Zografos George N, Farfaras Athanasios Konstantinos, Kassi Eva, Vaidakis Dennis N, Markou Athina, Kaltsas Gregory, Piaditis George
Department of Surgery, Athens General Hospital, Athens Medical School, University of Athens, Greece.
Surg Laparosc Endosc Percutan Tech. 2011 Apr;21(2):116-9. doi: 10.1097/SLE.0b013e318213bb1f.
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.
腹腔镜肾上腺切除术已成为治疗良性肾上腺疾病的首选手术方式。由于分泌儿茶酚胺肿瘤患者气腹可能产生的全身影响以及大尺寸肿瘤被认为恶性风险增加，腹腔镜下嗜铬细胞瘤切除术一直存在争议。在本研究中，我们介绍了腹腔镜切除嗜铬细胞瘤的经验，并评估延迟肾上腺静脉结扎的安全性。
1997年6月至2009年12月期间共进行了32例嗜铬细胞瘤肾上腺切除术。同期手术的4例副神经节瘤不包括在本系列中。所有患者均按照既定的科室方案进行检查和手术。从同期接受208例肾上腺良性和恶性肿瘤切除术的200例患者的医院记录中记录术前诊断、手术细节、并发症、住院时间、发病率及随访情况。
从31例患者（17例男性；平均年龄54岁；范围19至72岁）身上切除了32个肿瘤。1例IIA 型多发性内分泌腺瘤病患者分两期进行了双侧嗜铬细胞瘤切除术。腹腔镜手术中肿瘤大小为2.2至10.5厘米（平均4.97厘米）。手术时间为55至210分钟（平均110分钟）。27例患者为散发性疾病（2例可能为恶性，2例为恶性），4例为家族性综合征（分别为2例IIA 型多发性内分泌腺瘤病综合征、1例冯·希佩尔-林道综合征和1例雷克林豪森病）。24例患者接受了腹腔镜肾上腺切除术，2例患者分别因复发性恶性嗜铬细胞瘤和大的良性肿瘤一开始就采用开放手术，1例患者因无法手术切除的恶性嗜铬细胞瘤采用开放手术，4例患者由腹腔镜手术转为开放手术。所有副神经节瘤患者一开始就采用开放手术。腹腔镜手术患者的平均住院时间为2天（范围1至3天）。所有患者均进行了肾上腺主静脉的延迟结扎。5例患者术中接受硝普钠治疗高血压。1例患者术后发生肺栓塞，1个月后死亡。随访期间良性肿瘤无复发。
嗜铬细胞瘤的腹腔镜肾上腺切除术虽然安全，但对于困难的解剖应转为开放手术，以避免肿瘤破裂和复发。血流动力学不稳定可以预防，且不受肾上腺静脉早期或晚期结扎的影响。延迟肾上腺主静脉结扎是“先结扎静脉”技术的一种安全替代方法。
