Objective To clarify the biomechanical properties of oblique lumbar interbody fusion(OLIF)combined with lateral plate(LP)fixation under different bone conditions by means of finite element(FE)analysis,so as to provide mechanical basis for clinical practice.Methods The three-dimensional nonlinear L3_5 FE model of the spine was constructed.Different material properties were assigned to each part of the model to establish a model of normal bone(NB),osteopenia(OS)and osteoporosis(OP)of the lumbar spine.OLIF combined with the following three internal fixation models were established.For NB,there were OLIF alone(M0),OLIF+LP fixation(M1),and OLIF+bilateral pedicle screw(BPS)fixation(M2);for OS,there were OLIF alone(N0),OLIF+LP fixation(N1),and OLIF+BPS fixation(N2);for OP,there were OLIF alone(P0),OLIF+LP fixation(P1),and OLIF+BPS fixation(P2).A 500 N load was applied on the upper surface of L3 to represent the weight of the upper body,and a 7.5 N·m moment was used to simulate the vertebral motion under six different conditions:flexion(FL),extension(EX),left bending(LB),right bending(RB),left rotation(LR)and right rotation(RR).The range of motion(ROM)of the fixed segment of NB,OS and OP models was calculated,and the overall stress of the vertebral body,the stress of the cage and the internal fixation device were recorded.Results Compared with the complete model,the stability of each surgical model increased.Compared with M0,ROM of M1 decreased,especially in the LB and RB,which was roughly equivalent to the stability of BPS but weaker than BPS in the control FL and EX direction.The situation in OS and OP model was similar to that in NB.Under the same internal fixation,L4_5 ROM gradually increased with bone deterioration.The overall intervertebral ROM of N1 in the FL direction increased by 16.1％compared with M1,P1 in the FL direction increased by 32.1％compared with M1,and P1 in the FL direction increased by 19.0％compared with N1.With the increase of posterior internal fixation,the overall stress of vertebral body,Cage and internal fixation stress showed a downward trend.Under the same internal fixation,with the loss of bone mass,the overall stress of the model gradually increased.Compared with M0,P0 increased the most in LR,reaching 56.5％.In the NB and OS models,the peak stress of the LP fixation under FL exceeded the minimum yield strength of the material by 22.7％and 33.8％,respectively,and was less than the minimum fatigue strength and yield strength of the material under the rest of the motion.In the OP,the peak stress of the internal fixation exceeded the minimum fatigue strength of the material at FL and EX,and reached 53.3％(＞50％)at FL.Conclusions Under NB and OS,OLIF combined with LP fixation can significantly improve the stability of the surgical segment,especially in LB and RB directions,and the overall stability is weaker than that of BPS fixation.Under OP,FL and EX may increase the risk of internal fixation failure.Combination with BPS fixation should be considered to improve the safety of fixation.

Objective To clarify the biomechanical properties of oblique lumbar interbody fusion(OLIF)combined with lateral plate(LP)fixation under different bone conditions by means of finite element(FE)analysis,so as to provide mechanical basis for clinical practice.Methods The three-dimensional nonlinear L3_5 FE model of the spine was constructed.Different material properties were assigned to each part of the model to establish a model of normal bone(NB),osteopenia(OS)and osteoporosis(OP)of the lumbar spine.OLIF combined with the following three internal fixation models were established.For NB,there were OLIF alone(M0),OLIF+LP fixation(M1),and OLIF+bilateral pedicle screw(BPS)fixation(M2);for OS,there were OLIF alone(N0),OLIF+LP fixation(N1),and OLIF+BPS fixation(N2);for OP,there were OLIF alone(P0),OLIF+LP fixation(P1),and OLIF+BPS fixation(P2).A 500 N load was applied on the upper surface of L3 to represent the weight of the upper body,and a 7.5 N·m moment was used to simulate the vertebral motion under six different conditions:flexion(FL),extension(EX),left bending(LB),right bending(RB),left rotation(LR)and right rotation(RR).The range of motion(ROM)of the fixed segment of NB,OS and OP models was calculated,and the overall stress of the vertebral body,the stress of the cage and the internal fixation device were recorded.Results Compared with the complete model,the stability of each surgical model increased.Compared with M0,ROM of M1 decreased,especially in the LB and RB,which was roughly equivalent to the stability of BPS but weaker than BPS in the control FL and EX direction.The situation in OS and OP model was similar to that in NB.Under the same internal fixation,L4_5 ROM gradually increased with bone deterioration.The overall intervertebral ROM of N1 in the FL direction increased by 16.1％compared with M1,P1 in the FL direction increased by 32.1％compared with M1,and P1 in the FL direction increased by 19.0％compared with N1.With the increase of posterior internal fixation,the overall stress of vertebral body,Cage and internal fixation stress showed a downward trend.Under the same internal fixation,with the loss of bone mass,the overall stress of the model gradually increased.Compared with M0,P0 increased the most in LR,reaching 56.5％.In the NB and OS models,the peak stress of the LP fixation under FL exceeded the minimum yield strength of the material by 22.7％and 33.8％,respectively,and was less than the minimum fatigue strength and yield strength of the material under the rest of the motion.In the OP,the peak stress of the internal fixation exceeded the minimum fatigue strength of the material at FL and EX,and reached 53.3％(＞50％)at FL.Conclusions Under NB and OS,OLIF combined with LP fixation can significantly improve the stability of the surgical segment,especially in LB and RB directions,and the overall stability is weaker than that of BPS fixation.Under OP,FL and EX may increase the risk of internal fixation failure.Combination with BPS fixation should be considered to improve the safety of fixation.

