| name | ppgl-surgical-approach-selection |
| description | This skill selects the surgical approach (laparoscopic/robot-assisted vs open adrenalectomy) for pheochromocytoma and paraganglioma (PPGL) based on tumor size and suspected organ invasion. It is triggered when imaging shows PPGL tumor size approaching 6 cm, suspected tumor invasion into adjacent structures on imaging, or when determining the surgical approach for a confirmed PPGL. |
PPGL Surgical Approach Selection Based on Tumor Size and Invasion Risk
STEP 1 — Gather Information
Measure tumor diameter in centimeters on contrast-enhanced CT or MRI and evaluate for imaging signs of organ invasion (e.g., loss of fat plane, vascular encasement, irregular margins, or direct extension into adjacent organs).
STEP 2 — Rule In / Rule Out
If tumor size <6 cm AND no evidence of organ invasion → proceed to laparoscopic/robot-assisted adrenalectomy consideration; otherwise (tumor ≥6 cm or suspected invasion) → proceed to open adrenalectomy consideration.
STEP 3 — Classify or Stratify
For laparoscopic/robot-assisted candidates, confirm surgical team expertise and absence of contraindications (e.g., severe cardiopulmonary instability, prior extensive abdominal surgery); for open surgery candidates, assess need for potential vascular reconstruction or extensive lymph node dissection based on invasion extent.
STEP 4 — Decide
Select laparoscopic or robot-assisted adrenalectomy for tumors <6 cm without invasion; select open adrenalectomy for tumors ≥6 cm or with suspected organ invasion, and schedule the procedure accordingly.
Clinical Guardrails / Mimics / Pitfalls
Do not rely solely on tumor size without assessing invasion, as small tumors with local infiltration may still require open surgery; avoid laparoscopic approach in patients with uncorrectable coagulopathy or hemodynamic instability despite preoperative α-blockade.
Concrete Clinical Example
A 52‑year‑old patient with a 5.8 cm left adrenal PPGL on MRI shows a clear fat plane and no vascular encasement. Tumor size is <6 cm and no invasion is suspected, so laparoscopic adrenalectomy is chosen. Intraoperatively, the tumor is excised successfully with minimal blood loss.
Source: Japan Endocrine Society Clinical Practice Guideline for the Diagnosis and Management of Pheochromocytoma and Paraganglioma 2025, Japan Endocrine Society, 2025, doi:10.1507/endocrj.EJ25-0165
