Giant adrenal pseudocyst: laparoscopic management

Abstract

Cystic lesions of the adrenal gland are rare clinical entities, with a reported incidence of 0.064% to 0.18% in autopsy studies 1 and 5-6% in clinical series. 2,3 In most cases, adrenal cysts are non-functional. 2 A 45-year-old man was admitted with a 2-month history of abdominal discomfort and dull pain mainly in the right hypochondrium.Physical examination revealed a large non-tender mass in the sub-hepatic area. A computed tomography (CT) scan showed a large cystic mass of the right abdomen compressing the right lobe of the liver and right kidney. Magnetic resonance imaging (MRI) showed a large cystic thin-walled homogeneous mass originating from the right adrenal gland. The mass was compressing the liver, the right kidney and the inferior vena cava (Figs 1,2). Since an adrenal lesion was considered, a careful hormonal work-up was performed, which was negative. During surgery, the patient was placed in the left lateral decubitus position. Laparoscopy was performed with the open Hasson technique at the umbilical level, while two additional 5-mm trocars were introduced: one in the right mammary (midclavicular) line, 3 cm below the coastal margin and one in the anterior axillary line. The peritoneal reflection of the right triangular ligament of the liver was divided and the hepatic flexure of the colon was mobilized. The lesion was then noted, but we could not grasp it due to the tension of its content. The cyst was punctured and a large amount of serous fluid was aspirated. The cystic fluid was sent for cytologic analysis, but there was no evidence of malignant cells. The collapsed cyst was retracted outward and a wide unroofing was performed in order to preserve the adrenal parenchyma. Intraoperative frozen section examination revealed no evidence of malignancy. After a careful haemostasis, a drain was placed to the operating site and the trocar sites were closed using absorbable sutures. The patient had an uncomplicated post-operative course. Histological findings were suggestive of an adrenal pseudocyst without an endothelial or epithelial lining, whereas some calcifications were noted (Fig. 3). The patient remains well and asymptomatic 9 months after surgery.The first case of an adrenal cyst was described by the Viennese anatomist Greiselius in 1670. 4 Adrenal cysts are histologically classified into four categories: endothelial cysts (45%), pseudocysts (39%), epithelial cysts (2%) and parasitic cysts (7%). 5 Although they can occur at any age, they do, however, occur more frequently in the fourth and fifth decades of life and affect mainly women with a female-to-male ratio of 2-3:1. 2,3,6 In 34% of the cases, the diagnosis is made incidentally, whereas only 56% of the cases are correctly Fig. 1. Coronal T1-weighted MR image demonstrating a large cystic mass measuring 15.5 ¥ 13.5 cm compressing the right kidney.Fig. 2. Axial T1-weighted MR image demonstrating a large cystic mass compressing the inferior vena cava (arrow).

Surgical Management of a Giant Adrenal Pseudocyst: A Case Report and Review of the Literature in the Last Decade

“…Except for the general contraindications of laparoscopic procedures (unacceptable cardiopulmonary risk, uncorrected coagulopathy, abdominal sepsis, and intestinal obstruction), the absolute contraindication of laparoscopic adrenal surgery is the suspicion of a large adrenal cortical carcinoma, since open procedures allow better vascular control [ 13 ]. Other possible procedures for simple cysts, such as unroofing, open or laparoscopic, and percutaneous needle aspiration, were also referred [ 24 ].…”

Giant adrenal pseudocyst in trauma patient

“…They are found in the medulla or the cortex of the adrenal gland, sometimes obliterating the gland due to their size. 2,[4][5][6] Their cause is debated, though they are believed to be caused by abdominal trauma, vascular malformation, infectious process or sepsis, hemorrhage directly into the adrenal parenchyma, or degeneration of a neoplasm. 1,3,6,7 Furthermore, there is debate on whether estrogen increases the likelihood of pseudocyst formation, possibly explaining the increased prevalence in females.…”

“…Although rarely reported as a pure traumatic event, they are more commonly evaluated in an emergency department than a trauma bay. They are more common in females, with a ratio to males of 2-3:1, and are more frequently found in the fourth to sixth decade of life; [1][2][3][4] however, reports of younger patients have also been described. 3 Symptoms at presentation are typically vague abdominal pain, fullness, or mass effect from compression of adjacent organs, including gastrointestinal compression, but are frequently asymptomatic.…”

Adrenal cysts - optimal laparoscopic treatment.

“…5% of patients. Cysts comprise 5.4% to 8.2% of all adrenal pathologies [ 1 – 3 ]. They may accompany hormonal hyperactivity of the adrenal cortex and medulla in about 15% of cases as well as primary or metastatic tumors in about 7% of cases.…”