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NUJHS Vol. 2, No.4, December 2012, ISSN 2249-7110 Nitte University Journal of Health Science LAPAROSCOPIC ADRENALECTOMY IN PEDIATRIC PATIENTS
- A REPORT OF 2 CASES.
Sandeep B. Rai , Rajesh Ballal , Raghu Shankar
Professor and Head, Associate Professor, Pediatric Surgery, Professor and head, Department of Surgery, Justice K.S. Hedge Medical College, NITTE University, Mangalore - 575 018.
Raghu Shankar
Associate Professor, Pediatric Surgery, Justice K.S. Hegde charitable super speciality hospital, Deralakatte, Mangalore - 575 018, Karnataka.
Phone : +91 824 2204471 E-mail : drraghubhat@yahoo.com Abstract :
Reporting on the laparoscopic technique for adrenal disease in children and adolescents has been limited. Laparoscopic adrenalectomy
are been performed in selected patients in centers with advanced laparoscopic expertise. Here we report two cases of laparoscopic
adrenalectomy done for functional adrenal tumors in pediatric patients.
Keywords : Laparoscopic adrenalectomy, feminizing adrenal tumor, Cushing's adenoma.
Introduction :
The adrenal gland is considered suitable for laparoscopic
resection because of its relatively small size and
retroperitoneal location. Laparoscopic adrenalectomy (L A)
has become the standard procedure for benign adrenal
masses in adults. Despite multiple studies in the adults,
Quick Response Code
this technique in pediatric p a t i e n t s . I n f r e q u e n t i n d i c a t i o n s f o r adrenalectomy in children and small body habitus pediatric patients. Also, neuroblastoma is the most common adrenal lesion in this age group and this lesion is LAPAROSCOPIC ADRENALECTOMY - Sandeep B. Rai
NUJHS Vol. 2, No.4, December 2012, ISSN 2249-7110 Nitte University Journal of Health Science infiltrative and invasive in nature. As laparoscopic skills However, the superior margin could not be defined well. have developed in the pediatric surgical community, Hence, keeping the possibility of malignancy, a biopsy was laparoscopic adrenalectomies are being performed for taken. Histopathology showed a benign adrenal tumor, selected pediatric patients. However, this procedure is Cushing's adenoma . And so, in the next sitting a week been performed in centers with advanced laparoscopic later, transperitoneal laparoscopic adrenalectomy was expertise. We report two cases of adrenal tumors in carried out. Recovery was uneventful. Child was started on pediatric patients who were managed with laparoscopic oral liquids the next day and progressed to full diet on the subsequent day. The final histopathology revealed an intermediate grade adrenocortical tumor.
Case report :
Case 1
: A six year old male child was referred with
Technique:
gynecomastia of six months duration. Child had been For LA, the patient is placed in the 90° lateral decubitus evaluated elsewhere and was receiving systemic steroids position with the operative side up.
for the past three weeks. Examination revealed cushiongoid facies with bilateral gynecomastia. Other A bolster is placed underneath the lumbar region and the systemic examination findings were within normal limits. table flexed maximally to create the largest possible The size of the penis was normal for the age and bilateral distance between the costal margin and the iliac crest. testes were normal. Serum estradiol was found elevated Ports were introduced at the sites shown in the figure 1&2. three times the normal value, and serum cortisol level was Adrenal vein was seen only after initial dissection of the normal. Abdominal sonology showed a 3.5 cmx 2.6 cm mass from lateral, inferior and superior borders using the mass lesion in the right adrenal gland with specks of harmonic dissector. Adrenal vein was coagulated with the calcification. CT abdomen showed a well encapsulated harmonic dissector blades. The remaining gland was freed right adrenal tumor. Transperitoneal laparoscopic by circumferential dissection. In the first case at the adrenalectomy was done. Post –op recovery was completion of laparoscopic dissection, the hemostasis uneventful. As the histopathology revealed malignant achieved was in doubt. Hence, to ensure absolute adrenocortical feminizing tumor. Child received hemostasis, a small subcostal incision was put which also served to retrieve the specimen. Similarly, in the second case the small subcostal incision was used to deliver the Case 2: An eleven month old male child presented with
excessive weight gain and excessive body hair. On examination, child had cushingoid features, hirsutism and Discussion:
weighed 11 kgs . However, there were no features of The laparoscopic approach for excision of adrenal gland precocious puberty. Child had borderline hypertension. was first described by Gagner et al in 1992. Laparoscopic Systemic examination including abdominal, respiratory, adrenalectomy has become the gold standard for removing cardiovascular and central nervous system did not reveal adrenal lesions of almost any pathology in adults. Despite any abnormality. Serum cortisol levels were found to be infrequent cases in the pediatric population, the wide grossly elevated with the value of 36.14 microgram/dl (5.7- applicability of laparoscopy to multiple pediatric surgeries 16.6). Random sugar was 97mg/dl; creatinine, sodium and has enabled pediatric surgeons with necessary skill and potassium levels of serum were normal. Contrast equipment to perform laparoscopic adrenalectomies. enhanced CT of the abdomen showed a well-defined Potential benefits of laparoscopic adrenalectomy are heterogeneously enhancing, 4.3 cmx3.7 cm soft tissue similar to those of other minimally invasive procedures, density lesion arising from the right adrenal. There was no including decreased postoperative pain, shorter evidence of local invasion. A diagnosis of Right side hospitalization, and faster return to normal activity.