Objective:To analyze the efficacy of laparoscopic radical surgery, compared to open surgery, for incidental gallbladder cancer following cholecystectomy.Methods:Clinical data of 106 patients with incidental gallbladder cancer treated at the Second Affiliated Hospital Zhejiang University School of Medicine from April 2010 to February 2018 were retrospectively analyzed, including 66 males and 40 females, aged (64.7±7.9) years old. According to surgical approach, patients were divided into the laparoscopic group ( n=45) and open group ( n=61). Perioperative data, including intraoperative blood loss, postoperative hospital stay, and postoperative complications, were compared between the groups. Follow-ups were conducted via outpatient visits or telephone reviews. Survival analysis was performed using the Kaplan-Meier method, and the survival rates were compared using the log-rank test. Results:All 45 patients in the laparoscopic group successfully underwent the surgery without conversion to open surgery. Compared to the open group, the laparoscopic group had a reduced intraoperative blood loss [(100±25) ml vs. (200±46) ml] and a shortened postoperative hospital stay [3(2, 5) d vs. 5(4, 7) d] (both P<0.05). The postoperative complication rates were 6.7% (3/45) in the laparoscopic group and 13.1% (8/61) in the open group ( χ2=4.16, P=0.041). The cumulative survival rate after radical surgery for incidental gallbladder cancer was better in the laparoscopic group ( χ2=4.58, P=0.032). Conclusion:Compared to open surgery, laparoscopic radical surgery for incidental gallbladder cancer showed benefits in intraoperative blood loss, postoperative hospital stay, complication rates, and cumulative survival.

OBJECTIVE To establish an analytical method for the simultaneous determination of multiple anesthetics and their metabolites in aquatic products by ultra performance liquid chromatography-tandem mass spectrometry with pass-through solid phase extraction purification. METHODS After homogenization, the samples were extracted by 80% acetonitrile aqueous solution, and purified by ProElt PLS-A pass-through solid phase extraction column. The extract was determined by positive ion mode with mobile phase of 0.1% formic acid water and 0.1% formic acid acetonitrile in the separation by programmed gradient. Multiple reaction monitoring mode was used to draw standard curves with the matrix-matched method. RESULTS The calibration curves of the 14 anesthetics showed good linearity in the concentration range of 1-50 µg·L-1 and their metabolites showed good linearity in the concentration range of 10-500 μg·L-1, with the correlation coefficients >0.99. The limits of detection were 0.5 μg·kg-1 in anesthetics and 5 µg·kg-1 in their metabolites. The lower limits of quantification were 1 μg·kg-1 in anesthetics and 10 μg·kg-1 in their metabolites. The recoveries at high, medium and low concentrations ranged from 62.48% to 116.5% with RSDs<10%. CONCLUSION The method is simple and can be used for the accurate detection of anesthetics and their metabolites in aquatic products with high reliabilities.

