“Hanging Maneuver” for paraganglioma resection – A Great Idea!
- Carlos E Costa Almeida
- há 1 dia
- 4 min de leitura
Paraganglioma (PGL) is a rare entity. According to the WHO Classification of Tumours (5th edition, 2025), paragangliomas and pheochromocytomas (PPGLs) are considered a single family of neuroendocrine tumors derived from neural crest–derived chromaffin cells. Their distinction is primarily based on anatomical location, as they are histologically indistinguishable. Pheochromocytomas arise within the adrenal medulla (i.e., intra-adrenal paragangliomas) and usually secrete catecholamines, whereas paragangliomas arise from extra-adrenal paraganglia. Extra-adrenal paragangliomas are subdivided into two types: sympathetic paragangliomas, which arise along the sympathetic chain (thorax, abdomen, and pelvis) and are often functioning; and parasympathetic paragangliomas, which are typically located in the head and neck region (e.g., carotid body and jugulotympanic region) and usually do not secrete catecholamines.
When symptomatic due to hormone secretion, PPGLs typically present with paroxysmal hypertension. Although the classic triad consists of headache, palpitations, and diaphoresis, it is observed in only approximately 25% of patients. Diagnosis is primarily based on clinical presentation and biochemical testing, while imaging studies are used to localize the tumor. For non-metastatic PPGLs, surgical resection is the gold standard whenever feasible. However, in some cases, the anatomical location of the paraganglioma poses significant surgical challenges. A retrocaval location is one such example, as it increases the risk of vascular complications.
A recent paper by Dr. Marta Silva from Braga, Portugal, reports two challenging cases of retrocaval paragangliomas managed with surgical resection. The first case was diagnosed after an emergency department evaluation for headache and hypertension, while the second was identified in a hypertensive patient undergoing staging for prostate cancer. In both cases, the diagnosis was ultimately established by computed tomography rather than by clinical presentation or biochemical testing. This underscores the difficulty of early diagnosis, as these rare entities are often overlooked by clinicians. As Prof. Martin Walz stated during the meeting “Adrenal Surgery: When and How” (Coimbra, 2024), some hypertensive patients are misdiagnosed with anxiety and referred to psychiatry. Early biochemical testing can therefore be highly valuable in the evaluation of patients with hypertension.
Surgical resection was offered to both patients, as the tumors were non-metastatic. An open surgical approach was used in the first case, whereas laparoscopic surgery was performed in the second. Both tumors were similar in size (40 mm and 35 mm). The authors state that the difference in surgical technique was related to location (retrocaval bellow renal vessels) and the surgical team’s experience at the time of the first case, which occurred several years earlier. Historically, due to their challenging anatomical location, these tumors were more commonly managed with open surgery, as reflected in the worldwide review conducted by Dr. Marta Silva et al., in which 9 of 15 reported retrocaval paragangliomas were resected using an open approach. I believe surgical expertise is always a factor to consider when choosing surgical approach.
As with many other surgical procedures, minimally invasive surgery offers several advantages and is both safe and feasible. According to Dr. Marta Silva, the laparoscopic approach to paragangliomas provides excellent exposure and reduces complications in potential future operations, given the high risk of recurrence. For pheochromocytomas, a tumor size of approximately 12 cm is often considered the threshold for selecting an open approach over laparoscopy, whereas a maximum size of 6–8 cm is generally recommended for a retroperitoneal approach. For paragangliomas, the authors state that “size is no longer regarded as a decision criterion in surgical planning.” While this may hold true for many diseases and surgical procedures, surgeons must carefully consider the feasibility of achieving an R0 resection and avoiding tumor rupture. As lesion size increases, achieving a laparoscopic R0 resection without tumor rupture becomes progressively more challenging. Within the overall context presented by the authors, I believe the surgical choices made in both cases were appropriate. I am looking forward to seeing Dr. Marta Silva use the posterior retroperitoneoscopic approach in a future retrocaval PGL resection. I know she will.
The “hanging maneuver” described by the authors is particularly interesting, as it allows tumor mobilization and dissection without direct grasping or risk of rupture. This technique has been widely used in liver surgery since its description by Belghiti et al. in 2001 for right hepatectomy, in which a tape is passed between the liver and the inferior vena cava, suspending the liver and facilitating parenchymal transection. In hepatic surgery, the hanging maneuver has also been shown to reduce bleeding and minimize tumor manipulation. In the second case of retrocaval paraganglioma (laparoscopic resection), Dr. Marta Silva et al. encircled the tumor with a textile tape, secured it with a Hem-o-Lok® clip, and suspended the tumor to facilitate dissection, thereby improving visualization of the narrow retrocaval plane while avoiding inferior vena cava hanging techniques. Great idea! I will keep it!
It is encouraging to see surgeons adapting techniques from other procedures to achieve improved surgical outcomes. This highlights why performing a wide range of diverse procedures is crucial for surgical innovation and success. Keep up with the good work!
Lastly, I would like to congratulate Dr. Marta Silva on her outstanding work in the field of Endocrine Surgery. It has been a true privilege and a great source of pride to have worked with her in the past and to continue collaborating with her in this area. Beyond being a good surgeon and researcher, Dr. Marta Silva is also a good friend of mine, which makes this professional journey even more meaningful. Her dedication, expertise, and scientific rigor are clearly reflected in this newly published work. Congratulations on yet another excellent publication — it was a real pleasure to read.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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