IPEG 2018 - LAPAROSCOPIC RESECTION OF A 13 CM ADRENAL MASS IN A 13 YEAR OLD GIRL
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What the experts said
The patient is a 13-year-old girl with FAP syndrome who had multiple tubular adenomas on colonoscopy.
The patient's father was diagnosed with stage 4 colon cancer at the age of 34.
During laparoscopic total proctocolectomy, a large left retroperitoneal mass was discovered intraoperatively.
Due to the intraoperative finding of the mass, the procedure was changed from total proctocolectomy to total abdominal colectomy with diverting ileostomy to allow further workup of the abdominal mass.
The patient's review of systems was notable for hematochezia.
On exam, the patient had normal heart rate and blood pressure.
The patient had a BMI of 15 and a firm palpable left-sided abdominal mass on exam.
Urine catecholamines were normal, as were random cortisol, ACTH, and aldosterone levels.
CT scan showed a large 14 × 13 × 8 cm calcified left retroperitoneal mass displacing the left kidney inferiorly.
The patient was placed in a modified right lateral decubitus position for the procedure.
45 millimeter ports were used for the laparoscopic procedure.
The peritoneal layer overlying the left adrenal mass was incised to begin the dissection.
A combination of ligature device and blunt dissection was used to reflect the pancreas medially off the anterior surface of the mass.
There was clear separation between the left adrenal mass and the left kidney during dissection.
The golden hue characteristic of the adrenal gland was visible as dissection proceeded inferiorly and medially around the mass.
Given the size of the mass, it was easier to proceed with dissection along the posterior aspect, reflecting it anteriorly.
The spleen was mobilized medially by taking down its attachments.
Circumferential mobilization of the mass was completed laparoscopically by taking down the final diaphragmatic attachments.
A 15 cm endocatch bag was placed through a small Pfannenstiel incision to contain the mass.
The mass was brought down to the pelvis and the Pfannenstiel incision was extended to remove the mass in its entirety.
Final pathology showed a 14 cm adrenal cortical neoplasm with adjacent normal adrenal gland that was completely encapsulated.
The patient was discharged on a regular diet on postoperative day 4.