Pheochromocytoma does not increase risk in laparoscopic adrenalectomy
Laparoscopic adrenalectomy (LA) has become the standard approach to an adrenal mass. This technique provides for decreased convalescence, less postoperative pain, and improved cosmesis. The use of LA for pheochromocytoma (PHE) has been questioned due to concerns of increased morbidity and negative hemodynamic sequelae. This study aimed to compare the outcomes of LA for PHE with the results of LA for other adrenal pathologies.
A retrospective chart review was performed for an 11-year period from July 1997 to December 2008. Patient demographics, perioperative data, and outcomes were recorded. Statistical analysis was performed using SPSS 16.0. Statistical significance was defined as a p value less than 0.05.
A total of 102 LA procedures were completed for 95 patients. The data for 33 PHE cases were compared with the data for 69 non-PHE cases (26 adenomas, 14 aldosteronomas, 5 cortisol-secreting tumors, 5 multinodular hyperplasias, and 19 other disorders). Five LA procedures were converted to open surgery. Four of these conversions involved patients with PHE (p = 0.03). There was no difference in the mean estimated blood loss (p = 0.2) or operative time (p = 0.1) between the two groups. The frequency of intraoperative hypertension and hypotension did not differ between the PHE and non-PHE cohorts. The complication rate was 7.5% for the PHE group and 6.9% for the non-PHE group (p = 0.7). The patients with PHE had a longer postoperative hospital stay (3.6 vs 2.3 days; p < 0.001) and overall hospital stay (4.9 vs 2.6 days; p < 0.001). Time in the intensive care unit (1.1 vs 0.1 days; p < 0.001) and time until oral intake (1.5 vs 1.0 days; p = 0.02) also were increased in the PHE population. There was one death in the PHE group secondary to congestive heart failure.
Concerns of increased morbidity related to a laparoscopic approach for patients with a diagnosis of PHE are unfounded. In this series, the only disparity in outcomes between the two groups was an increased conversion rate with PHE.
KeywordsAdrenalectomy Laparoscopic surgery Laparoscopy Pheochromocytoma
Laparoscopic approaches to intraabdominal pathology were first introduced by Semm  in 1983 with his description of the pelviscopic appendectomy. The ensuing decade witnessed an exponential growth in the indications for minimally invasive techniques in general surgery [2, 3, 4, 5]. Laparoscopy for benign surgical disease of the adrenal gland currently is widely considered to be the gold standard approach . Benefits over open adrenalectomy include decreased postoperative pain, shorter hospital stay, and convalescence with improved cosmesis.
Laparoscopic adrenalectomy (LA) for pheochromocytoma (PHE) has been challenged due to concerns of increased morbidity and adverse hemodynamic sequelae [3, 4]. These vasoactive tumors tend to be larger, with increased vascularity, complicating laparoscopic dissection.
Some authors have proposed a selective application of the laparoscopic approach for PHE . In response, several institutions have published their experience with LA for PHE [6, 7, 8]. Early discussions reported that PHE could be safely addressed laparoscopically compared with open PHE and laparoscopic techniques for other adrenal pathologies (OAP) [5, 8, 9, 10]. However, many have described longer operative times and increased blood loss even in the hands of experienced laparoscopic surgeons.
In response to these concerns, we performed a retrospective review of our experience with LA for PHE and analyzed the results relative to those for LA used to treat OAP. This study aimed to establish whether LA for PHE has morbidity and mortality similar to those of LA for OAP.
The patients enrolled in this study were identified by their International Classification of Diseases-9 (ICD-9) code as having adrenal pathology addressed laparoscopically from July 1997 to December 2008. All information was collected retrospectively through a review of hospital and clinic charts. Demographic, procedural, and postoperative data were documented. Hypertension was defined as a systolic blood pressure highter than 180 mmHg, and hypotension was identified as a systolic blood pressure lower than 80 mmHg. All operative data were collected from the anesthesia records.
All the patients underwent preoperative abdominal imaging. The diagnosis of PHE was confirmed with serum and urinary catecholamines or urinary vanillylmandelic acid. Preoperative blood pressure control was established with alpha-blockers. A beta-blocker was added if indicated for the treatment of tachycardia. When necessary, patients were admitted to the surgical intensive care unit (SICU) 1 day before surgery for invasive cardiac monitoring and optimization of intravascular volume status.
The technique for LA has been described previously . In short, the patient is positioned in the lateral decubitus position. Laparoscopic access is established followed by the placement three or four trocars. For a left-sided PHE, the lateral attachments of the splenic flexure and sigmoid colon are taken down. In addressing a right PHE, a liver retractor is used to retract the right lobe of the liver to facilitate exposure of the lateral border of the vena cava and its junction with the adrenal vein. The adrenal vein then is identified and ligated. Additional small venous and arterial branches are divided if necessary. Finally, the mass is elevated from its adventitial attachments, amputated, and removed from the abdomen.
Data analysis was completed using SPSS 16.0 (SPSS, Chicago, IL, USA). For those variables that satisfied the normality and equal variance assumptions, Student’s t tests were performed. Nonparametric data were analyzed with the Mann–Whitney test. Binary variables were assessed with Fisher’s exact test. Additional analyses were performed to determine whether the results were affected by the adjustment for location of the tumor (left or right side). All patients who had tumors on both the left and the right sides were removed from this analysis. A series of analysis of variance (ANOVAs) and logistic regression techniques were used to complete this assessment. Statistical significance was defined as a p value less than 0.05. Permission from the Ohio State University Medical Center Institutional Review Board (IRB) was obtained before the study was initiated.
