In a breakthrough surgery that was possible because of robotic technology, three large tumors were removed from the adrenal glands of two siblings. Now this gland is vital to maintaining blood pressure and surgery is tricky as its functioning can be impacted with the slightest damage. Besides, both the children, Manan and Disha Joshi, had high blood pressure, a no-no for even a minor surgery, let alone a delicate one.
Manan Joshi, an eight-year-old boy from Almora, Uttarakhand, had a large tumor of 4.5 cm in his left adrenal gland. His older sister Disha, 15, had a tumor in both her adrenal glands. The larger one in the right gland measured 5.5 cm and another in the left adrenal gland was 2.5 cm. Genetic testing showed that they had a very rare syndrome called the Von Hippel-Lindau (VHL) syndrome that they had inherited from either of their parents.
Dr Ashwin Mallya, Urologist and Robotic Surgeon, Sir Ganga Ram Hospital, who operated on both the patients, said, “Both were suffering from pheochromocytoma, a condition that causes production of excessive hormones that increase the blood pressure. It produces 1000 times more adrenaline and noradrenaline than what is required in the body. The young boy had very high blood pressure to the tune of 200/120 mm Hg, along with seizures, which is too high for an eight-year old”. He underwent minimally-invasive laparoscopic surgery after his blood pressure and seizures were brought under control.
According to Dr Ajay Sharma, Chairperson, Urologist and Robotic Surgeon, Sir Ganga Ram Hospital, “The tumors of the adrenal gland are very challenging to operate because of their sensitive location. These are small, triangular shaped glands located on top of both kidneys. They are very close to the major blood vessels and during operation there are chances of life threatening fluctuation in blood pressure and heart rate.”
First, Manan was taken for laparoscopic surgery, for left adrenal tumor removal. It was done in two hours with 50 ml blood loss. After that Disha was operated using robotic technology. Her right adrenal gland along with a 5.5 cm tumor was removed completely. The tumor in the left adrenal gland, measuring 2.5 cms, was removed, sparing as much of the normal adrenal gland as possible. Her surgery took 3.5 hours.
“In such a surgery, preparation is crucial. If that is not done well, then the patient can collapse,” said Dr Mallya. Preparation includes balancing blood pressure levels both before and after the surgery to levels that the body can adapt to.
“The body had a certain balance with the tumor and the challenge was to stabilize it as the blood pressure levels would drop dramatically post-surgery. Dealing with that was a big challenge at hand”, Dr Mallya explained. “There is a scientific way of preparing the patient. Manan was optimally prepared and given IV fluids before the surgery,” he added.
The girl was operated robotically after she was optimised. Her blood pressure levels were more refractory as compared to the boy and she had twin tumors. Explaining why robotic technology was used in her case, Dr Mallya said, “It allows more accurate movements of the instruments. We can visualize the structures much better with ten times magnification and can control the instruments that are inside the body through a 3-D console. It feels like we are sitting inside the patient’s body while conducting the surgery with a replication of the human wrist movement.”
Elaborating more on the wrist movement technology that robots offer, he said, “These robotic instruments replicate wrist movements with such accuracy that I could get close to the largest vein of the human body, the inferior vena cava, without touching it.”
Contrasting it with laparoscopic surgery, he said, “In laparoscopic surgery the instruments are like straight sticks. When you are doing such an operation, you want the most accurate movement of the hand.”
Both the patients have recovered completely and have returned to their normal self, with both going to school but the doctors have to keep their hormone levels under check. As Dr Mallya said, “The only complication that we are watching out for is the recurrence of these tumors because they have genetically inherited a rare syndrome. However, there is no specific complication that could arise because of the kind of surgery they have undergone. The one big takeaway from this case is that whenever you see high blood pressure among children, you should get them examined. It is not the same as blood pressure in adults and might have an underlying cause.”