BACKGROUND: Preliminary researches conformed that neoadjuvant immunotherapy combined with chemotherapy had a significant short-term effect in resectable non-small cell lung cancer (NSCLC), but there were few clinical trials about neoadjuvant chemoimmunotherapy in China. We aimed to assess retrospectively the antitumour activity and safety of neoadjuvant chemoimmunotherapy for resectable stage Ib-IIIb NSCLC. METHODS: Twenty patients who had been diagnosed as stage Ib-IIIb NSCLC and received chemoimmunotherapy as neoadjuvant treatment between November 2019 and December 2020, in Beijing Chest Hospital, Capital Medical University were recruited. These patients received neoadjuvant treatment for 21 days as a cycle and antitumour activity and safety were evaluated every two cycles. RESULTS: Of 20 patients received neoadjuvant chemoimmunotherapy, 17 patients underwent surgical resection. 16 patients had R0 resection (no residual tumor resection) and 1 patient had R1 resection (microscopic residual tumor resection). Radiographic objective response rate (ORR) was 85.0% (4 complete response, 13 partial response). 5.0% (1/20) of patients had stable disease, and 10.0% (2/20) of patients had progression disease. The major pathologic response (MPR) was 47.1% (8/17), and complete pathologic response (CPR) was 29.4% (5/17). 1 case developed grade IV immune-related pneumonia (IRP) and 9 (45.0%) cases had grade III hematologic toxicity. CONCLUSIONS Immunotherapy combined with chemotherapy as neoadjuvant therapy has a better efficiency and tolerable adverse effects for patients with resectable NSCLC in stage Ib-IIIb.

Objective:To evaluate the etiological diagnosis value of soft bronchoscopy in children with laryngeal stridor.Methods:The clinical data of 402 children with laryngeal stridor wheezing were retrospectively analyzed, which examined by soft bronchoscopy in Anhui Provincial Children′s Hospital from January 2016 to January 2019.Results:A total of 402 cases of laryngeal stridor were diagnosed by soft bronchoscopy, 317(78.8%) cases were diagnosed as congenital airway dysplasia, including 200(49.7%)cases of congenital laryngeal chondromalacia, which including 132 cases of single laryngeal chondromalacia and 68 cases with other respiratory tract dysplasia, and 117(29.1%) cases of respiratory dysplasia other than laryngeal chondromalacia; 46(11.5%) cases of laryngitis; 28(7.0%) cases of airway acquired stenosis and 11 (2.7%)cases of foreign body.Among 402 cases of children with laryngeal stridor who were diagnosed according to clinical feature, combined with chest X-ray, chest CT, CT angiography and color Doppler echocardiography as well as other imaging data, 335(83.3%) cases were congenital laryngeal chondromalacia, 16(4.0%) cases were other respiratory tract dysplasia (including six cases of subglottic and tracheal stenosis, five cases of laryngeal space occupying lesions, four cases of tracheobronchial malformation, and one case of subglottic hemangioma), 35 (8.7%)cases of laryngitis, acquired airway stenosis in 15 cases including 13 cases of congenital heart disease, one case of pulmonary artery sling, one case of mediastinal cyst, and one case of foreign body.Congenital laryngeal chondromalacia, other causes of respiratory dysplasia and foreign body detected by flexible bronchoscopy were not consistent with clinical examination( P<0.05). Conclusion:Congenital laryngeal chondromalacia is the main cause of laryngeal stridor, but it is often associated with other airway dysplasia.Soft bronchoscopy can provides etiological diagnosis for children with laryngeal stridor wheezing, especially in the diagnosis of respiratory tract dysplasia and airway foreign body.

