Robotic versus laparoscopic adrenalectomy in obese patients

Erol Aksoy • Halit Eren Taskin • Shamil Aliyev •

Jamie Mitchell • Allan Siperstein • Eren Berber

Received: 22 June 2012 / Accepted: 26 August 2012 / Published online: 17 October 2012

� Springer Science+Business Media New York 2012

Abstract

Background Recently, we demonstrated better perioper-

ative outcomes with robotic versus laparoscopic adrenal-

ectomy (LA) with the posterior retroperitoneal approach in

general, and for removal of large adrenal tumors. It is

unknown if robotic adrenalectomy (RA) is equivalent to

LA in obese patients. The aim of this study is to compare

perioperative outcomes of RA versus LA in obese patients.

Methods Between 2003 and 2012, 99 obese (BMI C 30

kg/m2) patients underwent adrenalectomy at a tertiary

academic center. Of these, 42 patients had RA and 57 had

LA. The perioperative outcomes of these patients were

compared between the RA and LA groups. Data were

collected from a prospectively maintained, institutional

review board approved database. Clinical and perioperative

parameters were analyzed using Student t and v2 tests. All

data are expressed as mean ± standard error of the mean.

Results The groups were similar in terms of age, gender,

and tumor side. Body mass index was lower in the robotic

versus laparoscopic group (35.4 ± 1.0 vs. 38.8 ± 0.8 kg/m2,

respectively, p = 0.01). Tumor size (4.0 ± 0.4 vs.

4.3 ± 0.3 cm, respectively, p = 0.56), skin-to-skin opera-

tive time (186.1 ± 12.1 vs. 187.3 ± 11 min, respectively,

p = 0.94), estimated blood loss (50.3 ± 24.3 vs.

76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay

(1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06)

were similar in both groups. The conversion to open rate

was zero in the robotic and 5.2 % in the laparoscopic group

(p = 0.06). The 30-day morbidity was 4.8 % in the robotic

and 7 % in the laparoscopic group (p = 0.63).

Conclusions Our study did not show any difference in

perioperative outcomes between RA and LA in obese

patients. These results suggest that the difficulties in

maintaining exposure and dissection in obese patients

nullify the advantages of robotic articulating versus rigid

laparoscopic instruments in adrenal surgery.

Keywords Robotic adrenalectomy � Laparoscopic

adrenalectomy � Obesity

Robotic adrenalectomy (RA) has received recent attention

due to the perceived benefits of advanced wristed instru-

mentation and a three-dimensional imaging platform. Mul-

tiple groups have described techniques for removing a

variety of adrenal tumors [1, 2]. Our group has described the

robotic posterior technique and reported benefits with the

robot in regards to shorter operative time (OT), less pain, and

shorter hospitalization compared with the laparoscopic

technique [3]. The same benefits were also identified for

removal of large adrenal tumors using both the transab-

dominal lateral and posterior retroperitoneal approach [4].

Obesity is currently a significant health problem, with

more than one-third of the population reported to be obese

[body mass index (BMI) [ 30 kg/m2] in the USA. Data

from the National Health and Nutrition Examination Sur-

vey 2009–2010 show that more than one-third of adults and

almost 17 % of youth were obese in 2009–2010. Obesity

prevalence did not differ between men and women [5].

As for any intra-abdominal procedure, laparoscopic

adrenalectomy (LA) is also challenging in obese patients. It

is unknown if the robotic approach would be a better option

in obese patients due to the advantages reported above.

E. Aksoy � H. E. Taskin � S. Aliyev � J. Mitchell �A. Siperstein � E. Berber (&)

Division of Endocrine Surgery, Robotic Endocrine Surgery,

Endocrinology and Metabolism Institute, Cleveland Clinic,

9500 Euclid Avenue/F20, Cleveland, OH 44195, USA

e-mail: berbere@ccf.org

123

Surg Endosc (2013) 27:1233–1236

DOI 10.1007/s00464-012-2580-1

and Other Interventional Techniques

The aim of this study is to compare LA with RA in obese

patients regarding perioperative outcomes.

Patients and methods

Between 2003 and 2012, 99 obese (BMI C 30 kg/m2)

patients underwent adrenalectomy at a tertiary academic

center. Of these, 42 patients had RA and 57 had LA. The

perioperative outcomes of these two approaches were

compared. Both the robotic and laparoscopic lateral

transabdominal (LT) and posterior retroperitoneal (PR)

approaches were used, with the latter being preferred for

tumors \6 cm. Data were collected from a prospectively

maintained, institutional review board (IRB)-approved

adrenal database. Clinical and perioperative parameters

were analyzed using Student t and v2 tests. Univariate and

multivariate regression analyses were performed to study

the effects of various clinical parameters on OT. The skin-

to-skin OT also included the time spent for ‘‘docking’’ in

the robotic group. All data are expressed as mean ± stan-

dard error of the mean (SEM).

