Adrenal Schwannoma Treated With Laparoscopic Surgery

Objective:

We report a case of left adrenal schwannoma in a 62-year-old man, incidentally discovered on an abdominal computed tomography. It was successfully treated with laparoscopic adrenalectomy.

Methods:

On admission, no remarkable findings were recognized in the patient''s blood and urine examination, including adrenal function. Laparoscopic left adrenalectomy was performed with the diagnosis of a nonfunctioning adrenal tumor.

Results:

Macroscopically, the tumor (45 mm × 30 mm, 60 g) arose from the medulla of the adrenal gland with a clear border distinguishing it from surrounding tissues. Histologically, the tumor consisted uniformly of spindle cells that were positive for S-100. The cortex was compressed but showed no atrophy. The diagnosis of adrenal schwannoma was made.

Conclusion:

Although an increasing number of adrenal incidentaloma have been identified with the recent advances in imaging techniques, only a few cases of schwannoma of the adrenal gland have been reported. We reviewed the cases reported previously in an attempt to reveal the characteristic features of this rare disease.     

Laparoscopic Resection of Large Adrenal Tumors

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.     

Laparoscopic Resection of Giant Adrenal Cavernous Hemangioma

Background:

Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy.

Methods:

Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass.

Results:

The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland.

Conclusion:

The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.     

Laparoscopic Adrenalectomy for Pheochromocytoma Versus Other Surgical Indications

Objective:

Laparoscopic adrenalectomy is widely recognized as the preferred technique for surgical removal of adrenal masses. This study aimed to evaluate the outcomes of consecutive laparoscopic adrenalectomies performed at a high-volume referral center and compare operative results for pheochromocytomas with that of other adrenal diseases.

Materials and Methods:

We retrospectively reviewed a single surgeon''s experience with laparoscopic adrenalectomy performed between July 2002 and June 2007. Patient records were analyzed in regards to demographics, pathology diagnoses, operative time, postoperative complications, tumor size, hospital stay, among others.

Results:

Seventy-two consecutive laparoscopic adrenalectomies were performed on 70 patients, including 2 bilateral adrenalectomies and one partial adrenalectomy. Surgical indications included pheochromocytoma (n=11), aldosteronoma (n=26), malignant adrenal disease (n=4), nonfunctioning adenomas (n=17), Cushing''s disease (n=6), and other adrenal disease (n=8). No mortality was observed. Perioperative complications occurred in 7 cases (9.7%). When a comparison between pathological diagnosis groups was made, no statistical differences were seen between pheochromocytomas and other adrenal neoplasms with respect to estimated blood loss, open conversion rate, length of stay, preoperative and postoperative hemoglobin values, blood transfusion rates, peri-operative complication occurrence, tumor size, and ASA class.

Conclusion:

Laparoscopic adrenalectomy is a safe and appropriate surgical technique for most adrenal lesions, including pheochromocytomas.     

Surgical strategy in abnormally increased Fluorine-18 fluorodeoxyglucose uptake in an asymptomatic lower esophageal submucosal tumor – Report of a case

INTRODUCTION

Leiomyoma is the most common benign tumor of the esophagus (67–80%), it represents 0.4–1% of all esophageal tumors.

PRESENTATION OF CASE

An incidentally discovered gastro-esophageal submucosal tumor was found to have increased fluorine-18-fluorodeoxyglucose (FDG) uptake on positron emission computed tomography (PET/CT). After laparoscopic surgical exploration and local enucleation the tumor turned out to be a benign esophageal leiomyoma.

DISCUSSION

There are few reports of esophageal leiomyomas with a positive uptake on (PET/CT) and even fewer adopting our combination of a minimally invasive approach and frozen section examination as a management plan. Our approach avoided excessive morbid surgical resections and underestimation of a malignant disease.

CONCLUSION

We report this case hoping to expand the existing literature on the topic and to highlight the limitations of PET/CT in guiding the diagnosis and subsequently the management of esophageal submucosal tumors.     