Objective:To established the diagnostic criteria for venomous snakebite of Trimeresurus stejnegeri in Guangxi by ourselves, and explore the clinical effect and mechanism of covered vacuum sealing drainage (VSD) in the treatment for venomous snakebite of Trimeresurus stejnegeri in Guangxi.Methods:According to the Chinese emergency medicine for snakebite and the Chinese snake, the diagnostic criteria for venomous snakebite of Trimeresurus stejnegeri in Guangxi were formulated: ① the responsible venomous snake was identified as Trimeresurus stejnegeri in Guangxi; ② the appearance and morphology of the venomous snake described by the patient basically conformed to the characteristics of Trimeresurus stejnegeri in Guangxi;③ clinical manifestations of hematotoxin included local swelling, severe wound pain, and subcutaneous ecchymosis in some patients; having① or both ② and ③ could be diagnosed. The patients with venomous snakebite of Trimeresurus stejnegeri in Guangxi admitted to Snake Injury Treatment Base in Central and Northern Guangxi/Liuzhou Integrated Chinese and Western Medicine Snake Injury Treatment Center from January 2016 to January 2020 were enrolled. The patients were divided into the general treatment group and the covered VSD technology group, with 60 patients in each group. The general treatment group was treated with antivenom, anti-tetanus, closed injection around the wound, anti-inflammatory, magnesium sulfate gauze applied on the affected limb, symptomatic support treatment. The covered VSD technique was used in the covered VSD technology group based on the treatment options of the general treatment group. Treatment cycle of both groups were calculated from the next day of admission and lasted for 7 days. In the treatment cycle, blood was collected at 08:00 every day. The red blood cell count (RBC) and hemoglobin (Hb) were detected by automatic blood cell analyzer. The prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (Fib) were detected by automatic blood coagulation analyzer, and the affected limb swelling degree and the appearance of subcutaneous ecchymosis were recorded. Results:At different time points in the treatment cycle, the dynamic change trends of PT, APTT and Fib in the covered VSD technology group and the general treatment group were significantly different. Fib in both groups decreased on the 1-4 days, and gradually rose on the 5th day, and the lowest Fib value in the covered VSD technology group on the 4th day was higher than that in the general treatment group (g/L: 0.70±0.03 vs. 0.41±0.01, P < 0.05). In the treatment cycle, PT of both groups increased in the early and middle stage, but decreased in the later stage. The peak value of PT of the covered VSD technology group on the 5th day was significantly lower than that of the general treatment group (s: 25.2±0.1 vs. 35.4±0.2, P < 0.05), and the PT of the covered VSD technology group returned to the normal range on the 7th day, while the PT of the general treatment group was still abnormal. APTT in both groups increased at the beginning of the treatment cycle and gradually decreased. The peak value of APTT of the covered VSD technology group on the 3th day was lower than that in the general treatment group (s: 47.3±0.1 vs. 55.7±0.2, P < 0.05), and the rate of increase and decline was also more gradual than that in the general treatment group. There was no significant difference in RBC or Hb between the two groups. With the passage of time, the degree of affected limb swelling was relieved to different degrees in both groups, and the remission degree in the covered VSD technology group was more obvious than that in the general treatment group, and there was significant difference between the two groups (χ 2 = 86.060, P = 0.000). The occurrence rate of subcutaneous ecchymosis in the covered VSD technology group was significantly lower than that in the general treatment group (13.3% vs. 40.0%, χ 2 = 10.909, P = 0.002). Conclusions:The application of covered VSD technology to the venomous snakebite of Trimeresurus stejnegeri in Guangxi does not aggravate the bleeding. It is beneficial to the reduction of the swelling of the affected limb, and also promotes the recovery of coagulation function, which can better control the occurrence of adverse events caused by coagulation dysfunction.

