laparoscopic adrenalectomy , first reported by gagner et al , is the standard of care for management of adrenal diseases .
recent technological advances in the form of newer energy sources , such as ultrasonic shears and the vessel - sealing system , have made performance of such advanced laparoscopic surgical procedures safer .
these devices have led to decreased operative blood loss and risk of thermal injuries compared with blood loss and thermal injuries with conventional electrocoagulation .
they provide an excellent alternative to clips , sutures , and staplers , both during open and laparoscopic surgery .
the vessel - sealing system is a bipolar system that uses thermal energy to permanently seal vessels , including 7 mm in diameter without dissection .
we report our initial experience with clipless and sutureless laparoscopic surgery using ultrasonic shears and the vessel - sealing system for removal of adrenal and extra - adrenal tumors .
between march 2004 and may 2007 , we operated on 10 patients who had adrenal tumors and 4 patients who had extra - adrenal tumors by using the laparoscopic ultrasonic shears and the ligasure vessel - sealing system . of the 10 patients with adrenal tumors , 8 had a mass in the right adrenal and 2 had in the left adrenal .
three of 4 patients with extra - adrenal masses were males , and all 3 presented with hypertension . in 2 patients , the extra - adrenal tumor was located in the para - aortic region , inferior to the hilum of the left kidney . in the remaining 2 patients ,
the demographic , clinical , and operative details of the patients are listed in table 1 .
clinical and operative data clinical features of pheochromocytoma were present in 10 of 14 patients .
all patients underwent a detailed workup , including history , physical examination , laboratory evaluation , and estimation of 24-hour urinary catecholamines .
ultrasound , contrast enhanced computed tomography ( cect ) and magnetic resonance imaging ( mri ) were used as imaging methods for localization .
meta - iodo - benzyl - guanidine ( mibg ) scans were also used in all the patients with suspected pheochromocytoma .
the patients underwent laparoscopic surgery via a transperitoneal approach with the patient in the lateral position .
no clips or sutures were used during the entire surgery in any of the patients .
surgery could be completed in all the cases by using the energy devices ultrasonic shears and the ligasure vessel - sealing system .
the mean operative blood loss was 70 ml ( range , 10 to 150 ) .
blood loss could be defined as minimal ( not requiring suction during the procedure ; < 10 ml ) , mild ( infrequently requiring suction during the procedure ; 10 ml to 50 ml ) , moderate ( frequent suction during the procedure ; 50 ml to 150 ml ) and severe ( > 150 ml ) .
two patients had minimal blood loss , 9 had mild blood loss , and 3 had moderate blood loss .
histopathological examination ( table 2 ) revealed pheochromocytoma in 7 patients , 6 with adrenal masses and one with an extra - adrenal mass . of the 4 extra - adrenal tumors , one patient had pheochromocytoma , and the remaining 3 had benign nerve sheath tumors , though 2 of these patients had presented with hypertension and other clinical features of pheochromocytoma . of 10 adrenal tumors ,
the histopathological examination in other patients with adrenal tumors included cortical adenoma in 2 patients and angiolipoma in 1 patient .
this young patient , a physician by profession , had clinical features of pheochromocytoma and an mibg scan suggestive of adrenal pheochromocytoma .
however , his 24-hour urinary catecholamines were normal . moreover , the mass was small and of doubtful significance .
postoperative final histopathological diagnosis ( n = 14 ) four patients with pheochromocytoma developed significant hypotension in the immediate postoperative period .
they were kept overnight in an intensive care unit and treated with fluids and inotropic support .
all patients had an uneventful recovery following surgery and were discharged from the hospital after an average postoperative stay of 2 days ( range , 1 to 7 ) .
since gagner et al performed the first laparoscopic adrenalectomy ( la ) in 1992 , this approach has been used extensively for the treatment of adrenal pathology and is considered the standard of care .
the advantages of laparoscopy over the open approach have been discussed in a number of reports .
these include less pain , minimal blood loss , shorter operative time , faster recovery of bowel function , and reduced hospital stay .
the surgery has been made easier by the introduction of newer energy sources for hemostasis like the ligasure vessel - sealing system and ultrasonic coagulator .
the ligasure system is a unique bipolar system that seals vessels up to 7 mm by application of precise pressure and thermal energy .
it uses thermal energy to breakdown the elastin and collagen of the vessel wall leading to apposition of the vessel wall .
this process operates under the control of a feedback mechanism and stops when the vessel gets completely sealed off .
this seal has been reported to have burst strength comparable to that of mechanical devices like clips and ligatures . during laparoscopic adrenalectomy , control of adrenal veins
the use of the ligasure vessel - sealing system does not require isolation of the adrenal veins .
moreover , it produces a seal of partially denatured protein with no risk of dislodgement as the lumen of the vessel gets obliterated .
we used the ligasure system in 10 patients with adrenal tumors and 4 patients with extra - adrenal tumors . in most patients , ultrasonic shears were also used for initial dissection followed by the use of the vessel - sealing system .