functional adrenal tumor was made. Child was taken up for The principal approaches described for L A are the laparoscopic adrenalectomy. The mass was noted to be of transperitoneal and the retroperitoneal approach. The about 6x5 cm, well encapsulated and compressing the IVC. LAPAROSCOPIC ADRENALECTOMY - Sandeep B. Rai
NUJHS Vol. 2, No.4, December 2012, ISSN 2249-7110 Nitte University Journal of Health Science lateral transperitoneal approach offers a more efficient patient . The surgeon's experience also should be working space and excellent exposure. It has been considered in these cases. Relative contraindications advocated by many to be the preferred approach.
include uncorrectable coagulopathy and previous trauma in the region of spleen and kidney .
The indications for adrenal surgery differ in adults and children. Literature reveals neuroblastic tumours to be the Conclusion:
most common adrenal lesions, requiring excision in the Laparoscopic adrenalectomy can be performed safely and pediatric age group. The safety and feasibility of LA for all effectively with a short hospital stay and minimal blood loss stages of neuroblastomas in pediatric patients (including in pediatric patients. Patient selection for laparoscopy is infants) has been documented in earlier studies. crucial and is dependent on the child's body habitus, as Although no absolute contraindications to LA has been well as the experience of the surgical and anaesthetic clearly identified in adults, open approach has been teams. A low threshold for open conversion in the early preferred in malignancies with metastatic nodes in phase of the learning curve is recommended.
periaortic area and close to the bladder. However, in Acknowledgment:
children, LA has even been suggested as an option for Our sincere thanks to department of pediatrics and residual tumours that have a favourable cytoreductive department of anaesthesia, without whom the clinical response to chemotherapy . Rather than stating an course would not have been a smooth one. Also, thanking absolute contraindicated mass size for pediatric patients, the nursing staff of the pediatric ward. the size of the tumor may limit the laparoscopic approach when evaluated individually relative to the size of the Reference :
1. Gagner M, Lacorix A, Bolte E. Laparoscopic adrenalectomy in Cushing's
syndrome and pheochromocytoma. N Engl J Med 1992;327:1033. 2. Vargas HI, Kavoussi LR, Bartlett DL, Wagner JR, Venzon DJ, Fraker DL, et al. Laparoscopic adrenalectomy: A new standard of care. Urology 1997;49:673-8. 3. Gil-Cardenas A, Cordon C, Gamino R, Rull JA, Gomez-Perez F, Pantoja JP, et al. Laparoscopic adrenalectomy: Lessons learned from an initial series of 100 patients. Surg Endosc 2008;22: 991-4. 4. Suzuki K, Kageyama S, Hirano Y, et al: Comparison of 3 surgical approaches to laparoscopic adrenalectomy: A nonrandomized, background matched analysis. J Urol 166:437-443, 2001 5. Miller K.A , Albanese.C, Harrison.M, Farmer.D, Ostlie D.J, Gittes G, Holcomb G.W III. Experience with laparoscopic adrenalectomy in pediatric patients. J Pediatr Surg 2002 37:979-982. 6. Skarsgard ED, Albanese CT. The safety and efficacy of laparoscopic adrenalectomy in children. Arch Surg 2005;140:905-8 7. Kadamba P, Habib Z, Rossi L. Experience with laparoscopic adrenalectomy in children. J Pediatr Surg 2004;39:764-7 8. Gagner M, Pomp A, Heniford BT, et al: Laparoscopic adrenalectomy:Lessons learned from 100 consecutive procedures. Ann Surg 226:238-247, 1997 LAPAROSCOPIC ADRENALECTOMY - Sandeep B. Rai

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