Laparoscopic adrenalectomy for pheochromocytoma: take the vein last?

These data demonstrate the safety of delayed adrenal vein ligation during laparoscopic adrenalectomy for pheochromocytoma. They also challenge the importance of the long-standing tradition of early adrenal vein ligation for these patients. This slight variation in the standard approach may prove useful to the laparoscopic adrenal surgeon in circumstances that make early ligation of the vein cumbersome or difficult. This technique also could be adapted to other lesions of the adrenal gland for which early ligation of the vein is performed.

For a recent large series of laparoscopic resection of pheochromocytomas, rates of 7.5% for morbidity and 53% for incidence of intraoperative blood pressure greater than 170 mmHg were reported [8]. The tumors in this series were much larger, with more than 50% exceeding 5 cm. The authors described early ligation of the vein whenever possible. They also mentioned adding an additional port on the left side sometimes for large tumors to retract the kidney or gland itself when the vein was difficult to expose.

Although our series included smaller tumors and fewer patients, delayed vein ligation did not seem to be associated with greater morbidity or hemodynamic instability than reported in the current literature. Using the traditional “vein-first” technique for laparoscopic adrenalectomy, the incidence of intraoperative hypertension ranges from 35 to 100% [4, 8, 9, 10].

Interestingly, Fernandez-Cruz et al. [2] compared increases in catecholamines with gland manipulation in a series of pheochromocytoma patients undergoing either laparoscopic or open (transabdominal) adrenalectomy. Increases in catecholamines were measured in both groups. However, they were noted to be two- to threefold higher in the open group. Despite profound catecholamine surges in both groups, hemodynamic sequelae were manifested only in the open group. The authors suggest that these findings may be partly related to aspects of laparoscopy such as magnification, gentle dissection, and meticulous hemostasis. Their findings also may be secondary to the helium pneumoperitoneum they used, which eliminated some of the hemodynamic effects related to carbon dioxide.

Tiberio et al. [7] recently published a prospective randomized trial comparing open and laparoscopic adrenalectomy for pheochromocytoma. No differences in hemodynamic events were demonstrated between the two groups. These authors caution that the laparoscopic approach is safe but not without significant fluctuations requiring vigilance on the part of both the surgeon and the anesthesiologist.

Zhang et al. [11] reported a series of 58 retroperitoneoscopic adrenalectomies for pheochromocytomas with delayed ligation of the adrenal vein. They described intraoperative pressure fluctuations exceeding 20 mmHg, with gland manipulation for 37.5% of their patients. Only six of the patients were noted to have a systolic pressure exceeding 200 mmHg at any time.

Bonjer et al. [12] also published a series of retroperitoneoscopic adrenalectomies with ligation of the vein at the end of the dissection. In their cohort of eight patients with pheochromocytomas, they did not observe any major intraoperative hemodynamic alterations. To our knowledge, no series of patients has had consistent delayed ligation of the vein using the laparoscopic lateral decubitus approach.

This study has many limitations, many of which emerge from the retrospective nature of the data. Although we thoroughly reviewed the anesthesia records, there may have been transient periods of hypertension that were quickly corrected but not recorded.

In addition, we did not have data regarding the type and amount of vasoactive drugs the patients required throughout the procedure. It is possible that this technique caused considerable catecholamine release for which the anesthesiologists compensated. We also do not know whether any of the hypertensive events correlated with manipulation of the gland. The use of laparoscopy may have permitted the anesthesia team to see the operative events more clearly and perhaps to anticipate changes before they become very pronounced.

Patient demographic data also suffered from the limitations of retrospection and were quite dependent on accurate documentation in operative reports and consultations. We could not gather sufficient data about the preoperative diagnostic workup and severity of patient symptoms before surgery. Many patients were referred from outside hospitals, with part or all of their diagnostic workup performed elsewhere and not available in many cases. Operative times and fluid administration also were not consistently available.

Finally, the significance of hypotensive events is not clearly stated in the literature. This may be related to anesthesia and the use of fluids and vasoactive medications. Systolic pressures lower than 80 mmHg were not observed in our population, but almost half of the cohort had documented systolic pressures of 80 to 90 mmHg. It is not clear whether this was intentional or related specifically to operative events.

Delayed vein ligation does not appear to cause a significant increase in hemodynamic variations during laparoscopic adrenalectomy for pheochromocytoma. This retrospective series, despite its limitations, challenges the “vein-first” dogma. The findings may be related to multiple factors including excellent laparoscopic visualization, gentle and meticulous dissection, and improved monitoring and anesthesia care. In the setting of large or bulky tumors, or in cases for which early vein dissection is not feasible, postponing ligation of the vein is a safe alternative. In some circumstances, this technique may be even safer because concerns about catecholamine surges causing swings in blood pressure are not manifested clinically.