all tumors were removed laparoscopically by using the transperitoneal approach with the patient in the lateral position . the retroperitoneal approach for removal of adrenal tumors at our institution including pheochromocytomas has been described . however , we prefer the transperitoneal approach for laparoscopic removal of larger tumors .
one of the extra - adrenal tumors located inferior to the left renal vein was removed by using a novel transperitoneal , transmesocolic approach without mobilization of the left colon .
the conversions during laparoscopic adrenalectomy are mainly due to uncontrollable bleeding , large tumor size , and periadrenal fibrosis .
thus , there was no case with excessive bleeding , and the use of the ligasure device and harmonic shears played an important role in minimizing blood loss .
only 2 reports in the literature describe the use of the ligasure vessel - sealing device during laparoscopic adrenalectomy . in both of these studies ,
the ligasure device was the sole instrument used for hemostasis . in a series of 23 laparoscopic adrenalectomies in which the ligasure device was used ,
the reported operative time was 57 minutes ( range , 30 to 75 ) for unilateral adrenalectomy . however ; the average size of the adrenal mass in this series was 4 cm .
the higher operating time in our series ( mean , 138 minutes ) can be attributed to the fact that the average size of the adrenal tumors was 6.2 cm and that half of the cases were pheochromocytomas .
another reason for longer operating time for pheochromocytomas is that the surgery has to be frequently halted due to intraoperative blood pressure fluctuations .
similar results have been reported for pheochromocytomas in a series of 100 cases of laparoscopic adrenalectomy .
the average tumor size and the operative time for pheochromocytomas in this series were 6.3 cm and 2.5 hours , respectively .
the mean operative time for the whole group was 123 minutes ( range , 80 to 210 ) .
there are a number of reports on the use of the ligasure system for laparoscopic splenectomy ( ls ) .
romano et al reported less blood loss and a lower conversion rate in 10 patients who underwent splenectomy performed with this device .
the authors concluded that use of the ligasure device results in less blood loss , lower operative time , and increased safety when used for splenectomy .
moreover , compared with the ultrasonic coagulator , endostapler , and even clips if disposable clip applier is used , it is more cost - effective .
gelmini et al reported that use of the ligasure vessel - sealing system is associated with less operative time and increased safety . in their series of 63 consecutive patients who underwent laparoscopic splenectomy ( ls ) ,
the ligasure vessel - sealing system was the only instrument used for hemostasis . according to the authors , the low operative blood loss was mainly attributable to the use of this bipolar vessel - sealing system .
the ligasure system has also been used for several other thoracic and abdominal procedures , both open and laparoscopic .
its use has been reported for nephrectomy , donor - nephrectomy , colectomy , adrenalectomy , hepatic resection , hysterectomy , and appendectomy .
the ligasure vessel - sealing system has made surgery easier to perform with a decrease in operating time .
it also leads to a lower conversion rate , possibly as a result of decreased bleeding .
the instrument is not only effective for sealing blood vessels ; it can be used for dissection as well .
the precise feedback control mechanism ensures minimal lateral spread of energy , limited to less than 1.5 mm beyond the area of application . in obese patients with fat around vessels , individual dissection , and isolation of blood vessels
is not required , which can minimize the chances of their avulsion and troublesome bleeding .
the contraindications for using the vessel - sealing system are few and include a large vein on the right side .
based on our initial experience , we feel that newer energy devices like ultrasonic shears and the ligasure vesselsealing system are useful tools that facilitate safe laparoscopic excision of adrenal and extra - adrenal tumors .
their use during these advanced laparoscopic procedures leads to reduced blood loss , shorter operating time , and a lower conversion rate .
 background : newer , energy - based devices like the ultrasonic coagulator ( harmonic scalpel , ethicon endo - surgery , inc . , cincinnati , oh ) and the ligasure vessel - sealing system ( valleylab , boulder , co ) are increasingly being used in advanced laparoscopic procedures . 
 use of these devices has resulted in shorter operative time , less blood loss , and lower conversion rates . 
 we present our experience with these devices for laparoscopic removal of adrenal and extra - adrenal tumors.methods:ten patients with adrenal tumors and 4 with extra - adrenal tumors were operated on laparoscopically with the ultrasonic shears and ligasure vessel - sealing system . 
 the entire surgery was carried out using these energy - based devices without using any clips or sutures.results:no conversions were necessary . 
 none of the patients experienced any major intraoperative or postoperative bleeding . 
 the mean size of the tumor was 6.2 cm ( range , 3 to 8) . 
 the mean operative time was 123 minutes ( range , 80 to 210 ) , and the mean blood loss was 70 ml ( range , 10 to 150 ) . 
 histopathology revealed pheochromocytomas in 7 patients.conclusions:use of the ligasure vessel - sealing device along with ultrasonic shears for laparoscopic removal of adrenal and extra - adrenal tumors is safe and effective . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION