Total Hepatic Vascular Occlusion For Difficult Right Adrenalectomy

Abstract

A new approach to resect a functioning malignant pheochromocytoma originating from the right adrenal gland and large enough to encircle the retrohepatic inferior vena cava is reported. The adrenal vein in this situation is difficult to expose and ligate in the initial phase of the dissection and in order to occlude venous outflow from the tumor and prevent a catecholamine surge while handling the tumor. The inferior vena cava (IVC) was controlled above and below the liver. This report describes the value of Total Hepatic Vascular Exclusion ( THVE) in this situation. The IVC is controlled by encircling it above the liver and also just above the junction of the renal vein where the approach is unrestricted by the adrenal tumor. Pringle's maneuver of occluding the hepatic vascular inflow is also used to prevent acute hepatic venous congestion. Following this maneuver in our patient, the adrenal tumor was separated from the retrohepatic IVC with minimal bleeding and no recurrence of precipitous rise in blood pressure that resulted from handling the tumor prior to control of the IVC.