Projects

Abstract

INTRODUCTION AND OBJECTIVE:

Functional retroperitoneal paragangliomas present unique challenges due to their metabolic activity and proximity to critical vascular structures. This video demonstrates a robotic-assisted approach to excise a large paraganglioma located in the inter aortocaval region, extending to the undersurface of the liver and encasing the aorta, left renal vein, and right renal hilum. The primary objectives were to achieve complete oncologic resection while preserving renal function and vascular integrity.

METHODS:

A 67-year-old female with accelerated hypertension and chronic kidney disease (CKD) presented with elevated plasma free metanephrines and normetanephrines, indicating a functional paraganglioma. Due to her CKD, an MRI was performed, revealing an irregular, lobular tumor in the interaortocaval region, encasing major vessels. Blood pressure was optimized preoperatively. During surgery, robotic access was established, and dissection began with isolation of the infrarenal IVC and mobilization of the caudate lobe of the liver, with ligation of short hepatic veins. Intraoperative Doppler ultrasound assessed the tumor’s extent and proximity to vascular structures. Key steps included isolating the left renal vein, separating right renal hilar vessels, and dissecting along the aorta to identify the right renal arteries. Adrenalectomy and dissection of the suprarenal aorta and IVC defined the tumor’s cranial limits, followed by full IVC mobilization and ligation of posterior abdominal wall feeders to facilitate tumor removal. Renal perfusion and preservation of hilar structures were confirmed with ICG injection.

RESULTS:

The total operative time was 240 minutes, with a console time of 200 minutes and an estimated blood loss of 250 ml. The patient had an uneventful recovery and was discharged on postoperative day 5. Histopathology confirmed paraganglioma with a PASS score of 4, and the adrenal gland was noted separately. The robotic approach enabled precise dissection and safe isolation of major vessels, achieving complete tumor excision while preserving renal and vascular integrity. Intraoperative Doppler and ICG imaging confirmed intact renal perfusion. Close coordination with anesthesia managed the tumor's metabolic effects, and a vascular surgeon on standby provided added safety for vascular management.

CONCLUSIONS:

This case demonstrates the utility of robotic-assisted surgery in managing complex functional paragangliomas within challenging anatomical locations. By enabling meticulous dissection and minimizing manipulation of critical structures, robotics improves oncologic and functional outcomes, offering a minimally invasive alternative to open surgery for high-risk retroperitoneal tumors.