Laparoscopic transperitoneal bilateral adrenalectomy for pheochromocytoma: step by step video demonstration

Ten percent of all pheochromocytomas are bilateral and require bilateral adrenalectomy. Laparoscopy bilateral simultaneous surgery can be safely performed in most patients. We describe a step-by-step approach to these surgeries. A 19-year-old female presented with progressive vision loss in both eyes for 3 years and was diagnosed to have bilateral retinal hemangiomas. On further evaluation, she was detected to have bilateral adrenal masses. She had no history of adrenergic symptoms and her plasma normetanephrines were elevated. Contrast enhanced tomography of the abdomen showed a 5 cm lesion in the right adrenal gland and two nodules on the left. DOTANOC scan showed uptake in bilateral adrenal glands and a diagnosis of VHL syndrome with bilateral pheochromocytoma was made. She was planned for synchronous bilateral laparoscopic adrenalectomy. Right adrenalectomy was performed first in the left lateral decubitus position. The peritoneum over the cranial and medial borders of the tumor was incised and the tumor was separated from the liver to minimize respiratory movements and inadvertent traction on the liver parenchyma. Medial dissection was performed to ligate and divide the adrenal vessels. Dissection was continued and the gland was separated from the kidney. The patient was turned into the right lateral decubitus position for left adrenalectomy. The splenic flexure was mobilized, and the splenic attachments were divided to maximize exposure. Medial dissection was performed to identify the renal and adrenal veins. The adrenal vein was ligated, and the gland was isolated by dividing its attachments to the kidney. Specimen were extracted through a single incision. The surgical time was 110 min with minimal blood loss. She was started on lifelong steroid supplementation. Post operative period was uneventful and follow up showed no recurrence at one year. Bilateral simultaneous laparoscopic adrenalectomy can be safely performed for pheochromocytomas.