Operative Management of Pheochromocytoma

"No-Touch" technique:
- ligate the central draining vein first to prevent secretion of catacholamines into the systemic circulation.
- "no-touch" also thought to prevent wide blood pressure swings.

Open technique:
- Advantages were to facilitate "no-touch" technique, permit bilateral and central exploration.
- however, with improvements in laparoscopic technique and pre-operative imaging, currently open technique reserved for large pheos and obviously malignant lesions.

Laparoscopic technique:
- Lateral Transperitoneal Lap Adrenalectomy is now the gold standard for most-benign appearing pheos <8cm in size.
- Right adrenal is easier to excise whereas left side requires more extensive visceral medialization or access to the lesser sac.
- describe laparoscopic right and left adrenalectomy...

Management of intraoperative complications:
- hypotension: phenylephrine or ephedrine and volume expansion
- hypertension: nitroprusside
- ventricular arrhythmia: lidocaine

Post-operative care:
- blood pressure will commonly be low (SBP<100) in 1st 12hrs post-op until the pre-op doses of alpha-blocker absorbed
- hold all anti-hypertensive medications post-op unless the pt was taking chronic B-blocker
- Specimen examined pathologically for DNA ploidy.  Diploid tumors behave in malignant fashion, however, even 30% of nondiploid tumors will also recur.