Laparoscopic Resection of Paracaval Functioning Paraganglioma

Aaron Lee, MD, Nisha Dhanabalsamy, MD, Rajmohan Rammohan, Lisandro Montorfano, MD, Federico Perez Quirante, MD, Alex Ordonez, MD, Emanuele Lo Menzo, MD, Samuel Szomstein, MD, Raul J Rosenthal, MD, FACS, FASMBS. Cleveland Clinic Florida

Introduction: Pheochromocytoma is a rare but potentially devastating tumor. Although usually related to adrenal adenoma, extra-adrenal lesions can produce similar hormonal findings. Laparoscopic Adrenalectomy has been widely preferred for surgical removal of adrenal masses.This video demonstrates the laparoscopic dissection of Right Adrenal mass and total excision of Paracaval mass.

Methods: We present a case of a 76 year old female, BMI of 15.83 kg/m2, with new onset of hypertension, weight loss and right adrenal mass on abdominal CT scan. After induction of anesthesia and successful endotracheal intubation, the patient was repositioned on the left lateral decubitus on a beanbag. The procedure began with the final retraction of the large right lobe of the liver through a 5-mm trocar placed in the subxiphoid area. Additional 12 and 5- mm trocars were placed in the right mid abdomen as well as in the anterior axillary line. The patient had a pelvic right kidney. Upon elevation of the liver, dissection was carried out and the adrenal gland was immediately identified. The adrenal gland was mobilized from lateral to medial. Getting to the caval aspect of the gland, hypertensive crisis was noted which was controlled with nitroglycerin. Once the blood pressure was controlled, the gland was completely detached from the cava, the adrenal vein closed with hemoclip. A mass was noticed to be located under the cava and aorta. With meticulous careful blunt dissection using the harmonic scalpel and hook, it was detached from the cava and the aorta. All vessels were clipped with hemoclips or regular clips. Thorough hemostasis performed.

Results: The patient tolerated the procedure well with minimal blood loss. The patient was discharged home on post-operative day 3. The patient was hemodynamically stable without BP medication.

Conclusion: Paracaval function paragangliomas are rare. These can be safely excised laparoscopically.

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