ROBOTIC-ASSISTED EXCISION OF FUNCTIONAL PARA-AORTIC PARAGANGLIOMA

Objectives: Paragangliomas are rare neuroendocrine tumors derived from the chromaffin cells of the autonomic nervous system. These tumors are exceedingly rare, with approximately 500 to 1000 diagnosed per year in the United States. Functional paragangliomas typically come from sympathetic paraganglia and are most commonly found in the abdomen. Treatment of functional paraganglioma is complete surgical removal of the tumor. The anatomic location of the mass dictates the operative approach and technical difficulty, as many of these masses are found along major intraabdominal vascular structures. This video demonstrates the utility of a robot-assisted transabdominal approach to remove a para-aortic paraganglioma.

We present a 41-year-old male patient with a past medical history of hypertension treated with lisinopril who presented to an outside hospital with a complaint of worsening epigastric pain for two weeks. He has no prior surgical history or family history. Imaging revealed an approximately 5cm retroperitoneal mass of unknown origin abutting the third portion of the duodenum and anterior to the aorta, suspicious for paraganglioma. Diagnosis was confirmed with PET dotatate scan, EUS, and elevated plasma and urine metanephrines. The patient received adequate preoperative alpha followed by beta blockade before undergoing surgery. He was placed in the reverse Trendelenberg position. Laparoscopic access was obtained via Veress needle in the left upper quadrant. Three additional 8 mm robotic ports, one 5 mm, and one 12 mm laparoscopic assist ports were placed under direct observation. Inspection of the peritoneum did not identify any metastatic disease. The ligament of Treitz was identified and the and the duodeno-jejuno junction was mobilized. The mass was identified posterior to the duodenum. Using fenestrated bipolar forceps and a vessel sealer, the mass was circumferentially dissected free of surrounding structures while keeping the capsule intact. Small feeding vessels were carefully ligated, taking care to avoid injury to the duodenum and inferior mesenteric vein. The specimen was removed en bloc using a specimen bag. The pathology analysis demonstrated a well-encapsulated paraganglioma and further genetic testing was negative. The patient was discharged home on postoperative day  one without complications.

This video illustrates the technical details of a robot-assisted resection of a para-aortic paraganglioma. The robotic approach conferred several advantages that include enhanced observation using the robotic endoscope, dexterous instrument arm/wrist articulation in a tight space, and the ability for the operating surgeon to control multiple instruments. This allowed for precise and safe dissection in an otherwise difficult-to-access anatomic location.

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