Robot-assisted laparoscopic partial adrenalectomy for pheochromocytoma: the National Cancer Institute technique

Abstract

Background: Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma.

Objective: To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes.

Design, setting, and participants: From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6-45).

Surgical procedure: Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue.

Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.

Results and limitations: Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3-5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6-45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up.

Conclusions: RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

Fig. 1

Lateral and superior port placement. The camera port and the robotic axis are rotated superiorly and laterally to access the adrenal gland in the posterior retroperitoneum.

Fig. 2

Port placement for robot-assisted laparoscopic partial adrenalectomy. This case was performed on an obese patient. In addition to the 5-mm trocar used between the camera port and right robotic port, another assistant port is placed between the camera and the left robotic port in patients with extreme obesity. A 5-mm subxyphoid port is used for liver retraction. Note the axis of the camera port directed at the ipsilateral clavicle.

Fig. 3

Laparoscopic ultrasound aids in identifying pheochromocytoma. The pheochromocytoma appears as a well-demarcated, homogenous, dark mass that is distinct from the surrounding normal adrenal cortex.

Fig. 4

Identification of the plane between normal adrenal cortex and pheochromocytoma. The enhanced visualization allows identification of the plane between tumor tissue and adjacent normal adrenal cortex. A plane of dissection can then be developed.

Fig. 5

Dissection of tumor from uninvolved adrenal cortex. By following the pseudocapsule of the lesion, the pheochromocytoma is carefully enucleated. Locking laparoscopic clips are used to control small perforating vessels.

Fig. 6

Minimal handling of normal adrenal tissue. The dissection is performed to maximize the separation of tumor tissue from the underlying uninvolved adrenal bed. The precise movements of the robotic instruments allow for minimal handling of normal adrenal tissue, which may help preserve blood supply and minimize long-term damage to normal healthy adrenal cortical tissue.