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.
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.
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.
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.
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 on the right side. In this schematic, note that the purple organ
is a liver. It’s been retracted now using a fan retractor. As a reminder, the right renal vein
directly drains into the inferior vena cava. The left renal vein however, drains to either variably
to the left phrenic vein that supplies the diaphragm or the left renal vein.