Posterior Approach

In contrast to prior recommendations by us and others, we now feel that the technology is sufficiently accurate to allow a posterior approach for pheochromocytomas as well as most other benign adrenal tumors. The minimum investigations to allow this approach include both physiologic and anatomically precise preoperative imaging tests to ensure that the tumor is intra-adrenal and to exclude additional tumors (Fig. 71-8). Key technical points for excision of pheochromocytomas from the posterior approach include the following: (1) manipulation of the tumor by this approach may exceed that by the anterior approach; (2) on both sides, the tumor is initially exposed by dissecting its superior border first, with anatomic landmarks being the

FIGURE 71-8. A, CT scan of a relatively large right pheochromocy-toma, located in the adrenal gland. B, Gross photograph demonstrates a tumor slightly larger than 5 cm. This tumor was removed by a posterior approach.

FIGURE 71-8. A, CT scan of a relatively large right pheochromocy-toma, located in the adrenal gland. B, Gross photograph demonstrates a tumor slightly larger than 5 cm. This tumor was removed by a posterior approach.

diaphragm superiorly, the inferior phrenic vein superomedially on the left, and the liver on the right.

Paragangliomas

By virtue of their location, paragangliomas may present difficult challenges and require special care to prevent serious hemorrhage. However, even when located between the aorta and vena cava and obscured by the portal triad, it is rare for these vessels to be invaded, and meticulous dissection is rewarded with tumor removal, protecting these vessels. Because 40% of these tumors are malignant, careful search for and removal of lymph node and liver metastases should be undertaken if possible.

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