Objective To compare the short-term clinical efficacies of Da Vinci robotic surgical systemassisted and laparoscopy-assisted radical gastrectomy for locally advanced gastric cancer (GC).Methods The retrospective cohort study was conducted.The clinicopathological data of 162 patients who underwent minimally invasive radical gastrectomy for locally advanced GC in the First Affiliated Hospital of Army Medical University between September 2016 and September 2017 were collected.Of 162 patients,65 undergoing Da Vinci robotic surgical system-assisted radical gastrectomy were allocated into the robotic group and 97 undergoing laparoscopyassisted radical gastrectomy were allocated into the laparoscopic group.According to Japanese gastric cancer treatment guidelines,patients with upper GC and with middle or lower GC underwent respectively total gastrectomy + D2 lymph node dissection and distal subtotal gastrectomy + D2 lymph node dissection,and then Billroth Ⅱ or Roux-en-Y digestive tract reconstruction.Observation indicators:(1) surgical and postoperative situations;(2) detection of lymph node;(3) follow-up and survival situations.Measurement data with normal distribution were represented as x±s,and comparisons between groups were analyzed using the t test.Comparisons of count data were done using the chi-square test.Ordinal data were analyzed by the nonparametric test.Results (1) Surgical and postoperative situations:all 162 patients underwent successful surgery,without conversion to laparoscopic or open surgery,and pathological resection margins were confirmed as R0.Volume of intraoperative blood loss,levels of amylase in peritoneal drainage fluid at day 1,2 and 3 postoperatively,levels of serum amylase fluid at day 1,2 and 3 postoperatively were respectively (123±39) mL,(557± 181) U/L,(357± 127) U/L,(183±86) U/L,(181±47)U/L,(123±29)U/L,(85±22)U/L in the robotic group and (142±40)mL,(793±284)U/L,(497±199)U/L,(279±157) U/L,(218±45) U/L,(162±37) U/L,(120±31) U/L in the laparoscopic group,with statistically significant differences between groups (t =-3.015,-2.817,-2.364,-2.132,-2.372,-3.338,-3.720,P＜0.05).Cases with distal subtotal gastrectomy + D2 lymph node dissection and with total gastrectomy + D2 lymph node dissection,cases with Billroth Ⅱ and Roux-en-Y of digestive tract reconstruction,time of distal subtotal gastrectomy + D2 lymph node dissection,time of total gastrectomy + D2 lymph node dissection,cases with anastomotic leakage,pulmonary infection,wound infection or liquefaction and delayed gastric emptying,cases in grading Ⅱ,Ⅲ,Ⅳ and Ⅴ of postoperative complications,time of postoperative drainage-tube removal and duration of postoperative hospital stay were respectively 47,18,40,25,(222±37) minutes,(274±43) minutes,1,1,1,1,2,1,0,0,(6.5-± 1.5) days,(10.0±4.0) days in the robotic group and 74,23,69,28,(213±40) minutes,(262±39)minutes,2,4,1,0,4,1,0,1,(6.9±1.7)days,(10.0±5.0)days in the laparoscopic group,with no statistically significant difference between groups (x2=0.326,1.628,t =1.272,0.960,x2=2.501,Z=-1.342,t=-1.142,-0.115,P＞0.05).One and 1 patients in the robotic and laparoscopic groups who were complicated with esophagus-jejunum anastomotic leakage after total gastrectomy + Roux-en-Y anastomosis were cured by nutrition support therapy using feeding tube placement under gastroscopy,and 1 patient in the laparoscopic group who were complicated with gastrojejunal anastomosis leakage after distal subtotal gastrectomy +Billroth Ⅱ anastomosis received the second surgical exploration and jejunal feeding tube placement.Patients with pulmonary infection,wound infection or liquefaction and delayed gastric emptying were cured by conservative treatment.Levels of amylase in peritoneal drainage fluid and serum amylase fluid at day 1,2 and 3 postoperatively were not higher than 3 times of upper limit of normal,without treatment interventions.(2) Detection of lymph node:overall number of lymph nodes detected in the robotic and laparoscopic groups were respectively 36.82±13.41 and 35.21 ± 11.52,with no statistically significant difference between groups (t =0.786,P＞ 0.05).Results of further analysis showed that numbers of lymph node dissected in the 2nd station and upper region of pancreas in patients undergoing distal subtotal gastrectomy + D2 lymph node dissection were respectively 6.04±3.98,13.51±6.53 in the robotic group and 4.45±3.12,11.40±5.30 in the laparoscopic group,with statistically significant differences between groups (t=2.461,1.986,P＜0.05).Numbers of lymph node dissected in No 7 and 8 groups and upper region of pancreas in patients undergoing total gastrectomy + D2 lymph node dissection were respectively 5.44±2.63,2.92±1.87,10.81±4.78 in the robotic group and 3.11±1.82,1.62±1.33,7.76±3.34 in the laparoscopic group,with statistically significant differences between groups (t =3.340,2.689,2.522,P＜0.05).(3) Follow-up and survival situations:of 162 patients,148 were followed up for 2-14 months,with a median time of 8 months.During the follow-up,patients in the 2 groups had tumor-free survival.Conclusions Da Vinci robotic surgical system-assisted radical gastrectomy is safe and feasible.Compared with laparoscopy-assisted radical gastrectomy for locally advanced GC,it has advantages of clear vision of the local anatomy,less intraoperative bleeding,more numbers of lymph nodes dissected in the upper region of pancreas and lighter pancreatic injure,meanwhile,it has also certain operating advantages around the great vessels and in the deep and narrow spaces.

