right LA, 210 min (range 135–355 min). We demonstrated a yearly trend in lower operative times. The largest adrenal gland removed measured 13.8 × 6.7 × 3.5 cm. Intraoperative blood loss was low. Only one patient received a blood transfusion. Conversion to open adrenalectomy was not required. Postoperative analgesic requirements were low. The average length of stay was 3.8 days for bilateral LA and 3 days for unilateral LA. Complications occurred in 5 patients (2 wound infections, 2 hematomas, and 1 pleural effusion). There was no mortality. Lateral transperitoneal adrenalectomy is a safe and efficient technique for the removal of functional and nonfunctional adrenal masses. This technique is associated with low morbidity, a minimal postoperative analgesic requirement, and a short hospital stay and, in our opinion, is more versatile than the retroperitoneal approach.

Nonoperative management of blunt pediatric liver injury--late complications: case report.

Selective nonoperative management of blunt liver injuries has become a standard of care, especially in pediatric trauma centers. Recent studies report few complications with this form of therapy. Complications that occur arise over a wide time period, frequently weeks after injury. We report a patient with blunt liver trauma managed nonoperatively, who developed hemobilia 56 days after injury.

Bilateral laparoscopic adrenalectomy for adrenocorticotropic dependent Cushing's syndrome.

PURPOSE We report our experience with bilateral laparoscopic adrenalectomy for total adrenal ablation in patients with Cushings syndrome. MATERIALS AND METHODS Four women (mean age 63 years) with Cushings syndrome secondary to nonlocalized ectopic adrenocorticotropic hormone production in 3 and pituitary microadenoma after failed transsphenoidal ablation in 1 underwent bilateral transabdominal laparoscopic adrenalectomy. Preoperatively risk was III or IV according to the American Society of Anesthesiologists classification. RESULTS In all cases bilateral laparoscopic adrenalectomy was successfully performed. Operative time ranged from 375 to 475 minutes (mean 404) and mean blood loss was 162 cc. All patients resumed oral intake on postoperative day 1, mean number of postoperative parentral narcotic doses was 2.25 and mean postoperative hospital stay was 5.75 days (range 3 to 8). Complications included an abdominal wall hematoma. All patients resumed baseline activity by postoperative day 14. CONCLUSIONS Our experience in 4 cases of Cushings syndrome suggests that bilateral laparoscopic adrenalectomy is a safe and effective alternative to open adrenalectomy. Further experience with this technique will likely decrease operative time, and confirm the benefit of a decreased hospital stay and convalescence.

Reperfusion seizures after innominate endarterectomy

Seizures occurring after carotid revascularization are an uncommon complication that has received increasing recognition. The development of postoperative seizures has been estimated to occur in 0.4% to 1.0% of all carotid endarterectomies. Patients with high-grade carotid arterial stenoses appear to be at highest risk for postoperative seizures, which are thought to be due to cortical hyperperfusion states. We report two cases of focal motor seizures occurring after innominate endarterectomy, demonstrating that this complication is not limited to carotid arterial surgery.

Confluence of the right adrenal vein with the accessory right hepatic veins : A potential hazard in laparoscopic right adrenalectomy

Abstract. Confluent drainage of the right adrenal vein and large accessory right hepatic veins was encountered during a laparoscopic right adrenalectomy. In a review of previous reports of laparoscopic adrenalectomies we found no mention of this finding. However, an anatomic study reported that the right adrenal vein joins with an accessory right hepatic vein in as many as 22% of individuals. A complete understanding of the anatomic variations in the drainage of the right adrenal vein is required for the safe performance of laparoscopic right adrenalectomy.

Current Concepts in Cutaneous Melanoma: Malignant Melanoma

Melanoma of the skin is one of the most clinically important skin and soft tissue lesions encountered by the practicing general surgeon. If it is properly diagnosed and treated in its early stages, its prognosis and outcome are uniformly favorable. The current concepts in malignant melanoma are discussed.

Evolving strategies for the management of non-palpable breast abnormalities

Increased public and professional awareness has resulted in more women obtaining mammograms. As a result, the surgeon is often called on to diagnose and treat occult breast lesions. The development of new diagnostic modalities has changed the way such breast lesions are approached. Management decisions are made in the context of new pressures applied by the growing managed care imperative and increased mediocolegal exposure. In this review, we establish guidelines for the management of non-palpable breast abnormalities that place the welfare of the patient first.