Bilateral Laparoscopic Adrenalectomy for Phochromocytoma in Men2a: Tips and Tricks in Difficult Gland Dissection.

Andrea T Costanzi, MD, Dario Maggioni, MD, Valter Berardi, MD, Paola Sartori, MD, Angelo Miranda, MD. Ospedale di Desio


Bilateral laparoscopic adrenalectomy for pheochromocytoma in MEN 2A was performed on a 72 year old woman admitted to our surgical department due to edema of the right lower limb and inguinal adenopathy. The patient underwent total thyroidectomy plus central neck dissection for medullary thyroid cancer in 1988 with residual hypoparathyroidism. She denied arterial hypertension. She was on daily  Calcium carbonate 1 g /day, levotiroxine 100 micrograms /day. Preoperatively she underwent an abdominal CT scan showing bilateral adrenal masses (right adrenal 4 x 5 cm and left adrenal 2 cm), lumboaortic and right ilio-femural adenopathy. An abdominal MRI indicated bilateral pheochromocytoma. Hormonal tests were normal except for metanephrine and normetanephrine, MIBG scan showed bilateral adrenal pathologic uptake. A biopsy of inguinal nodes was performed to assess the origin of the adenopathy (histology: low grade B cell lymphoma). The patient was started on preoperative preparation with alpha blocker (Doxazosin 8mg x 2/day) but she experienced a hypertensive attack followed by cardiac ischemia delaying surgery of 2 weeks. She finally underwent bilateral laparoscopic adrenalectomy by a lateral transperitoneal approach. 

The video shows some tips and tricks useful, according to our experience, in identifying and dividing the adrenal veins when the clivage of the gland from the surrounding structures is not easily detected.  The small dimensions of the left gland and the difficulty to dissect its upper pole required dissection of the left diaphragmatic vein tributary of the left adrenal vein in order to identify its lower limit and dissect it from the left upper renal pole. The right gland was very adherent to the VC and compressed it. The identification of the right adrenal vein was not possible at the initial stage of dissection. After mobilization of the upper and lower pole of the gland, the adrenal veins were safely clipped and sectioned. Postoperative course was uneventful with good control of both hypotension and Addison syndrome. Final histology confirmed bilateral pheochromocytoma.

Session Number: VidTV1 – Video Channel Rotation Day 1
Program Number: V095

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