Adrenal tumors that are more than 4 cm in size, hormonally indeterminate, or suspected to be malignant receive treatment with adrenalectomy. Total adrenalectomy has been the standard treatment for adrenal masses for years. Benign appearing on imaging, less than 4 cm in size adrenal adenomas which are hormonally active on biochemical testing are treated with adrenalectomy as well. There is a definitive trend towards the use of partial adrenalectomy in the treatment of benign small adrenal masses. Partial adrenalectomy can be performed with open surgery, laparoscopic transperitoneal or retroperitoneal and robot-assisted laparoscopic transperitoneal or retroperitoneal methods. We present a case of pheochromocytoma managed with robot-assisted laparoscopic retroperitoneal partial adrenalectomy.
In a 46-year-old woman with history of urinary stone disease and hypertnsion, a 40 HU 24x24 mm in size non-adenoma mass was noted in the left adrenal gland. In the 24-hour urine analysis, the level of metanephrine was 367.5 µg (30–180), normetanephrine level was 1182.5 µg (119–451), and free cortisol was 20 µg (4.3–176). The patient was accepted as pheochromocytoma and underwent robot-assisted laparoscopic retroperitoneal left partial adenalectomy, after 2 weeks of phenoxybenzamine treatment.
After sterile covering in the left flank position, open (Hasson) technique was used for obtaining initial access. A 1.5 cm incision was made in the lumbar (Petit's) triangle below the 12th rib at the lateral border of paraspinalis muscles. The muscle fibres were carefully separated and entry was gained into the retroperitoneum by gently piercing the thoracolumbar fascia with the tip of a forceps. The retroperitoneal fat tissue was removed from front of the psoas muscle by palpating with the index finger. The peritoneum was felt and medialized. Finger dissection was performed in the cranial until the kidney lowerpoly was felt. A balloon dilator was then inserted into the opening and a adequate working space for retroperitoneoscopic surgery within that area created. Subsequently, an 8 mm robotic port was placed just under the left 12th rib by palpating. A 12 mm port was inserted from the first incision and entered with a camera and peritoneal medialization was continued. The other two 8 mm robotic ports were placed in the form of a half moon, leaving approximately 4 fingers wide distances in the caudal under direct vision. The left kidney back side was separated via the psoas muscle and the renal hilus was reached. Adrenal mass was observed and dissected from surrounding tissues. It was observed that arterial blood pressure increased up to 220/100 mmHg during dissection. The vein of the adrenal mass was found and ligated. Subsequently, the adrenal gland and adrenal vein were preserved and the mass was excised. No complications developed during and after the surgery. On the second postoperative day, the patient whose vitality was stable (Ta: 105/65 mmHg) was discharged. Operation time 160 minutes, console time 115 minutes, blood loss 40 cc was calculated. The pathology result was reported as pheochromocytoma. On the postoperative 3rd week control, it was learned that the patient had no pheochromastoma attack.