Background

Adrenal incidentalomas are relatively common, with some imaging series pointing to 5% incidence. Cross-sectional abdominal imaging is the cornerstone for adrenal evaluation and commonly provide information to guide management alongside the metabolic study. Among other indications, lipid poor adrenal masses above 4 cm should be managed with surgical excision. Adrenalectomy is a challenging procedure, particularly on the right side. We present a case of a robotic-assisted laparoscopic right adrenalectomy.

Case Presentation

Female patient, 62 years old, smoker (2-3 cig/day), with a past medical history of dyslipidemia, medicated with atorvastatin + ezetimibe. She had history of hysterectomy.  The patient was referred to our clinic after a incidental finding of a 75 mm right adrenal mass in an abdominal ultrasound. She was asymptomatic. Contrast-enhanced CT showed: “…heterogenous lesion in the right adrenal with 6,5x5,7 cm, compressing adjacent structures but without signs of contiguous invasion…” Metabolic study was negative.

The patient was proposed for a transperitoneal robotic-assisted laparoscopic excision of right adrenal gland. The patient was positioned in left side decubitus. The first 3 ports were placed in the midclavicular line. The fourth port was placed more lateral in the direction of the iliac crest. The assistant port was placed medial to the midclavicular line, close to the umbilicus. After mobilization of the ascending colon, dissection of the superior pole of the right kidney was performed. The right adrenal was freed from the kidney and vena cava. Right adrenal vein was identified and ligated. The gland was completely removed. There were no intraoperative complications.  Surgical time was 1h. Estimated blood loss was 150 mL. Patient admission time was 2 days.  Final histology revealed adrenal adenoma, with fibrosis, calcifications and areas of myelolipoma.

Conclusion

Robotic excision of the right adrenal gland is safe and feasible. Robotic approach may be particularly useful in very large tumors (> 6 cm) without contiguous invasion of adjacent structures. It allows delicate dissection in otherwise difficult surgical fields and my replace the standard open approach in the future.