Laparoendoscopic single site adrenalectomy: initial results of cosmetic satisfaction and the potential for postoperative pain reduction
© Sasaki et al.; licensee BioMed Central Ltd. 2013
Received: 11 January 2013
Accepted: 4 April 2013
Published: 12 April 2013
Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.
Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.
Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.
LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique.
KeywordsLaparoendoscopic single site surgery (LESS) Single-port surgery Single-incision surgery Laparoscopy Adrenalectomy
A conventional multiport laparoscopic adrenalectomy (MPLA) using three or four ports is the gold standard operative treatment for benign adrenal tumors [1–3]. The advantages of MPLA include decreased pain, shorter hospital stay, and an earlier return to normal activity. Recently, a laparoendoscopic single site (LESS) surgery was developed as an extension of the standard laparoscopic minimally invasive procedures. LESS surgery has the potential to provide patients with improved cosmesis and decreased pain; as such, it satisfies a growing demand for less invasive surgical procedures [4, 5]. Since the initial report of laparoscopic adrenalectomy using a single-incision , several investigators have demonstrated the technical feasibility of a variety of LESS procedures for adrenal tumors [7, 8]. LESS surgery obviates the need to externally space ports for triangulation, thus allowing for the creation of a small, solitary portal of entry into the abdomen. However, we have previously reported our initial developmental experiences with select LESS procedures [9–13]. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.
Data were prospectively entered in an LESS adrenalectomy database and retrospectively reviewed. Between January 2010 and July 2012, 14 consecutive patients (7 men and 7 women) with benign adrenal tumors underwent LESS adrenalectomies at the Iwate Medical University Hospital. All procedures were performed by a single surgeon. Informed consent was received from all the patients for the procedure, and the difference between the LESS and the conventional multiport approaches were explained. This study was approved by the institutional review board at Iwate Medical University Hospital and conducted in accordance with Declaration of Helsinki.
Indications for LESS adrenalectomy
< 5 cm
Previous upper abdominal surgery
Functioning and nonfunctioning tumors
A visual analog scale (VAS) was used as an objective assessment of incisional pain on postoperative days 1, 3, and 14, and for incisional cosmesis on postoperative days 3 and 14. The VAS was used to score incisional pain on a 10-point scale with a range from 0 (no pain) to 10 (worst possible pain). The VAS was also used to score cosmesis on a 10-point scale with a range from 0 (worst) to 10 (best). Data are expressed as mean ± standard deviations (SD).
LESS adrenalectomy (n=14)
Age (years) *
51.7 ± 11.6
BMI (kg/m2) *
24.4 ± 3.3
Tumor location (Right/Left)
Previous abdominal operation
Indication for surgery
LESS adrenalectomy (n=14)
Operating time (min) *
128.1 ± 31.5
Blood loss (ml) *
10.5 ± 12.1
Tumor size (mm) *
21.2 ± 7.0
Resumption of oral intake (days) *
Analgesics within 12 h after surgery (n)
Length of hospital stay (days) *
3.9 ± 1.0
Conversion to two port surgery
A limited cost analysis was performed on the series of patients undergoing SPLA. LESS adrenalectomy was associated with 18% lower mean operative charges compared with the standard MPLA (¥147,000 vs ¥180,000).
Conventional multiport laparoscopic surgery is the gold standard operative treatment for a variety of diseases. Generally, the goal has been to minimize the invasiveness of this procedure by reducing the number or size of the operating ports. Recently, LESS surgery was developed as an extension of standard laparoscopic minimally invasive procedures. The potential for decreased pain, faster recovery, and improved cosmesis has surgeons, their patients, and the industry interested in pushing the technique forward. In 2008, Castellucci et al.  reported the first LESS adrenalectomy in a 63-year-old female patient with a 4.5-cm left adrenal incidentaloma. They used a 3-port technique, introduced through a 2-cm supraumbilical incision and successfully removed a pheochromocytoma. However, LESS adrenalectomy is still limited by the surgical team’s adrenal and laparoscopic experience [6–8, 12].
Since March 2009, we have been using LESS cholecystectomies in selected patients with benign gallbladder diseases. Additionally, our team has recently performed successful advanced LESS procedures, such as gastrectomy, colectomy, splenectomy, Heller-Dor procedure, and Nissen fundoplication [9–13]. At our institution, LESS adrenalectomy was introduced after more than 100 MPLAs were conducted. Since our first description in 2010 , we have performed LESS adrenalectomies on consecutive patients with benign adrenal tumors. In a LESS left adrenalectomy, as in conventional MPLA, the spleen is mobilized which provides a good operative field surrounding the left adrenal gland. The applicability of a LESS right adrenalectomy has not resulted in its widespread use, however, due to its technical challenges. The most important technical challenge for LESS right adrenalectomy is providing a good operative field surrounding the right-sided tumors. However, an elevation of the right liver lobe using a percutaneous instrument provided good visualization of the operative field, which reproduced a result similar to that observed in MPLA. The assistance of the needlescopic instrument does not compromise the cosmetic outcomes; this fact is considered to be one of the main advantages of LESS adrenalectomy over MPLA. An additional 5-mm port was required in two patients with body mass indexes greater than 27 kg/m2. Good laparoscopic skills and careful patient selection are essential; additional ports should be considered to help with liver retraction.
Two matched-control studies have reported that patients undergoing LESS adrenalectomy had significantly lower pain scores or required significantly less analgesia [7, 14]. Jeong et al.  reported the first matched case–control study to demonstrate the technical feasibility of LESS adrenalectomy, compared with conventional MPLA, in the removal of a benign adenoma. Nine patients undergoing LESS adrenalectomies were compared with 17 patients undergoing conventional MPLA. No significant differences were found between the groups in terms of mean operating time, blood loss, or postoperative hospitalization. However, the degree of postoperative pain was significantly lower in the LESS adrenalectomy group than in the MPLA group. Our study also demonstrates that the postoperative VAS scores for incisional pain were lower. However, evaluation of postoperative cosmetic outcomes is a challenge, due to the absence of a reliable objective scale. The combination of multiple contributing factors, potential observer bias, and variations in patients’ expectations contributes to difficulties in assessing cosmetic outcomes . In our series, we observed that patients scored the single-wound technique significantly better with regard to cosmetic appearance. However, operating surgeons should consider carefully which patients would be ideal candidates for initial LESS adrenalectomies.
LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique. Further studies are necessary to clearly identify the risks and benefits of this new approach to the adrenalectomy.
Written informed consent was obtained from the patient for publication of this report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Laparoendoscopic single site
Multiport laparoscopic adrenalectomy
Visual analog scale
The authors would like to thank Dr Toru Obuchi for helpful discussions and Yuka Nyuzuki for copy-editing.
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