Pheochromocytoma: Management

00:01 Let’s move on to the management. Now that you’ve diagnosed a pheochromocytoma, what should we do? Vast majority of patients with pheochromocytomas require surgery. But the preparation is very, very important and extremely high-yield. Let’s say you’ve decided to go surgery, what’s the first step? We begin with alpha adrenergic blockade prior to the surgery for about two weeks.

00:29 Then, we expand a contracted volume. With pure alpha adrenergic blockade, the vasculature particularly the peripheral vessels will be relaxed allowing a tolerance for more volume.

00:44 The alpha adrenergic blockade of choice is a medication called phenoxybenzamine. Please familiarize yourself with this medication. And remember, some patients may need a beta blocker as an unopposed beta can drive tachycardia. Let’s move on to surgery. This is an image of a laparoscopic adrenalectomy. Remember, if you want to perform an open, there’s nothing wrong with that.

01:12 These are some standard trocar placements with the patient placed on their side. I’ll describe to you what a right adrenalectomy looks like. In this image of a laparoscopic adrenalectomy on the right side, notice the clip applier on the right lower quadrant of that screen. The clip applier is about to ligate the right adrenal vein. Anatomically, remember, it’s very important.

01:38 Drainage of the right adrenal vein goes directly into the inferior vena cava. Therefore, injury to the inferior cava is a potential catastrophic complication of this surgery. If you decide to perform this surgery, be careful on the side. The procedure for this surgery is usually involving the exposure of the Gerota’s fascia. As a reminder, the right adrenal vein directly drains into the inferior vena cava. The left adrenal vein however, drains to either variably to the left phrenic vein that supplies the diaphragm or the left renal vein.