Pneumoretroperitoneum: An Alternative Approach for Completion Adrenalectomy in a Hostile Abdomen

A 43-year-old woman developed morning headaches, sweating, palpitations and uncontrolled hypertension for 12 months. She was known to have Von Hippel-Lindau and had previously had a left adrenalectomy in 1995 (open anterior approach) and a partial right adrenalectomy in 2000 (open lateral approach). She required an exploratory laparotomy in 1991 for a gunshot wound to the epigastrium. She suffered from type II diabetes mellitus, obesity (body mass index of 42), hypothyroidism, gastritis, cirrhosis (Child’s-Pugh class A) and recurrent right renal stones.

Her biochemical evaluation revealed elevated norepinephrine, normetanephrines, and vanillylmandelic acid. Computed tomography imaging revealed a heterogenous right adrenal mass (1.9 x 1.7 cm), bullet fragments in the right psoas, and absence of the right rectus abdominal muscle. Metaiodobenzylguanidine scan revealed a focal area of intense uptake within a retroperitoneal mass adjacent to the aorta and right kidney.

We made the presumptive diagnosis of recurrent right pheochromocytoma and recommended right completion adrenalectomy. After preoperative blood pressure control with phenoxybenamine, propranolol and hydration, we performed a completion right adrenalectomy using a posterior retroperitoneoscopic approach. The operative time was 2.5 hours and our blood loss was less than 5 mL. Pathology revealed a 1 mm pheochromocytoma focus in a 3 x 2.5 cm specimen of normal adrenal gland, inflammatory tissue, and old surgical clips.

The patient was discharged to home 3 days after her operation. Her symptoms resolved and she has required no antihypertensive medications.

Session: Podium Video Presentation

Program Number: V012

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