En Bloc Right Adrenalectomy with Right Hepatectomy for Locally Advanced Adrenocortical Carcinoma

Abstract

Background: The management of locally advanced adrenocortical cancer (ACC) with tumor thrombus in the inferior vena cava (IVC) is challenging. We present the technical details of the surgical procedure in a young patient who presented with such a tumor. Methods: A 40-year-old woman presented with signs of Cushing's syndrome. Her biochemical work-up showed elevated plasma and urine cortisol levels, with suppressed plasma adrenocorticotropic hormone levels. A CT scan showed a 10-cm right adrenal mass with tumor thrombus involving the IVC. Her chest CT preoperatively was negative. She had a transesophageal echo (TEE) preoperatively that did not show thrombus above the diaphragm. She was consented for a resection of this mass with en bloc right hepatectomy, as on imaging, a clear plane between the mass and the right lobe of the liver was not seen. Results: The procedure was performed under general anesthesia with the patient in a supine position. Through a Chevron incision with an extension to the xiphoid along the midline, the abdomen was entered. No carcinomatosis was identified. The mass was adherent to the right lobe of the liver, but the kidney was free. The procedure was performed under continuous TEE to monitor for possible thrombus propagation. Using a no touch technique to the adrenal, the right hepatic artery, the right portal vein, and the right hepatic vein were divided. Using an anterior approach, right hepatectomy was performed. Then, a cavotomy was performed under total vascular exclusion and the caval thrombus was removed. The cavotomy was closed with a running 4-0 Prolene stitch. En bloc right adrenalectomy and right hepatectomy was completed. A 10 mm Jackson Pratt drain was left in the surgical field. She was discharged uneventfully on postoperative day 5 with no complications. Pathology showed a 10 cm ACC with invasion into the right lobe of the liver. The patient was started on mitotane postoperatively. About a year later, she developed pulmonary recurrence and passed away from systemic progression of disease. Conclusions: Local invasion and tumor thrombus related to ACC requires a good surgical planning and meticulous surgical technique. The video demonstrates these principles in a successful management of a thrombus below the diaphragm. The case also highlights the importance of abdominal surgical skills in the comprehensive management of adrenal tumors in an endocrine surgical practice. No competing financial interests exist. Runtime of video: 7 mins 23 secs This case was presented in the video sessions at the past American College of Surgeons on April 10–12, 2016, in Baltimore, MD.