title: Laparoscopic right adrenalectomy for a large ganglioneuroma in a 12-year-old.
abstract: BACKGROUND
  Laparoscopic adrenalectomy is well established as the standard technique for all indications of adrenalectomy except adrenal carcinoma; however, some also consider large adrenal masses a relative contraindication. We present a video of a laparoscopic excision of a large ganglioneuroma and right adrenalectomy in a 12-year-old female.
  
  
  METHODS
  Our patient was noted to have a right suprarenal mass on a computed tomography scan following complaints of back and abdominal pain. Upon surgical consultation, she underwent a magnetic resonance imaging, which showed a 7.9 x 4.4 x 5.6 cm heterogeneously enhancing suprarenal lesion that was either arising from or compressing the right adrenal gland. The patient's preoperative work-up included normal urinary metanephrines, alpha-fetoprotein, and beta-HCG. After discussion with the patient and family, the decision was made to proceed with laparoscopic excision of the mass.
  
  
  RESULTS
  The patient underwent successful laparoscopic excision of the suprarenal mass and right adrenalectomy and was discharged from the hospital on postoperative day 2. During the procedure, retraction was achieved by using a combination of 5-mm grasping instruments, Endokittner dissectors (Ethicon Endosurgery Cincinnati, OH), and a suction irrigator to provide traction and counter traction. A flexible 5-mm liver retractor (Mediflex; Velmed, Inc., Wexford, PA) was placed directly through the abdominal wall without a trocar in order to elevate the liver from the area of the right adrenal and retroperitoneum. This enabled us to "rotate" the lesion out from behind the vena cava and from along the vertebral bodies. The pathology revealed an 8.5 x 7.0 x 3.0 cm ganglioneuroma, with primarily neural and Schwann cell-type tissue with interspersed large, prominent ganglion cells, and a normal adrenal gland.
  
  
  CONCLUSIONS
  As demonstrated by our video, large adrenal masses in the pediatric population can be successfully excised laparoscopically with appropriate surgeon comfort and experience.
authors.affiliation: Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Sohail R
authors.initials: SR
authors.lastname: Shah
authors.forename: Gretchen P
authors.initials: GP
authors.lastname: Purcell
authors.forename: Marcus M
authors.initials: MM
authors.lastname: Malek
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Kane
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods*; D002648:Child; D005260:Female; D005729:Ganglioneuroma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy