Advanced Robot-Assisted Laparoscopic Techniques in the Resection of Neural-Derived Retroperitoneal Masses

Abstract

Introduction and Objectives: Incidence of neurally derived retroperitoneal masses aside from even pheochromocytoma is exceedingly rare. In this video, we describe techniques for the robot-assisted approach to safely excising both a paraganglioma arising from the organ of Zuckerkandl and a Schwannoma in two distinct patients. We aim to show that with careful planning and consideration, these masses can be removed safely robotically with proper monitoring and techniques. Methods: Robot-assisted excision of a left juxtarenal paraganglioma consistent with Organ of Zuckerkandl was performed in case 1. Excision of a left retroperitoneal Schwannoma was performed in case 2. In the first case, the patient was a 36-year-old female who presented with palpitations and sweating and was found on work-up to have a 6 cm left retroperitoneal mass and elevated plasma metanephrines concerning for paraganglioma. Full blockage of catecholamines was achieved preoperation. The paraganglioma was exposed with minimal manipulation. Feeding vessels were controlled along with a left accessory renal artery injury that required repair. Indocyanine green was administered to confirm completed perfusion of the kidney. In the second case, the patient was a 44-year-old male who presented with left lower back pain and leg pain and found to have a 9.6 cm left parapsoas retroperitoneal mass originating from the left femoral nerve sheath; neurosurgically placed electrodes were used to monitor nerve activity during excision of the schwannoma. Nerve stimulation at the end of the case confirmed appropriate nerve responses in the involved lumbar nerve segments. Results: There were no intraoperative complications and all procedures were effectively completed robotically. The first patient exhibited some reflex tachycardia postoperation secondary to a paraaortic lymph node dissection, which resolved and was discharged home postoperative day 4 off all antihypertensive medications. The second patient was discharged home postoperative day 4 without any significant postoperative complications. The 2-month follow-up visit for case 2 showed significant improvement in quadricep strength and sensation. Conclusions: Robotic approach and excision of unusual neural-derived masses must be approached carefully and uniquely taking into account the preoperative symptoms and the suspect pathology. With careful preparation, caution, and monitoring, these masses can safely be removed robotically. M.D. is a consultant for Auris, Procept. M.A. is a consultant for Baxter, Boston Scientific, Intuitive Surgical. For the remaining authors, no competing financial interests exist. Runtime of video: 8 mins