V11-08: Laparoscopic nephron-sparing excision of hilar paraganglioma: tips and technique

Video

Introductions and Objectives
Paragangliomas are extra-adrenal pheocromocytomas arising from the neural crest and comprise 10% of all pheocromocytomas. They are often located near the renal hilum and, when large or surrounding the renal vessels, pose a surgical challenge in preserving the adjacent kidney. Through this video, we demonstrate the technique of managing such patients, providing complete tumor resection while preserving renal parenchyma.

Methods
A 38 year old male was diagnosed to have a functional 5.9 x 5.7 cm paraganglioma, located in the left renal hilar region, extending between and splaying the left renal artery and vein. After pre-operative preparation as per a standard protocol, a 4-port transperitoneal laparoscopic approach was planned. The first step to a safe surgery was wide exposure through mobilization of the colon and spleen till the stomach, pancreas and diaphragm were clearly visible. Thereafter, the ureter, which was draping the lower pole of the tumor, was identified and separated. The aorta was exposed and the tumor was gently lifted off it, ligating multiple feeder vessels. The renal vessels were identified and looped. The tumor was gradually separated from the artery and vein, preventing injuries before final separation from the hilum.

Results
The operative time was 210 minutes; estimated blood loss was 500 ml. There were no complications and the patient was discharged on day 3 on lower doses of antihypertensive drugs. A renal dynamic scan at four weeks revealed a viable kidney with decreased function.

Conclusions
Careful preoperative preparation, meticulous intraoperative anesthetic management, and surgeon experience makes laparoscopic resection of difficult paragangliomas a safe and feasible treatment option.

Funding: None