This document discusses the surgical management of pheochromocytoma. It covers various surgical approaches including open adrenalectomy, flank retroperitoneal approach, transabdominal chevron approach, thoracoabdominal approach, and laparoscopic adrenalectomy. For each approach, it describes the patient positioning, incision details, dissection techniques, and closure. It also lists some operative complications and notes hypotension can occur after tumor removal in pheochromocytoma cases due to alpha blockade.

1. Surgical Management of
Pheochromocytoma
CHAIRMAN – DR. SHASHI M UPPIN
CO CHAIRMAN – DR. MANOJ D TOGALE
PRESENTER – DR. S S K KANTH KAVIPURAPU

2. Adrenalectomy is the treatment
Surgical Management includes
◦ Pre operative
◦ Intra operative
◦ Post operative
Surgical options :
◦ Transabdominal chevron
◦ Thoracoabdominal (large, usually right)
◦ Flank (11th rib) approach
◦ Laparoscopic transperitoneal / retroperitoneal

3. Open Adrenalectomy
Open Adrenalectomy can be performed through either a
transperitoneal or retroperitoneal approach.
The advantages of the transperitoneal approaches
◦ Better exposure for larger tumors
◦ Excellent access to the great vessels and retroperitoneum.
Main disadvantages
◦ Prolonged ileus
◦ Difficult exposure in morbidly obese patients.
The retroperitoneal approach results in less ileus and may result in
shorter hospital stays.

4. Flank Retroperitoneal
Approach
Right Side. The patient is placed in flank position with the right side
facing up

5. The skin and fat overlying the 11th
rib are incised, and the fascia and
muscle overlying the rib are
divided.
Once the anterior surface of the
rib is exposed, the anterior
periosteum is cauterized, and the
periosteal elevator is used to
scrape it off the anterior rib
surface.

6. With the rib cutter, the 11th rib is
excised

7. The neurovascular bundle is
identified and freed with sharp
and blunt dissection to avoid
injury during subsequent
dissection and closure.
The lumbodorsal fascia is entered
sharply with Metzenbaum scissors,
and blunt dissection is used to
dissect the peritoneum off the
transverse fascia anteriorly.

8. The flank muscles and their accompanying fasciae are divided
anteriorly—
◦ the external oblique, internal oblique, and transverse abdominal.
Next, the posterior muscle diaphragmatic attachments are divided with
cautery.
The pleura is sharply and bluntly dissected off the superior edge of the
12th rib.

9. The plane between the Gerota fascia and the peritoneum can be
maximally developed with blunt dissection.
Once the peritoneum is mobilized, on the right side, the vena cava can
be visualized, and with cephalad dissection, the adrenal gland and renal
vein can be seen as well.

10. Dissection of the adrenal gland typically begins along the medial border
of the gland with the vena cava.
The overlying peritoneum is divided, and blunt dissection is used to
expose the plane between the medial surface of the adrenal gland and
the lateral surface of the vena cava.
The adrenal vein is dissected out with a right-angled instrument such as
a Mixter forceps.
Surgical ties or clips can be placed to ligate the adrenal vein.

11. There are numerous arterial branches to the gland that can be ligated
and divided individually.
Once this is done, the psoas muscle is often visible posteriorly.
Superior attachments are divided with the aid of surgical cautery or
harmonic scalpel.
Downward traction on the kidney assists with this dissection.
Inferomedial attachments to the kidney are taken with sharp or cautery
hook dissection.

12. Dissection of the left adrenal gland is similar except that the aorta is
visualized, and the adrenal vein originates from the renal vein.
Closure of the incision consists of a two-layer closure with a running No.
1 polydioxanone suture.
The deep layer consists of the transverse abdominal muscle, internal
oblique muscle, and fascia. The outer layer consists of the external
oblique muscle and fascia.

13. Transabdominal chevron
approach
Sub costal anterior approach:
The anterior approach is useful for
larger tumors and can be extended
to the contralateral side as a
chevron incision for treatment of
bilateral lesions.

14. Left Side. The patient is placed supine on the surgical table. If
needed, a body roll can be placed under the back at the level of
the costal margin to accentuate the costal margin.
A skin incision is made approximately two fingerbreadths below the
costal margin.
This incision is extended medially to the midline or beyond,
depending on the degree of exposure needed.

15. The line of Toldt is incised, and the
left colon is mobilized medially.
The splenic flxure is taken down by
dividing the splenocolic ligament.
Division of the lienorenal ligament
will allow medial mobilization of the
spleen.
The tail of the pancreas may come
into view at this point.
In a thin individual, the adrenal may
be visible at this point.

16. The left adrenal vein is identified
on dissecting out the left renal
vein.
After ligation and division of the
left adrenal vein, medial
attachments to the aorta can be
taken with the harmonic scalpel or
with careful dissection and ligation
of small arterial vessels while
gentle lateral traction is placed on
the gland.

17. The lateral and inferior
attachments to the kidney can be
taken by blunt and sharp
dissection off of the renal capsule.
Care must be taken to avoid hitting
upper pole renal vascular
attachments
Right side:
For right-sided tumors, the
dissection is similar except for the
need to dissect the duodenum
medially by the Kocher manoeuvre

18. Thoracoabdominal approach
This approach is a maximally invasive way to ensure superb surgical
exposure of the retroperitoneum, adrenal gland, and great vessels.
However, this exposure comes at a price: increased incisional pain,
prolonged ileus, pulmonary morbidity, and a chest tube.

19. The incision is made through the eighth or ninth intercostal space,
dividing the intercostal muscles and fasciae. The costal cartilage is
divided with the surgical cautery.

20. The incision is carried farther
through the anterior and posterior
rectus sheaths and the rectus
abdominal muscle. The pleura is
entered, and the lung is packed
away with laparotomy sponge
The diaphragm is divided with the
cautery. Do not cut directly tothe
center of the diaphragm because
the phrenic nerve can be
damaged. Once the diaphragm is
divided, a Finochietto self-
retaining retractor is placed to
expose the surgical area.

22. Closure of the incision requires closure of the diaphragm and re-
approximation of the ribs.
The diaphragm is closed with interrupted figure-of-eight stitches with
nonabsorbable suture.
A chest tube is placed before the anterior thorax is closed.

23. LAPAROSCOPIC
ADRENALECTOMY
Transperitoneal laparoscopic adrenalectomy can be performed through
either an
In general, the anterior supine approach allows bilateral adrenalectomy
without having to reposition the patient. The lateral position
is advantageous because greater workspace is available
secondary to gravity-assisted retraction of the bowelanterior supine
approach or a lateral approach.

30. Operative complications
Hemorrhage
Inferior vena cava
Adrenal vein
Lumbar vein
Hepatic vein
Vascular
Ligation of renal artery branch
Ligation of mesenteric artery
Inferior vena cava involvement
Adjacent Organ Injury
Pneumothorax
Pancreas
Liver
Spleen
Stomach
Colon
Kidney

31. Specific for
Pheochromocytoma
HYPOTENSION secondary to α blockade after tumor removal

32. MCQ