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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 98-100

Laparoscopic adrenalectomy for a large adrenal cyst


1 Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Morbid Anatomy and Histopathology, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication3-Jul-2019

Correspondence Address:
Dr. Olanrewaju Samuel Balogun
Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_101_18

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  Abstract 


Cystic masses/lesions of the adrenal gland are becoming common as a result of improved imaging facilities and techniques. Adrenal pseudocysts are rare neoplasms which occur more frequently in young and middle-aged women. Laparoscopic adrenalectomy is considered the gold standard treatment for benign adrenal lesions. This review describes our first experience and challenges of laparoscopic treatment of a large nonfunctional adrenal pseudocyst in a 41-year-old female. She presented with bothersome right flank pain and a computed tomography diagnosis of a calcified right adrenal cystic mass with benign features. She had laparoscopic right adrenalectomy, and the histopathological diagnosis of the cyst was confirmed as an adrenal pseudocyst.

Keywords: Adrenal, adrenalectomy, incidentalomas, laparoscopic, pseudocysts


How to cite this article:
Balogun OS, Jeje EA, Bolarinwa BK, Fatuga AL. Laparoscopic adrenalectomy for a large adrenal cyst. J Clin Sci 2019;16:98-100

How to cite this URL:
Balogun OS, Jeje EA, Bolarinwa BK, Fatuga AL. Laparoscopic adrenalectomy for a large adrenal cyst. J Clin Sci [serial online] 2019 [cited 2019 Sep 22];16:98-100. Available from: http://www.jcsjournal.org/text.asp?2019/16/3/98/262066




  Introduction Top


Adrenal cysts account for <6% of newly discovered incidentalomas. Most adrenal cysts are found in women between the third and fifth decades of life.[1] Adrenal cysts occur in four distinct histologic forms: epithelial, endothelial, parasitic, and pseudocysts.[2] Adrenal pseudocysts lack true epithelial or endothelial lining and may originate from the cortex or medulla of the adrenal gland.

The management of adrenal pseudocysts is determined by the size and presence of symptoms. The size of adrenal pseudocyst is determined radiologically by abdominal ultrasound scan, computed tomography (CT) scan, or magnetic resonance imaging.[2] Surgical excision is indicated by the presence of symptoms, suspicion of malignancy, increase in size of the cyst, or detection of the functionality of the cyst.[3]

Since the first description of laparoscopic adrenalectomy by Michel Gagner in 1992, laparoscopic adrenalectomy has become the standard of care for removing most benign adrenal masses. In our local experience, adrenal tumors are surgically excised through open surgery. However, we have adopted laparoscopy in our surgical practice over the past 3 years. In this review, we report our first case of laparoscopic adrenalectomy in a middle-aged woman presenting with a large right adrenal cyst. This report was done to document the rarity of this lesion in our environment and share our experience with laparoscopic right adrenalectomy. We also highlighted some challenges we encountered that are probably peculiar in a resource challenged setting like ours.


  Case Report Top


A 41-year-old female presented to the outpatient clinic through a referral from her private physician on account of a history of dull constant right flank pain of 1 week duration. The pain was nonradiating with no known aggravating factors but was relieved by oral analgesic medications. There was no history of trauma, infective, or constitutional symptoms. She had no known medical comorbidities. She had appendectomy 15 years ago and myomectomy 2 months before presentation. She is single and does neither smoke cigarette nor drink alcohol.

On examination, her body mass index was 37.0. She had a nontender right upper quadrant mass which was dull to percussion. Her full blood count was within normal limits. Results of 24–h urine samples for metabolites yielded: vanilmandelic acid 20.1 umol/24 h, homovanilic acid 22.7 umol/24 h, and metanephrines 520 nmol/24 h. These values were within normal limits.

Her abdominal CT scan showed a 100 mm × 114 mm × 111 mm calcified right adrenal cystic mass causing indentation and mild displacement in the posterior border of the liver and superior pole of the right kidney [Figure 1]a, [Figure 1]b, [Figure 1]c. However, the kidneys, liver, and other abdominal organs were essentially normal.
Figure 1: Axial (a) sagittal (b) and coronal view (c) of the computed tomography scan showing the relationship between the right adrenal tumour and adjacent structures

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The patient was then counseled for laparoscopic excision of adrenal cyst because of her habitus, presence of symptoms, and benign radiologic features of the swelling.

Procedure

The lateral trans-abdominal adrenalectomy approach under general anesthesia approach was used with the patient in reverse Trendelenburg.

The patient was placed in the left lateral decubitus position, and the table flexed to maximally open the space between the tip of the 12th rib and iliac crest. The surgeon was positioned to the left of the patient with the first assistant, and the second assistant was on the right side of the patient. Four ports were inserted in the anterior axillary line (subcostal), mid-axillary line (subcostal), right subcostal region and epigastrium using two 10 mm ports and two 5 mm ports. With the patient in reverse Trendelenburg position, we began with the division of the right triangular ligament of the liver. The liver was then retracted superiorly with a snake liver retractor to expose the mass.