Local excision of rectal schwannoma using transanal endoscopic microsurgery: A case report

INTRODUCTION

Schwannoma is a neoplasm originating from the neural crest cells (schwann cells) that form nerve sheaths. These tumors are thought to be benign with little risk of malignant transformation. They rarely affect the gastrointestinal tract, and primary rectal involvement is extremely rare. Until 2013, only 11 cases of anorectal schwannoma have been reported. Optimal surgical treatment of rectal schwannoma has not been established.

PRESENTATION OF CASE

We herein describe a 70-year-old woman with a submucosal tumor arising from the posterior wall of the rectum with features mimicking a gastrointestinal stromal tumor. After discussing the operative procedures and obtaining written informed consent, we attempted local excision of the tumor using a transanal endoscopic microsurgery (TEM). The tumor was proved to be S-100 positive schwannoma on immuhistochemical studies. Her postoperative course was uneventful, and there is no evidence of tumor recurrence as of 6 months after surgical excision.

DISCUSSION

An extremely rare rectal schwannoma was successfully treated using a TEM without compromising anorectal function.

CONCLUSION

TEM is a feasible approach for local excision of rectal tumors with low risk of malignancy.     

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma

Background:

Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature.

Case Report:

We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively.

Conclusion:

Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.     

Angiodysplasia of the gallbladder

Introduction

Angiodysplasia is a term used to describe distinct mucosal vascular ectasias found mainly in the gastrointestinal tract. Angiodysplasia of the gallbladder is exceedingly rare.

Presentation of case

We encountered a patient who presented with biliary colic and subsequently underwent an elective laparoscopic cholecystectomy. The angiodysplasia of the gallbladder was found incidentally on histopathological examination of the excised gallbladder.

Discussion

Review of the literature showed only one other reported case of angiodysplasia of the gallbladder. The condition may be found incidentally after histopathological examination of the gallbladder removed for gallstone; or it may present with haemobilia.

Conclusion

We presented an extremely rare case of angiodysplasia of the gallbladder, which was found incidentally after histopathological examination of the gallbladder removed for gallstone. Angiodysplasia of the gallbladder has the potential to bleed. Laparoscopic cholecystectomy is effective in providing a definitive cure.     

Laparoscopic adrenalectomy for bilateral metachronous aldosteronomas

Introduction:

Primary aldosteronism affects 5% to 13% of patients with hypertension. Idiopathic bilateral hyperplasia (IHA) and unilateral aldosterone-producing adenoma (APA) are the most common types of primary aldosteronism. Bilateral APA is a very rare entity with only a few reports in the literature. We present the case of a patient with metachronous bilateral APA treated with metachronous bilateral total and near total adrenalectomy.

Case Report:

A 66-year-old female was evaluated for hypokalemia and hypertension refractory to medical therapy 2 years after laparoscopic adrenalectomy for right APA. Follow-up abdominal CT scan revealed a new 1.1-cm left adrenal mass. The patient underwent a laparoscopic near total adrenalectomy for her new left adrenal mass. Pathology examination revealed a new APA. The operation and the patient''s postoperative course were uneventful. Potassium levels were normalized and her hypertension became well controlled.

Conclusion:

APA can present metachronously months to years after adrenalectomy for APA in the contralateral adrenal gland. Laparoscopic adrenalectomy remains the approach of choice for this pathology.     

Laparoscopic Resection of Solitary Adrenal Metastasis from Lung Carcinoma: A Case Report

Background and Objectives:

Patients with adrenal metastases from bronchogenic carcinoma are considered incurable and any surgical treatment is usually excluded. A review of the few cases of adrenalectomy for metastases from lung cancer that have been reported in the literature shows that good results can be achieved in selected patients. We propose a laparoscopic approach to perform the adrenalectomy in these patients.

Methods:

A right laparoscopic adrenalectomy for metastasis from lung adenocarcinoma was performed. The right adrenal was resected using the anterior transperitoneal laparoscopic approach.

Results:

The tumor was resected in total. The operating time was two hours. One year after surgery the patient remains well.

Conclusions:

The current indications for laparoscopic adrenalectomy can include the removal of small metastatic adrenal lesions in selected cases.     

