Laparoscopic resection of a large functional paraganglioma in the organ of Zuckerkandl (SIU 2011)
- uploaded: Jun 12, 2011
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Institution:Ospedali Riuniti B.M.M. - Reggio Calabria, Italy
Introduction and Objectives
Paragangliomas of the organ of Zuckerkandl (PZ) are rare extra-adrenal pheochromocytomas and, according to a recent systematic review (Subramanian,A et al., Am J Surg 192:224-34, 2006), only 135 cases have been reported so far. Detection and appropriate treatment of these tumors is important, because PZ have a 43% mortality when presenting acutely. While the utility of the laparoscopic approach in adrenal pheochomocytoma is well established, information on the safety and effectiveness of this approach in PZ is still very sparse.
Materials and Methods
In this video we describe the successful laparoscopic resection of a large functional paraganglioma of the organ of Zuckerkandl in a 20-year-old women with infrequent, but severe, hypertensive crises. Urinary metanephrines were 3 to 5 times higher than the upper limit of the normal range and a CAT scan revealed a large, spherical (diameter 10 cm) abdominal mass, overlying the vena cava and the aorta, from the subpancreatic area to iliac bifurcation.
The tumor was excised by the transperitoneal laparoscopic approach. Laparoscopy produced excellent exposure, allowed proper identification of the tumor's origin and its relation to adjacent organs. First of all, we did a Kocher manoeuvre to mobilize the whole cefalo-duodenal-pancreatic bloc and the third and fourth part of duodenum to totally free the anterior vena cava and aorta. After that, we begin preparing the tumor, living laterally the right ureter, clipping large vessels arising from right iliac axis and freeing the interortocaval groove, clipping and sectioning two or three retrocaval vessels. Then, we resected the inferior mesenteric artery and divided the blood vessels coming, directly, from the aorta and vena cava. At the end, full resection was completed uneventfully and the tumor was retrieved in a bag through an enlarged incision of the periombelical port.
Available experience, although limited, suggests that laparoscopic exploration of suspected extra-adrenal pheochromocytoma is an appropriate approach to estimate the extension of the tumor and its resectability. Appropriate patient preparation, intra and post operative monitoring appear critical for successful clinical management of Zuckerkandl paragangliomas.
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