Only a few percent of pediatric adrenal lesions are benign. Adrenal tumors include those of neural and cortical origin. Although most neuroblastomas present as abdominal masses, pheochromocytomas and cortical tumors usually present with endocrine dysfunction. Although imaging may not be able to differentiate benign lesions from malignant tumors, or whether they arise in the adrenal medulla or cortex, imaging is useful in determining the extent of the lesion and its relation to surrounding anatomic structures, particularly to vessels. The most common pediatric adrenal tumor is neuroblastoma; this type of adrenal tumor is the most common extra cranial solid tumor in children.

In recent years, adrenal surgery has developed significantly because of progress in diagnostic tools, the growth of endocrinologic knowledge, and the advent of minimally invasive techniques. Because of their small size and their retroperitoneal location, the adrenal glands are suitable for laparoscopic excision [1,2].

The transperitoneal lateral approach has shown considerable benefits, as it provides a good view of the entire abdominal cavity, with excellent exposure of both adrenal gland and the surrounding structures[3].  In this manner, the surgeon has a large working space and can easily explore, detect, and resect all suspect lymph nodes and eventual second lesions [4].

In Left Adrenalectomy A plane along the anterior surface of the kidney, lateral and dorsal to the spleen and tail of pancreas, is established, and the splenocolic and spleen’s suspensory ligaments are divided to expose the adrenal gland. The dissection proceeded along the anterior surface of the kidney and adrenal gland until the inferior and medial border. Afterward, the splenic vein is identified and followed to identify the left renal vein, the left adrenal vein, and the left adrenal artery. The main adrenal vessels are isolated and sectioned with a vessel-sealing device. The dissection proceeded in a superior and lateral direction until the complete mobilization of the adrenal gland. The specimen is removed intact within an endosurgical bag, through a periumbilical port, enlarged when necessary. The surgery finished as on the right side. An abdominal drain is placed when necessary.

Some studies have compared the laparoscopic and open procedures and observed that the time to resumption of diet, the time to return of bowel function, and the length of hospital stay were shorter in the laparoscopic group, allowing postoperative chemotherapy to be started at the earliest time [5,6]. Additional advantages demonstrated were a lower morbidity rate, easier pain control, greater mobility after surgery, and notably better cosmetic results [5].

References:

1. Nerli RB, Reddy MN, Guntaka A, et al. Laparoscopic adrenalectomy for adrenal masses in children. J Pediatr Urol. 2011; 7(2):182–186.
2. Lopes RI, De´nes FT, Bissoli J, et al. Laparoscopic adrenalectomy in children. J Pediatr Urol. 2012;8(4):379 –385.
3. Heloury Y, Muthucumaru M, Panabokke G, et al. Minimally invasive adrenalectomy in children. J Pediatr Surg. 2012;47(2):415–421.
4. De Lagausie P, Berrebi D, Michon J, et al. Laparoscopic adrenal surgery for neuroblastomas in children. J Urol. 2003; 170(3):932–935.
5. Stanford A, Upperman JS, Nguyen N, et al. Surgical management of open vs. laparoscopic adrenalectomy: outcome analysis. J Pediatr Surg. 2002;37:1027–1029
6. Kelleher CM, Smithson L, Nguyen LL, et al. Clinical outcomes in children with adrenal neuroblastoma undergoing open versus laparoscopic adrenalectomy. J Pediatr Surg. 2013;48(8):1727–1732.