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Laparoscopic Hand-Assisted Adrenalectomy for pheochromocytoma

Author:

Sergio Rodrigo Pozo MD

Coauthors:

Marco A. Covarrubias Velásco MD

Adriana Y. Dávalos Casillas MD

Raul Vargas Ramírez MD

Jesús Raul Pérez Gomez MD

Hospital Country 2000, Guadalajara, Jalisco, México.

Indications for adrenalectomy

Functioning Tumors

- Aldosteronoma

- Cushing Syndrome * Cortisol Producing Adenoma

* Primary Adrenal Hyperplasia

* Failed treatment of pituitary Cushings

*Pheochromocytoma

- Non functionin cortical adenoma

* Large size (>5 cm) atypical appearance, enlargment

- Miscellaneous ( Myelolipomas, ganglioneuromas, cysts)

Non Functioning Tumors

Malignant Tumors

- Adrenal cortical carcinoma

- Malignant pheochromocytoma

Contraindicacions to Laparoscopic adrenalectomy

- Any tumor that appears locally invassive

- Need to perform regional lymphadenopathy or resect adjacent organs

Controversial in Laparoscopic adrenalectomy

- Large adrenal masses ( >10 cm)

- Primary adrenal malignancy

- Prior nephrectomy, splenectomy, or liver resection

.

Case Presentation

A 54-year-old female patient

4-year history of severe episodes of migraine, peripheral vasospasm

and abdominal pain

With no relevant history, denies allergies, transfusions, or suffering from any condition or chronic degenerative

CT :Presence of left adrenal tumor round 8.3 x 9 x 6.9 cm with plane of separation from the left kidney,

Metanephrines in blood of 6,778 pg / mL.

Preoperative Preparation

Multidisciplinary

-Prehydratation

- Alfa-blocker

-Beta-Blocker

-Postoperative dose reduction hydrocortisone stress schedule

- Screening genetic Disorders

Operating room

- Arterial catheter for patients

- Patient positioning, trocar distribution, dissection maneuvers, vascular ligation and extraction of the surgical specimen

Postoperative

- The histopathological examination confirmed the diagnosis of Pheochromocytoma with immunophenotype Syn +/ S100+ (Sustentacular) with proliferation index less than 1%.

- Patient was discharged at 48 hours completely asymptomatic, with any complications at the follow-up visits.

Conclusions

- The use of the hand-assisted device allows the removal of larger and more complex tumors. Plus an adequate management of structures and bleeding control.

-We prefer the transperitoneal approach due to the larger working space and greater orientation that this access usually provides.

-The management of pheochromocytoma requires the conviction that the key to success lies in an adequate preoperative preparation (pharmacological blockade) and having the appropriate material for the trans-surgery.

-Multidisciplinary approach, as well as collaboration between surgeons and anesthesiologists

-These measures, in addition to laparoscopy, have reduced the high morbimortality related to this surgery in the past.

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