0041 Endo
Bilateral laparoscopic adrenalectomy for myelolipoma and adrenocortical adenoma, with anatomic and functional adrenal sparing
Sroka G¹, Matter I¹, Dickstein G², Eldar S¹
Laparoscopic Surgery Unit; Department of General Surgery¹; The Endocrine Division²; Bnai Zion Medical Center; Haifa, Israel
Introduction:Laparoscopic adrenalectomy is considered the optimal approach for adrenal surgical disorders. Bilateral adrenalectomy has been described for Cushing’s disease or, in rare cases, for synchronous primary adrenal pathologies. No successful sparing of normal adrenal tissue in such cases has been described.
Case report: weintroduce a 62 y.o. male with complaints of a few months of non specific abdominal pain. His past medical history included stable angina pectoris, pure hypercholesterolemia, essential hypertension and mild depressive disorder. Surgical history was unremarkable with only stripping of varicous veins. An ambulatory abdominal CT was performed with the following findings: a 10 x 12 cm homogenic left adrenal mass; a 4.5 cm mixed density right adrenal mass, with normal appearing adrenal adjacent to the tumor. There ware no other pathologies. Complete endocrine workup – was within normal range.
Operation was performed in lateral transperitoneal approach with 4 trocars at each side. The righ mass was excised first due to its more suspicious radiological characteristics- with sparing of normal adrenal tissue and the adrenal vein. The left mass was separated carefully from the spleen, stomach, diaphragm and kidney. Removal of the endo-bags was performed through widening of the incision at the left lower flank. Blood loss was 100cc and the operating took 3.5 h to complete.
Post operative course: 8 h after surgery - cortisol level 1.7 mcg/dl and glucocorticoid replacement therapy was started. The full hydrocort replacement was gradually reduced. Synacten test showed blunt response. The patient started drinking & eating on POD 2 and was discharged on POD 6 with oral pednison 20 mg per day.
Pathological report revealed myelolipoma of the left adrenal and combined myelolipoma and adrenocortical adenoma on the right.
Follow up: surgically – there was good recovery. Endocrine follow up enabled a gradual reduction in prednison dosage. 5 months after surgery - basal cortisol was 11.8 mcg/dl ( N ) – but there was still a blunt response to ACTH and the patient remained on 5 mg of prednisone daily. 7 months after surgery -follow up CT revealed normal appearing adrenal on the right. 12 months later the tests were normal for adrenal function and the patient withdrew any prednisone treatment. He is feeling good ever since.
Disscution: the Indications for surgery in such large adrenal masses are mainly the fear of malignancy and the risk of rupture. The reason for an attempt to spare normal appearing adrenal tissue is prevention of life long treatment with corticoid replacement therapy. In this case the relative simplicity by which the mass was separated from the right adrenal lowered suspicion of malignancy and offered the hope of sparing adrenal tissue. Long term follow up proved it to be the right decision.