Surgical technique

Our laparoscopic and robotic techniques have been

described extensively in our previous reports [6, 7]. The

robot was kept in a dedicated operating room. The setup,

with draping of the arms, was completed during anesthesia

and the laparoscopic part of the procedure; hence,

additional time was not spent for the setup of the robot,

except for docking, in the surgical procedures.

Results

The groups were similar in terms of age, gender, tumor

side, and lateral or posterior approach (Table 1). BMI was

lower in the robotic versus laparoscopic group (35.4 ± 1.0

vs. 38.8 ± 0.8 kg/m2, respectively, p = 0.01). Tumor size

(4.0 ± 0.4 vs. 4.3 ± 0.3 cm, respectively, p = 0.56), skin-

to-skin OT (186.1 ± 12.1 vs. 187.3 ± 11 min, respec-

tively, p = 0.94), estimated blood loss (50.3 ± 24.3 vs.

76.6 ± 21.3 ml, respectively, p = 0.42), and hospital stay

(1.3 ± 0.1 vs. 1.6 ± 0.1 days, respectively, p = 0.06)

were similar in both groups. The conversion to open rate

was zero in the robotic and 5.2 % (n = 3) in the laparo-

scopic group (p = 0.06).

The causes of conversion were: difficulty of dissection

due to friability of the mass, adherence of tumor to inferior

vena cava, and difficulty of dissection due to loss of planes,

in one patient each. Pathology was similar between the two

groups (Table 1).

On univariate analysis, tumor size (p = 0.01) and BMI

(p = 0.02) affected skin-to-skin OT (Table 2). However,

on multivariate analysis, the only parameter that remained

significant was tumor size (p = 0.02).

The 30-day morbidity was 4.8 % in the robotic and 7 % in

the laparoscopic group (p = 0.63). The complications

included urinary infection and intraoperative pneumothorax

Table 1 Summary of

demographic and clinical data in

the study patients

Continuous data are expressed

as mean ± SEM

LT lateral transabdominal, PRposterior retroperitoneal, ACAadrenocortical adenomaa Other includes complex cyst

(n = 2), lipoma (n = 1),

myolipoma (n = 2), organizing

hematoma (n = 1),

adrenocortical neoplasm

(n = 1), and testosterone-

secreting adenoma (n = 1) in

the laparoscopic group, and

ganglioneuroma (n = 1),

lymphangioma (n = 1),

metastatic colorectal carcinoma

(n = 1), metastatic Merkel cell

carcinoma (n = 1), metastatic

thyroid carcinoma (n = 1),

myolipoma (n = 1), benign cyst

(n = 1), and pseudocyst

(n = 1) in the robotic group

Parameter Laparoscopic (n = 57) Robotic (n = 42) p value

Age (years) 51.3 ± 1.7 54.2 ± 2 0.28

Body mass index (kg/m2) 38.8 ± 0.8 (30.3–65.2) 35.4 ± 1 (30–47.1) 0.01

Gender (female/male) 35/22 29/13 0.43

Side (right/left/bilateral) 21/32/4 20/21/1 0.37

Approach (LT/PR) 42/15 28/14 0.23

Tumor size (cm) (range) 4.3 ± 0.3 (1–15) 4.0 ± 0.4 (1–12) 0.56

Previous upper abdominal surgery 11 (19.3 %) 10 (23.8 %) 0.62

Operative time (min) (range) 187.3 ± 11 (80–516) 186.1 ± 12.1 (106–380) 0.94

Estimated blood loss (cm3) 76.6 ± 21.3 (0–900) 50.3 ± 24.3 (0–400) 0.42

Hospital stay (days) 1.6 ± 0.1 (1–5) 1.3 ± 0.1 (1–3) 0.06

Conversion to open 3 (5.2 %) 0 0.06

Morbidity 4 (7.0 %) 2 (4.8 %) 0.63

Pathology 0.15

Nonsecreting ACA 16 (28.1 %) 10 (23.8 %)

Pheochromocytoma 12 (21.1 %) 8 (19.1 %)

Cushing’s 10 (17.5) 10 (23.7 %)

Aldosteronoma 8 (14 %) 6 (14.3 %)

Adrenocortical carcinoma 3 (5.3 %) 0

Othera 8 (14 %) 8 (19.1 %)

1234 Surg Endosc (2013) 27:1233–1236

123

in one patient each in the robotic group, and prolonged ileus

and intraoperative pneumothorax in one patient each in the

laparoscopic group. There was one mortality in the laparo-

scopic group and none in the robotic group. The mortality

was due to postoperative respiratory failure due to severe

pulmonary hypertension.

