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SAGES guidelines for minimally invasive treatment of adrenal pathology
Mon - June 20, 2016 10:41 am  |  Article Hits:2190  |  A+ | a-
The society of American gastrointestinal and endoscopic surgeons(SAGES) guidelines on minimally invasive approaches to adrenal pathology are timely because they take an evidence-based approach to review where we stand with laparoscopic adrenalectomy in 2013 the guidelines are comprehensive in their treatment of the various approaches to minimally invasive adrenalectomy and outline important parameters regarding difficult scenarios and preoperative patient management issues. Adrenal tumors are somewhat unique among surgical conditions for a number of reasons. First, there is a wide variety of tumors that may present with a broad range of clinical presentations, tumor sizes, and imaging characteristics. Second, due to the widespread use of abdominal cross-sectional imaging, the most common adrenal lesion currently is the incidentally discovered adrenal mass, the vast majority of which are benign and do not require surgery. third, adrenalectomy is an uncommon procedure, and the most surgeons in training get little exposure to this procedure, which requires operating in an area that may be less familiar to them anatomically. Finally, the current demographics of the patient population in the united states, particularly with regard to the obesity epidemic, add another element to the challenge of these procedures. It was not the purpose of the SAGES guidelines to review the clinical presentation and diagnostic evaluation of adrenal tumors or patient selection for adrenalectomy as these topic has been covered extensively in the guideline from the American association of endocrine surgeons and endocrinologists. However, surgeons who undertake adrenalectomy would behoove themselves to understand the details of diagnostic testing, including biochemical evolution, and should be familiar with adrenal imaging in order to select patients appropriately for operation and to avoid unnecessary adrenalectomy. Another unique aspect of adrenalectomy is the variety of operative approaches to the adrenal. The most common are the laparoscopic transabdominal lateral flank approach originally described by gagner and the retroperitoneal endoscopic approach, which has been perfected and popularized by walz. These approaches are highly successful in experienced hands, and their advantages and disadvantages have been well covered in the guidelines. For the transabdominal approach, which is the most commonly used technique , the key steps to steps to successful adrenalectomy in this author’s experience are adequate mobilization of adjacent organs to obtain clear access to the adrenal, which on the right means mobilization of the right lobe of the liver, on the left the splenic flexure of the colon, and together the tail of the pancreas and spleen; use of a gentle, meticulous homeostasis technique and avoidance of aggressive blunt dissection, which can lead to minor bleeding and obscure tissue planes; and care full handling of the adrenal itself and extracapsular dissection to avoid disruption of the tumor capsule and spillage of tumor cells ,which can lead to recurrence even with a benign adrenal neoplasm. The guidelines groups also discuss newer approaches including robotic and single-incision procedures .as they note, neither of these two techniques has any compelling advantages, and surgeons should await the results of additional studies and higher-level evidence before attempting to adopt them. certainly, the robotic and single incision laparoscopic surgery (SILS approaches can be performed, but should they be performing and at what cost and at what advantage?
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