Jamie Oh, MD, Alberto Vitela, MD, Roger Tatum, MD, FACS, Edgar Figueredo, MD, FACS. University of Washington
The patient is a 58 yo male MEN 2A syndrome presenting with bilateral pheochromocytomas. He had previously undergone a parathyroidectomy for hyperparathyroidism, and in undergoing a CT scan for a hip injury, he was found to have adrenal masses. He did not pursue further work-up until his daughter was diagnosed with thyroid cancer and subsequently genetic testing revealed MEN 2A syndrome. Subsequent work-up in our patient revealed a left adrenal gland containing two masses measuring 2.4×1.7cm and 2.2×1.3cm and the right containing a larger mass measuring 4.7×4.3cm. Urine metanephrines and normetanephrines were confirmed to be elevated, and in addition he was found to have elevated calcitonin with a thyroid nodule concerning for medullary thyroid carcinoma.
In the operating table, he was placed in prone jack-knife position, the retroperitoneal space was accessed by placing a trocar in the tip of the 12th rib with subsequent trocars placed under finger guidance 4-5 cm lateral below the 11th rib and 4-5 cm medial to the first port bellow the 12th rib. Pneumoperitoneum was set to 20 mmHg. The left adrenal gland was approached first. Using a combination of blunt dissection and electrocautery with a ligasure, the left adrenal gland was dissected free from its attachments. The adrenal vein was encountered and ligated using the ligasure. The gland was removed in its entirety from the body with an endocatch bag.
Attention was then brought to the right side and in similar fashion, it was taken down from its attachments using blunt dissection and electrocautery. The renal artery was encountered during the dissection and avoided. The gland was also found to be adherent to the IVC making dissection difficult. Tracing the gland along the IVC, the adrenal vein was found and ligated. As this gland was much larger than the previous, dissection of the apical portion of the gland was particularly difficult. We were able to better mobilize the gland and gain access to the most apical portion by releasing the lateral attachments to the kidney, letting us roll the whole structure medially. The mass was removed using an endocatch bag. Pathology confirmed bilateral pheochromocytomas.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93830
Program Number: V122
Presentation Session: Endocrine Videos
Presentation Type: Video