Surgical Approach For Pheochromocytoma

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Laparoscopic resection is now the procedure of choice for resecting most adrenal tumors under 6 cm in diameter. The techniques of laparoscopic adrenalectomy have been described in detail.73 This technique has largely replaced open laparotomy, owing to the accuracy of preoperative localization procedures. However, tumors > 6 cm are more difficult to resect laparoscopically and are more likely to be malignant. For such large tumors, a lateral laparoscopic approach can still be done as it allows greater space for exploration and examination of the liver for metastases. Use of laparoscopic adrenalectomy in suspected malignant tumors is controversial. A lateral laparoscopic approach may be converted to an open laparotomy if required. A posterior laparo-scopic approach can be used for patients with smaller tumors or a history of prior abdominal surgery.47,74 Laparoscopic adrenal surgery is usually accomplished through four subcostal ports of 10 to 12 mm.

The laparoscope provides magnified views of the tumor and vasculature (Figure 9-10). The anesthesiologist is notified when the tumor is about to be manipulated in order to prepare for the expected hypertension. Tumors are "bagged" to avoid fragmentation and intraperitoneal or port site spread of tumor cells. Very large tumors can also be removed through a small incision that allows the surgeon's hand to assist (laparoscopic hand-assisted adrena-lectomy). On average, the surgery time is about 1 hour longer with the laparoscopic approach compared with open surgery. However, with experience, the surgical time can be reduced (about 2 to 3 hours). With the laparoscopic technique, the frequency and severity of hypertensive episodes are not reduced; however, hypotensive episodes are less frequent and less severe. Laparoscopic adrenalec-tomy offers additional advantages compared with open adrenalectomy: reduced postoperative pain, quicker return to oral food intake (median 1.5 versus 4 days), and shorter average hospital stays (median 3 versus 7 days).75,76 This approach is the least invasive for the patient, who can usually begin eating and ambulating by the next day.77 The laparo-scopic approach may also be used during preg-

Figure 9-10. An abdominal computed tomographic scan performed in a 63-year-old woman because of mild right upper quadrant pain. A, The scan shows a 4 cm right adrenal tumor (large arrow) and a normal left adrenal gland (small arrow). B, Subsequent biochemical workup confirmed pheochromocytoma. The patient was a-adrenergic blocked, and the right adrenal tumor was resected laparoscopically. Courtesy of Quan-Yang Duh, MD.

Figure 9-10. An abdominal computed tomographic scan performed in a 63-year-old woman because of mild right upper quadrant pain. A, The scan shows a 4 cm right adrenal tumor (large arrow) and a normal left adrenal gland (small arrow). B, Subsequent biochemical workup confirmed pheochromocytoma. The patient was a-adrenergic blocked, and the right adrenal tumor was resected laparoscopically. Courtesy of Quan-Yang Duh, MD.

nancy.78 Very large and invasive tumors are best treated with open laparotomy. The surgical mortality is now < 3% in referral centers.47

"Needlescopic" adrenalectomy has been reported using three subcostal ports of 2 to 5 mm with a larger umbilical port for tumor removal. In one series of 15 patients, this technique resulted in surgical times and convalescence that improved on the standard laparoscopic approach. Prior experience with laparoscopic surgery is essential.79

Familial adrenal pheochromocytomas (a condition distinguished from MEN type II) are rarely malignant. Such pheochromocytomas are usually bilateral. Patients undergoing bilateral total adrena-lectomies require lifelong glucocorticoid and miner-alocorticoid hormone replacement. To avoid adrenal insufficiency, patients with benign familial or bilateral pheochromocytomas have had successful selective laparoscopic resection of small pheochromocy-tomas, sparing the adrenal cortex.80 Unfortunately, recurrent pheochromocytoma has been reported using such an approach.

An open laparotomy may be necessary for patients with very large pheochromocytomas or for those with intra-abdominal metastases that require debulking. An open anterior midline or subcostal approach is preferred and gives adequate exposure.47

Overall perioperative mortality is about 2.4%, whereas morbidity rates of up to 24% have been reported. Morbidity includes splenectomy, which is more common with open abdominal exploration than with laparoscopic surgery. Surgical complications are more common in patients with profound hypertension and highly secretory tumors and in those with repeated procedures. Complication risks are reduced by careful preoperative preparation, proper tumor localization, and intraoperative care noted above.81

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