Discussion

To our knowledge, this is the first report comparing the

outcomes of laparoscopic with robotic adrenal surgery in

obese patients. This study shows that the perioperative

outcomes are similar between the two approaches in this

patient population. We believe that these results underline

the significance and difficulty of obtaining and maintaining

appropriate exposure in obese patients.

There are a number of studies in literature comparing

laparoscopic adrenalectomy with open approach in obese

patients [8, 9]; however, only a few reports have com-

mented on the use of the robot for adrenalectomy in obese

patients [10]. This study shows that, in patients with

BMI [ 30 kg/m2, mean OT was higher in comparison with

patients with lower BMI in the LA group (90 vs. 78 min,

p = 0.03) but this difference was not observed in the RA

group patients (93 vs. 101 min, p = 0.3).

There were no conversions from robotic to open in this

study. This rate is reported to be between 0 and 6 % in the

literature [2, 10, 11]. The causes of difficulty with the

robotic approach in some patients in this study were mainly

related to lack of exposure due to patient habitus or

excessive fat tissue making dissection difficult. The causes

of difficulty with robotic adrenalectomy reported in the

literature were related to malposition of robotic trocars,

difficulty in obtaining hemostasis and dissection [10].

Nordenstrom et al. [12] demonstrated in their series that the

BMI of converted patients was significantly higher. The

complication rate in the robotic group in our study was

4.8 %; this number is in accordance with the 5–10 % rate

reported in the literature [13, 14].

Our findings in this study about RA in obese patients are

contrasting with those of Brunaud et al. [10], who reported

that the robotic approach offered advantages in obese

patients as well and that they did not encounter any technical

difficulty in their patients with mean BMI of 30 kg/m2

(maximum of 44 kg/m2 in their series). The difference might

be related to the fact that the BMI of the robotic patients was

higher in our series (mean 35.4 kg/m2). We also experienced

a difficulty in using the same robotic trocar configurations in

obese patients due to the need for retraction of the spleen and

liver compared with normal-weight individuals. We over-

came this difficulty by either using two first assistant trocars

or moving the position of the first assistant port.

The skin-to-skin OT was similar in our series between

RA and LA groups (186.1 ± 12.1 and 187.3 ± 11 min,

p = 0.94, respectively). Brunaud et al. [10] reported that

there was no difference in terms of robotic OT between

patients with BMI superior or inferior to 30 kg/m2. On the

other hand, for LA, they demonstrated a significant dif-

ference between the group of patients with BMIC or \30

kg/m2 (90 vs. 78 min, p = 0.03).

Although robotic surgery has been reported to be

1.2–3.2 times more costly than laparoscopy, several studies

indicate that, in high-volume centers with multidisciplinary

and increased use of the robot, the cost can decrease to

comparable level between the two approaches [11]. Winter

et al. also commented in their study of 30 robotic adrena-

lectomies that total hospital charges for patients in the

robotic and laparoscopic group were slightly less than the

total charges for patients in the open group (12.477,

11.599, vs. 14.600 US dollars, respectively) and that capital

and maintenance costs could be affordable at centers that

perform high-volume robotic surgery [13]. Brunaud et al.,

[14] however, discussed in their study that costs associated

with the robotic system were estimated to be twice the cost

of LA in high-volume robotic centers with [5 years

depreciation. In our previous studies, we commented that

the additional 900 dollars incurred with a robotic versus

laparoscopic adrenalectomy could be offset by decreased

OT [3] However, cost is still a significant concern for many

robotic general surgical procedures.

In conclusion, our study shows that there is no signifi-

cant difference in perioperative outcomes between RA and

LA in obese patients. Although benefits of robotic

Table 2 Univariate analysis of skin-to-skin operative time in the

study patients

Parameter Operative time (min) p value

Age (years) C60 162 ± 14 0.06

\60 195 ± 9

Gender Female 176 ± 10 0.14

Male 200 ± 13

BMI NA 0.02

Tumor size NA 0.01

Tumor type Pheochromocytoma 194 ± 16 0.55

Others 183 ± 10

Approach Lateral 189 ± 10 0.45

Posterior 176 ± 14

Procedure Laparoscopic 187 ± 11 0.94

Robotic 186 ± 12

Side Right 194 ± 12 0.35

Left 179 ± 10

Body mass index (BMI) and tumor size were taken as continuous

values, not categorical

Surg Endosc (2013) 27:1233–1236 1235

123

instruments and a 3D imaging platform are evident for

facilitating dissection, difficulty in maintaining exposure in

obese patients nullifies these benefits.

Disclosures Authors Erol Aksoy, Halit Eren Taskin, Shamil Aliyev,

Jamie Mitchell, Allan Siperstein, and Eren Berber have no conflict of

interest or financial ties to disclose.

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