Laparoscopic excision of a preperitoneal incidentaloma

Background:

Dermoid cysts are rare well-differentiated benign tumors derived from ectodermal cell origins. Usually caught incidentally, they have the potential for mass effect, malignant degeneration, and rupture. Dermoid cysts can often present a unique surgical challenge.

Case Report:

A 69-year-old male brought to the emergency department after a motor-vehicle accident had a preperitoneal incidental mass discovered on imaging. The patient was asymptomatic from the mass, though it was expanding in size. He was advised to have the mass removed, because of the possibility of malignant degeneration and rupture, and he was taken for laparoscopic surgical excision of the mass.

Discussion:

Dermoid cysts develop from embryonic migration of ectodermal tissue to aberrant locations or implantation of epidermal tissue. Dermoid cysts in the abdominal cavity are rare, and only case reports exist characterizing these tumors. Rupture can result in a chemical granuloma when localized and can cause peritonitis when the rupture is throughout the entire abdomen. Rare reports of malignant degeneration are also reported in the literature. Surgical excision is the standard of care minimizing risk of rupture with removal.     

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy

Objectives:

Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients.

Methods:

A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m² was considered obese.

Results:

Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity.

Conclusions:

A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.     

A rare cavernous hemangioma of the adrenal gland

INTRODUCTION

Cavernous hemangiomas of the adrenal gland are rare. We report a case of a cavernous hemangioma of the adrenal gland presenting as an adrenal incidentaloma suspicious for adrenal cortical carcinoma (ACC).

PRESENTATION OF CASE

A 78 year old woman was admitted after a fall. Abdominal computed tomography revealed a large right adrenal lesion with features suspicious for adrenal cortical carcinoma (5.4 cm × 3.3 cm, unilateral, tumor calcifications, average Hounsfield units 55). The tumor was removed intact by a laparoscopic approach and pathology revealed a cavernous hemangioma of the adrenal gland.

DISCUSSION

Adrenal incidentalomas are found in up to 10% of patients undergoing abdominal imaging. Differential diagnosis includes both benign and malignant lesions. Guidelines for removal of adrenal incidentalomas recommend surgery based on functional status, size, and presence of concerning features on diagnostic imaging. Cavernous hemangiomas are rare, benign vascular malformations which can be challenging to distinguish pre-operatively from malignant lesions such as ACC.

CONCLUSION

Cavernous hemangiomas of the adrenal gland are exceedingly rare. These benign tumors have imaging features which may be suggestive of adrenal cortical carcinoma. The treatment of choice is surgical excision due the difficulty of excluding malignancy.     

Laparoscopic Resection of a Small Bowel Lipoma with Incidental Intussusception

Background:

Small bowel tumors are rare entities that often present with nonspecific symptoms. The diagnosis is more likely in patients with occult gastrointestinal bleeding of unknown origin or in adults with small bowel intussusception. Even with exhaustive diagnostic testing, small bowel tumors are often not diagnosed preoperatively. Because 60% to 70% of small bowel tumors are malignant, surgical excision is always recommended.

Methods:

We report the case of a 73-year-old man with occult gastrointestinal bleeding. A small bowel tumor was discovered only after video capsule endoscopy, computed tomography, and multiple endoscopies were performed.

Results:

The patient underwent laparoscopic exploration. An incidental intussusception made the tumor simple to identify. By extending the umbilical port, the tumor was easily removed. The final pathology demonstrated a submucosal lipoma.

Conclusions:

Small bowel lipomas can cause intussusception and gastrointestinal bleeding. When diagnosed preoperatively, laparoscopic resection is feasible.     

Granulomatous Peritonitis After Laparoscopic Cholecystectomy

Background:

Granulomatous peritonitis may indicate a number of infectious, malignant, and idiopathic inflammatory conditions. It is a very rare postoperative complication, which is thought to reflect a delayed cell-mediated response to cornstarch from surgical glove powder in susceptible individuals. This mechanism, however, is much more likely to occur with open abdominal surgery when compared with the laparoscopic technique.

Methods:

We report a case of sterile granulomatous peritonitis in an 80-y-old female after a laparoscopic cholecystectomy. Management was conservative, and no relapse was observed after over 1-y of follow-up.