OBJECTIVETo identify the value of lymphography in the location and treatment decision of chyle leakage.

METHODSThe clinic data of 177 patients suffered from chyle leakage admitted in 6 medical centers in Shanghai from February 1998 to December 2014 was analyzed retrospectively. There were 94 male and 83 female patients aging from 9 to 84 years with a mean of 49 years, including 128 cases of chyluria, 34 cases of primary chylothorax and 15 cases of other chyle leakage. All patients had failed to conservative treatment more than 2 weeks. Pedal lymphography was performed in every patient to investigate the site and range of chyle leakage. Effect of surgical or conservative management was compared according to the different results of lymphography.

RESULTSNo serious complication was noticed. For all 177 patients, lymphography showed localized lymphatic diseases in 148 cases (83.6%), including 125 cases of lymphatic renal pelvic leaks, 14 cases of unilateral identified leak within thorax and 9 cases of chyle leakage in neck, heart, abdomen or scrotum. Among these patients, surgical treatment cured 129 and improved 3 patients but failed in 2 patients, while the remaining 14 cases had their leaks decreased after lymphography and cured by conservative management. For those 15 patients having disseminated lymphatic diseases or 14 with no abnormality under lymphography, surgery only cured 2 and improved 1 patient but failed in 8 patients (with 3 death), whereas continuous conservative treatment cured 11 patients, improved 5 patients but only failed in 2 patients (with one death). For localized leakage, surgical treatment showed better efficacy (98.5% vs. 3/11), whereas conservative treatment had significantly higher successful rate than surgical interventions in patients with disseminated lymphatic diseases or no abnormality under lymphography (16/18 vs. 3/11).

CONCLUSIONSLymphography could identify the location and range of complicate chyle leakage failed to primary conservative management. Patients with disseminated lymphatic diseases or no abnormality under lymphography would be better managed by continuous non-operative treatment partly due to therapeutic effect of lymphography, while surgical intervention could be a good option for patients having localized lymphatic etiology.

Abdominal Cavity ; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Child ; Chyle ; Chylothorax ; diagnosis ; surgery ; Female ; Heart ; Humans ; Kidney Pelvis ; Lymphatic Diseases ; Lymphography ; Male ; Middle Aged ; Neck ; Retrospective Studies ; Scrotum ; Young Adult

Objective To investigate the clinical features , diagnosis and key technique points of laparoscopic partial adrenalectomy for small adrenal pheochromocytoma . Methods From Oct.2006 to Jun. 2011, clinical data of 32 cases with small adrenal pheochromocytoma (≤3.0 cm) were collected and retro-spectively analyzed .Hypertension was observed in 12 patients, whereas 20 patients presented with adrenal incidentaloma .Thirteen patients had a left adrenal neoplasm , eighteen patients had a right adrenal tumor , while one patients had bilateral tumors .The positive rate of plasma-free metanephrines ( MNs) and 24-hours urinary catecholamine (CA) in diagnosing small renal pheochromocytomas was 92.6%(25/27) and 81.3%(26/32) respectively.The main localization diagnosis included ultrasonography , 131I-MIBG, and CT or MRI, with positive rates of 71.9%(23/32), 93.8%(15/16) and 96.9%(31/32) respectively.All the laparoscopic adrenalectomies were performed retroperitoneally .During the surgery , the internal part of the adrenal gland closing to the retroperitoneum was dissected first , and the whole adrenal gland was resected completely. Results Partial adrenalectomy was performed for 30 cases and radical adrenalectomy for 2 ca-ses.All operations were successful without perioperative or postoperative complications .The maximum diame-ter of tumor was 1.7±0.2 (1.0-3.0) cm.Histopathological results showed that all the cases were benign pheochromocytoma.The operative time was 82 (40-210) min.The estimated blood loss was 57 (20-180) ml.No patient required blood transfusion . Conclusions Plasma-free MNs, 24-hours urinary CA and VMA are important qualitative examinations in detection of adrenal pheochromocytoma .Ultrasonography , CT,MRI, and 131 I-MIBG are important in the localization of adrenal tumors .Retroperitoneal laparascopic partial adrenalectomy is the preferred choice in the management of small adrenal pheochromocytoma .Dissecting the internal part of the adrenal gland closing to the retroperitoneum first and exploring the whole adrenal tissue are the key technique points during the operations .