Since the first successfully performed LA by Gagner in [3], the transperitoneal approach has became the most common therapeutic strategy for adrenal neoplasm, establishing itself nowadays like the gold standard technique [4,5,6, 20, 21].
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Adrenal surgery is a field where precision and thoroughness are highly important. As in every surgical procedure, anatomical knowledge should always be associated with the more appropriate instrument. A comparison of new and advanced devices in a surgical reliable technique, yet not fully investigated, is not trivial.
Is easy to find in Literature data from the application of these new devices in thyroid surgery [12, 13, 22]. In fact, many papers have been published in last decade with this debated topic, but few data are available concerning the impact of these instruments on laparoscopic adrenalectomy.
Same Authors describe personal experiences with one device [23], other ones compare results between LS and HS or between these two devices with electric hook (14,15,18, 24) but no papers analyze and compare the use of these three technologies.
In thyroid surgery, a large British meta-analysis concluded that in a ranking scale, ultrasonic coagulation (HS) is in the first position in terms of reduced IBL and drain output, shortest OT and HT, followed by LS [12]. Unfortunately, in this analysis is not considered TB and it is targeted to a single specific tissue, making data not applicable to all anatomical sites.
Recently, an American group, tested the heat spread of LS, HS and TB in three different tissues concluding that all devices were similar with an heat lateral diffusion &#;2&#;mm [22] but, in Literature, is not possible to find a comparative study on the quality of coagulation or the haemostatic power of these three devices.
In the field of adrenal surgery, during , an Italian group published a prospective study about the comparing of bipolar energy devices with ultrasonic ones (assisted by monopolar high-frequency) in laparoscopic adrenalectomy. The Authors demonstrated a significant difference in OT only for left-sided adrenalectomies and an overall decreased IBL in the bipolar energy devices group [24]. In Sartori et al., reported their experience of 46 patients underwent laparoscopic adrenalectomy using bipolar or ultrasound energy devices. The results could not demonstrate any differences in the surgical outcomes between the two groups and Authors concluded that hemostatic devices choice is up to surgeon&#;s preference [14]. In another Italian group analyzed, retrospectively, the difference between the use of bipolar, ultrasound and monopolar energy devices on 165 patients underwent laparoscopic adrenalectomy. Authors demonstrate that the use of advanced sealing devices is associated with a reduced OT, especially in left adrenalectomy, and with a better hemostasis when compared with monopolar energy devices. However, this study has some limitations represented by the retrospective analysis and the bias belonging from groups not well matched. [14, 15, 24]
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To the best of our knowledge, the current study is the first comparing all commercially available advanced energy devices in laparoscopic adrenal surgery.
Following indication of most recent Literature, in the current study advanced energy devices are not compared with electric hook due to the evidence of a longer OT and HT and of an increasing IBL and drainage output associated to the use of the latter [15].
It must be highlighted that in the study groups there was no significant statistical difference regarding the relationship between male/female, right site/left site, the mean age and the side (p&#;>&#;0.05). Therefore two step cluster and t test paired analysis were performed on our OT, IBL and HT results to evaluate the eventual superiority of an instrument over the others.
Is possible assert that TB is the best device to reduce OT with a significant statistical difference compared with LS and HS (p&#;<&#;0.001). Probably, this data is consistent with the presence in a single device of both modality of advanced energy, conferring to the surgeon a greater speed of execution. Another significant statistical difference is observable between HS and LS (p&#;=&#;0.048) probably due to the greater surgeon&#;s experience with the HS.
Regarding the IBL, between HS and TB no significant statistical difference were found (p&#;=&#;0.17), nevertheless both reduced IBL in case of comparison with LS (p&#;<&#;0.05).
No significant statistical difference were found in HT comparing each groups with the others but is very interesting to highlight the correlation between the use of advanced dissecting devices in laparoscopic adrenalectomy and shorter HT, leading to decreased costs, as evidenced by Valeri et al. in [25]. Unfortunately, this cost-benefit analysis, that demonstrate a considerable economic savings using HS, is not updated and not consider many economic and logistic variables changed in the last 15&#;years. In the current study, the Authors not performed a specific costs analysis of the use of the different energy devices. It would be interesting to analyse its economical implications in a future study.
The limitations of this article are all related to its retrospective nature. We are aware that the surgeon experience, his expertise or confidence whit one device may be a confounding factor affecting this study. However, all the procedures were performed by the same operator and the same surgical team. We therefore believe that the impact of this variable on the outcomes, if present, is minimal. Furthermore, is our opinion that the results of this study should not be considered true for other type of surgery but only in adrenal gland laparoscopic surgery.
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