Laparoscopic resection of pheochromocytomas with delayed vein ligation

Laparoscopic adrenalectomy has been established as the surgical procedure of choice for benign adrenal diseases. Laparoscopic adrenalectomy for pheochromocytoma has been the subject of debate, due to potential systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors and a perceived increased risk of malignancy for large-sized tumors. In this study we present our experience for laparoscopic resection of pheochromocytomas, and evaluate the safety of delayed adrenal vein ligation.

A total of 32 adrenalectomies for pheochromocytoma were performed between June 1997 and December 2009. Four paragangliomas, operated in the same period are not included in this series. All patients were investigated and operated on using an established departmental protocol. Preoperative diagnosis, operative details, complications, length of hospital stay, morbidity, and follow-up were documented from the hospital records of 200 patients who underwent 208 adrenalectomies for benign and malignant adrenal tumors in the same period.

Thirty-two tumors were removed from 31 patients (17 men; mean age, 54 y; range, 19 to 72 y). One patient with MEN IIA underwent bilateral resection of pheochromocytomas in 2 stages. Tumor size in laparoscopic procedures ranged from 2.2 to 10.5 cm (mean, 4.97 cm). Operative time was from 55 to 210 minutes (mean, 110 min).Twenty-seven patients had sporadic disease (2 potentially malignant, 2 malignant), and 4 in the context of a familiar syndrome (2 MEN IIA syndrome, 1 Von Hippel Lindau syndrome and Recklinghausen disease, respectively). Twenty-four patients underwent laparoscopic adrenalectomy, 2 patients had open approach from the start for recurrent malignant pheochromocytoma and large benign tumor respectively, 1 patient had open approach due to inoperable malignant pheochromocytoma, and 4 patients had conversions from laparoscopic to open procedure. All patients with paragangliomas underwent open approach from the start. The mean hospital stay was 2 days (range, 1 to 3 d) for the laparoscopic procedures. All patients underwent late ligation of the main adrenal vein. Five patients received sodium nitroprusside intraoperatively to treat hypertension. One patient developed pulmonary embolism after the operation, and succumbed 1 month later. There were no recurrences for the benign tumors during the follow-up period.

Laparoscopic adrenalectomy for pheochromocytoma although safe, should be converted to open for difficult dissection, to avoid tumor disruption, and recurrence. Hemodynamic instability can be prevented and is not influenced by early or late ligation of the adrenal vein. Delayed main adrenal vein ligation is a safe alternative to the "vein first" technique.