Discussion:

We propose that peritoneal exposure to bile acids during the laparoscopic removal of the gallbladder was the trigger of granulomatous peritonitis in this patient. Severe complications, such as peritoneal adhesions, intestinal obstruction, and fistula formation, were observed, but no fatalities were reported.

Conclusion:

We should be aware of this rare cause of peritonitis in the surgical setting.     

Laparoscopic Resection of Retroperitoneal Neural Tumors

Purpose

Retroperitoneal neural tumor (RNT) is rarely excised laparoscopically, and the laparoscopic management of RNT remains controversial. We herein report 4 cases of laparoscopic excision of RNT that resulted in diverse clinical outcomes.

Patients and Methods

Between August 2005 and January 2011, we performed laparoscopic excision of RNT in 4 patients. The mean tumor size was 4.5 cm. The mean operative time was 297 minutes and the mean amount of blood loss was 55 ml. The surgeries were uneventful, with no operative complications or evidence of intra-abdominal bleeding. However, 2 patients required reoperation for delayed hemorrhage and urinoma formation, respectively.

Results

The postoperative pathological diagnoses were schwannoma in 3 patients and ganglioneuroblastoma in 1 patient. All patients were well with no signs of peripheral neuropathy or radiculopathy, and CT and/or ¹⁸F-FDG PET/CT performed during follow-up indicated no evidence of disease.

Conclusions

Obtaining extensive preoperative knowledge of the source neural and vascular anatomy of the tumor is important for the surgical planning of laparoscopic resection of RNT. When a great deal of care is taken to divide the tumor and the source nerves and vital vessels, safe execution of RNT can be achieved for minimal postoperative mortality and morbidity.Key Words: Laparoscopy, Retroperitoneal neural tumor, Schwannoma, Ganglioneuroblastoma     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

Adrenalectomy by Retroperitoneal Laparoendoscopic Single Site Surgery

Background:

Laparoscopic adrenalectomy is the current standard for treatment of benign adrenal disease. To reduce the invasiveness of surgery, new techniques have been recently proposed, such as mini-laparoscopy, natural orifice transluminal endoscopic surgery, and laparoendoscopic single site surgery (LESS). Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports.

Case Report:

A 52-year-old female patient with an incidental finding of a 3-cm mass in the left adrenal was referred to us. Preoperative blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid were normal. She underwent an adrenalectomy by retroperitoneal LESS using conventional instruments and ports. Operative time and estimated blood loss were 82 minutes and <50cc, respectively. She was discharged 12 hours after surgery. No intra- or postoperative complications occurred. Pathological analysis of the specimen identified an adrenal cortical adenoma.

Conclusion:

Adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments is feasible. Further studies must be performed to evaluate safety, indications and benefits of this approach.     

Single-port transumbilical laparoscopic-assisted adnexal surgery

Objectives:

To evaluate the efficiency and feasibility of single-port access transumbilical laparoscopic-assisted surgery in patients with large (>8cm) adnexal tumors and to present our initial experience.

Methods:

Twenty-two patients with presumably benign adnexal tumors who have undergone single-port access transumbilical laparoscopic-assisted surgery were enrolled. The procedure was performed using the method of exteriorization and extracorporeal surgery of adnexal tumors outside the abdominal cavity under laparoscopic guidance with preservation of as much ovarian tissue as possible. In each case, a homemade single-port device was inserted into the abdomen through a 2-cm umbilical incision. The clinical characteristics and operative outcomes of these patients were reviewed.

Results:

Twenty of 22 cases were completed successfully. The one failed case required an additional trocar for adequate adhesiolysis, and the other case needed intraperitoneal drainage. The median operating time was 50 minutes (range, 35 to 120), and the estimated blood loss was 38mL (range, 10 to 300). Cyst rupture occurred in 2 cases, but there were no major postoperative complications.

Conclusion:

Single-port access transumbilical laparoscopic-assisted surgery for benign and relatively large adnexal tumors is feasible and could be an alternative to convention open laparotomy or laparoscopic surgery.