Flank approach versus anterior sub - mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study

Abstract: Background: Laparoscopy is commonly recognized as the gold standard in adrenal surgery. The most used surgical access is at present the so-called flank approach. The aim of this study was to compare the flank approach and the anterior sub-mesocolic access carrying out left laparoscopic adrenalectomy (LA). Methods: From January 2003 to January 2006 50 eligible left LAs were randomized to the flank (n = 25, group A) or sub-mesocolic transperitoneal approach (n = 25, group B). The two groups were similar concerning patient and lesion features. Comparing the two approaches, the main parameters analyzed, adjusted for tumor size and histology, were operating time (OpT), complication rate, and hospital stay. Results: There were no converted procedures. Mean overall OpT was 76.4 min (54–96 min) versus 65.6 min (45–95 min) in group A and B, respectively (p = 0.001), while the OpT required to tie the adrenal vein was 42.8 min (26–55 min) and 24.5 min (16–41 min) (p = 0.000). Oral feeding resumed within 12–24 h in both groups. Mean hospital stay was 3 and 2.4 days in groups A and B, respectively (p = 0.04). Mean tumor size was similar in group A and B: 3.6 cm (1.5–6.5 cm) and 3.8 cm (2–6 cm), respectively. Definitive histology in groups A and B were: Cushing adenoma (6 and 4), Conn adenoma (5 and 6), pheochromocytoma (4 and 9), and incidentaloma (8 and 5, respectively). A myelolipoma and an adrenogenital adenoma were observed in group A and one carcinoma was observed in group B. Conclusions: Sub-mesocolic approach provides a statistically significant shorter OpT and hospital stay. Identification and early closure of the adrenal vein by means of a really minimal dissection and no-touch gland technique resulted in the main benefits of this approach.