A critical analysis of intraoperative time utilization in laparoscopic adrenalectomy

Background: Time and efficiency analysis is a technique common in industry that is being applied to surgical procedures. The aim of this study is to analyze the time spent performing the component parts of laparoscopic adrenalectomy by both the lateral transabdominal and the posterior retroperitoneal approaches. Methods: Operational videotapes of 33 patients undergoing laparoscopic adrenalectomy (12 lateral, 21 posterior) were reviewed. The operation was divided into six steps: trocar entry, laparoscopic ultrasonography, exposure of the adrenal gland, dissection of the adrenal, extraction of specimen, and irrigation-aspiration. Time spent for each step and the relation with age, gender, body mass index (BMI), tumor size, side, and histology were assessed using Student's t-test, Pearson correlation, and regression analysis. Results: Although tumor size was larger in the lateral compared to the posterior approach (5.5 vs 2.5 cm, p < 0.001), there was no difference between the groups regarding total operating time (116.1 vs 112.8 min). Most of the operating time was spent on dissection of the adrenal gland with both techniques (lateral, 60%; posterior, 66%). Exposure of the adrenal gland was longer in the lateral compared to the posterior approach (15.1 vs 5.8 min, respectively; p < 0.05). In the transabdominal technique, this step was longer on the right side than on the left (18.9 vs 11.4 min, respectively; p < 0.05). In the lateral approach, dissection time was dependent on tumor size (r = 0.90, p < 0.05) but not on BMI, whereas in the posterior approach both tumor size and BMI were positively correlated (r = 0.56 and r = 0.64, respectively). Conclusions: To our knowledge, this is the first study to apply time analysis techniques to laparoscopic adrenal surgery. Understanding the variables that affect operative time may influence the choice of the surgical approach in a given patient. This study also suggests that efforts to improve operative efficiency are best directed at the dissection of the adrenal.