The gland was mobilized from superior to the lateral and medial boundaries progressively by reflecting the retroperitoneal covering using a combination of L-hook electrode and the Harmonic Ace scalpel [Figure 2]a and [Figure 2]b. On the medial side of the cyst, the right adrenal vessels were exposed and dissected free from the surrounding structures [Figure 3]a and clipped [Figure 3]b and [Figure 3]c. Dissection was finally completed through mobilization of the posterior and inferior aspect of the cyst away from the posterior abdominal wall. The patient was then positioned supine, and the freed cyst [Figure 4]a was brought out intact through a right-sided 16 cm Pfannenstiel incision.
Figure 2: (a) Initial view of the tumour occupying the Morrison's Pouch. (b) Circumferential dissection of the tumour

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Figure 3: (a) Exposure of right adrenal vein draining into inferior Vena cava. (b) Clipping of adrenal vein with ligaclip. (c) Tumour bed after excision with titanium clips on the adrenal vein

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Figure 4: (a) Excised adrenal tumour. (b) Histological section of the adrenal cyst wall shows dystrophic calcification of the lining and remnant of the normal tissue seen external to fibrocollagenous cyst wall. H and E, ×10

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The duration of surgery was 3 h 50 min with 300 ml of blood loss. The patient made an uneventful recovery and was discharged home on postoperative day 3. The patient has been followed-up in the clinic to date in a satisfactory condition.

The histopathological report of the excised mass confirmed a 560 g cystic adrenal mass measuring 14 cm × 13 cm × 10 cm with wall thickness of 0.3 cm arising from the adrenal cortex. The wall was found to contain fibrous tissue with calcifications. The cystic spaces were devoid of the epithelial lining, and there was no evidence of malignancy [Figure 4]b.


  Discussion Top


The occurrence of adrenal pseudocyst is relatively rare in our setting, and most documented cases in the literature were from case reports and case series.[4],[5],[6]

Surgical excision is recommended for adrenal cystic lesions of >5 cm in the widest diameter, hormonally active tumors, presence of symptoms, and in cases of suspicion of malignancy. Benign asymptomatic cystic adrenal lesions, <4 cm can be managed conservatively and followed up with regular radiologic monitoring.[3],[7]

Laparoscopic approach has become the favored modality of treatment for adrenal cysts. Benefits of laparoscopic surgery include less postoperative pain, early recovery and discharge, and better cosmesis.[8]

Adrenal gland can be accessed laparoscopically through two main routes: transperitoneal and lateral retroperitoneal approaches. We adopted the former approach because of our familiarity with the route in our routine laparoscopic surgeries. Thickened calcified wall of the adrenal pseudocyst aided our laparoscopic mobilization with little risk of rupture.

However, we noted an increased operating time compared to the mean duration of surgery (230 VS. 113.4 min) that was documented by some experts in high volume centers for adrenal lesions >8 cm.[9] Our increased operating time can be attributed to the large size of the cyst, patient's habitus, shortage of bariatric range hand instruments, and our learning curve in laparoscopic adrenalectomy. In dissecting the superior aspect of the cyst, we experienced a challenge in maintaining an upward retraction of the liver using the snake liver retractor. This difficulty was due to operating assistant inexperience and abutment of the cyst on the inferior surface of the liver, which restricted the working space. The large size of the cyst also made it difficult to manipulate and retract with laparoscopic instruments. We used gravity and appropriately manipulated the operating table for improved access while dissecting the tissues around the cyst.

At the conclusion of the surgery, we removed the intact cyst from the abdomen through the Pfannenstiel incision. An appropriate-sized specimen extraction bag that could accommodate the cyst was not available. The surgical procedure was concluded without any untoward events while rendering some of the aforementioned benefits of laparoscopic surgery to the patient.


  Conclusion Top


Adrenal pseudocysts are rare in our practice. Large adrenal cysts are amenable to laparoscopic resection even in our environment where resources for minimally invasive surgery are limited.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wieneke JA, Thompson LD. Non-neoplastic lesions of the adrenal gland. In: Thompson LD, Goldblum JR, editors. Endocrine Pathology. Series. Foundations in Diagnostic Pathology. Vol. 5. Philadelphia, PA: Churchill Livingstone Elsevier; 2006. p. 183-204.  Back to cited text no. 1
    
2.
Erickson LA, Lloyd RV, Hartman R, Thompson G. Cystic adrenal neoplasms. Cancer 2004;101:1537-44.  Back to cited text no. 2
    
3.
Kodama K, Takase Y, Niikura S, Shimizu A, Tatsu H, Saito K. Laparoscopic management of a complex adrenal cyst. Case Rep Urol 2015;2015:234592.  Back to cited text no. 3
    
4.
Olaoye IO, Adesina MD, Afolayan EA. A giant adrenal cyst with an uncertain preoperative diagnosis causing a dilemma in management. Clin Case Rep 2018;6:1074-6.  Back to cited text no. 4
    
5.
Kim BS, Joo SH, Choi SI, Song JY. Laparoscopic resection of an adrenal pseudocyst mimicking a retroperitoneal mucinous cystic neoplasm. World J Gastroenterol 2009;15:2923-6.  Back to cited text no. 5
    
6.
Nerli RB, Guntaka A, Devaraju S, Patil S, Hiremath MB. Adrenal cysts: Our laparoscopic experience. J Minim Access Surg 2012;8:145-8.  Back to cited text no. 6
    
7.
Staren ED, Prinz RA. Selection of patients with adrenal incidentalomas for operation. Surg Clin North Am 1995;75:499-509.  Back to cited text no. 7
    
8.
Haveran LA, Novitsky YW, Czerniach DR, Kaban GK, Kelly JJ, Litwin DE. Benefits of laparoscopic adrenalectomy: A 10-year single institution experience. Surg Laparosc Endosc Percutan Tech 2006;16:217-21.  Back to cited text no. 8
    
9.
Bozkurt IH, Arslan M, Yonguc T, Degirmenci T, Koras O, Gunlusoy B, et al. Laparoscopic adrenalectomy for large adrenal masses: Is it really more complicated? Kaohsiung J Med Sci 2015;31:644-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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