Patient and tumor characteristics of the pheochromocytoma (PHE) and non-PHE groups
Operative characteristics of the pheochromocytoma (PHE) and non-PHE groups
Operative time (min)
Conversion to open procedure
Patients with intraoperative hypertension
Total no. of hypertensive episodes
No. of times hypertensive agents were given
Patients with intraoperative hypotension
Total no. of hypotensive episodes
No. of times hypotensive agents were given
The size of the tumor was not influenced by the underlying pathology (p = 0.6). Additionally, the size of the tumor had no influence on the rate of complications for either the PHE or the non-PHE group. Furthermore, the location of the tumor did not influence the estimated blood loss in either group. Tumor size had no impact the time spent in the intensive care unit (ICU) or the length of the postoperative hospital stay.
Postoperative characteristics of the pheochromocytoma (PHE) and non-PHE groups
Tumor size (cm)
Total LOS (days)
Postoperative LOS (days)
Time in the ICU (days)
Time to oral intake (days)
Laparoscopy is now considered the standard of care for benign tumors of the adrenal gland. Notwithstanding this fact, there has been debate over the suitability of this approach for PHE. Discussions have concentrated on the hemodynamic consequences of pneumoperitoneum and tumor manipulation with a minimally invasive approach [12, 13]. Additionally, some question LA for PHE because of the potential for malignancy and tumor spillage caused by excessive manipulation . Based on these concerns, some investigators have described the laparoscopic approach to a PHE as an operation to be used with caution .
In an effort to define better the indications for laparoscopy used to treat PHE, different groups have compared their experience with this approach versus open surgery. Humphrey et al.  retrospectively reviewed a single institution’s experience with the selective use of laparoscopy for PHE. They noted no differences in intraoperative hemodynamic changes or postoperative complications. It should be noted that they used minimally invasive techniques for patients known to have smaller tumors and those without a history of extensive abdominal surgery. Similarly, Tiberio et al.  reported no differences in hemodynamic sequelae or morbidity in their prospective randomized comparison of LA with open adrenalectomy for PHE.
Other investigators have published their experience with LA versus OAP for PHE. Most reports indicate that the tumor size for a PHE is significantly larger than for a non-PHE [15, 16]. Interestingly, no consensus exists regarding the influence that this has on the operating time [15, 16, 17, 18]. The complexity of the dissection as it relates to the increased vascularity and vasoactive characteristics of PHE may contribute to this inconsistency.
Blood loss also is reported to be higher with PHE [16, 17]. Furthermore, there is variability in the reported morbidity for LA, with higher complication rates reported for PHE patients than for non-PHE patients [8, 19]. In summary, the minimally invasive approach is described as a more complicated and potentially dangerous operation for a PHE.
In the current series, 102 adrenal masses were addressed laparoscopically in 95 patients. The patients undergoing LA for OAP tended to be older than the patients with PHE. Despite this difference, the patients with PHE had a poorer functional status and a higher BMI. That is, the individuals undergoing a surgical resection of PHE had outcomes similar to those for non-PHE patients, although the PHE population had a higher risk for poor outcomes.
We noted no difference in the size of the mass between the patients with PHE and those with OAP. Additionally, no correlation was found between the location or size of the tumor and the blood loss. Furthermore, the size of the tumor did not have an effect on the complication rate. This suggests that the tumor can be safely addressed laparoscopically irrespective of its location or size. The principle risk for a minimally invasive approach to a PHE in this group of patients increased the need for conversion to an open operation (p = 0.03). This is significant because it supports the idea that a PHE can be treated with minimally invasive techniques without exposing the patient to an increased risk for negative outcomes.
Pheochromocytomas are hypervascular tumors that release vasoactive mediators when manipulated. These qualities add to the concerns for the safety of a minimally invasive approach to this disease. In this case series, there was no difference in the prevalence or incidence of blood pressure extremes between the two groups. Not surprisingly, the PHE group had a higher incidence of intraoperative treatment with antihypertensive agents. The number of patients treated for hypotension did not differ between the two groups. At no point did the blood pressure variation interrupt operative dissection or require conversion to an open procedure. Our data demonstrate that the risk of hemodynamic instability is minimal and, with proper monitoring, does not preclude a laparoscopic approach.
Patients undergoing laparoscopic resection of their PHE had longer postoperative and overall hospital stays. Additionally, they were more likely to spend more time in the ICU postoperatively. These patients also were slower to resume oral intake. However, this did not translate into a higher complication rate for the PHE group. Notwithstanding the increased time for convalescence, the operative outcomes were similar. A PHE can be approached laparoscopically without increasing the patient’s exposure to morbidity and mortality.
The analysis of our experience with 105 consecutive LAs demonstrates similar outcomes for PHE and OAP patients. Careful hemodynamic monitoring and meticulous dissection results in similar morbidities. The current series demonstrated an increased risk of conversion to open surgery with PHE. We suggest that the laparoscopic approach should be considered the gold standard approach for the surgical management of patients with PHE.
Peter Nau received a Covidien Training Grant for 2008–2009. Jeffrey W. Hazey received a Stryker Research grant and a Boston Scientific Training grant, and is on the Clinical Advisory Board for Covidien and Ethicon. W. Scott Melvin is on the Advisory Board for Endogastric Solutions, Surgiquest, and Stryker. He also received training grants from Covidien and Stryker. Christopher Ellison, Vimal Narula, Peter Muscarella, and Sebastian Demyttenaere have no conflicts of interest or financial ties to disclose.