V11-09: Robotic Assisted Laparoscopic Excision of a Retroperitoneal Ganglioneuroma
Ganglioneuroma is a rare benign neoplasm of the sympathetic nervous system. Although uncommon, the diagnosis must be considered during the evaluation of an adrenal mass. Most patients are asymptomatic. We describe the case of an incidentally found ganglioneuroma in a woman. To our knowledge this is the first described case of robotic excision of a retroperitoneal ganglioneuroma. (1)_x000D_ Objective: To present a case of retroperitoneal ganglioneuroma, describe its surgical management and reviwe current literature.
Case report and literature review.
Case presentation: A 41-year-old female had an incidental retroperitoneal mass found during an urinary tract US performed for evaluating nonspecific urinary symptoms. CT scan was performed showing a 8.3 x 5.0 x 3.8 cm homogeneous retroperitoneal mass, adjacent to left kidney upper pole, with slight peripheral contrast enhancement. MRI was done to evaluate possible neural foramen invasion. Metabolic tests were performed and excluded pheochromocytoma or another secreting lesion. The patient was positioned in a 60º modified left flank position. A total of five ports were introduced transperitoneally. A 4-arm Da Vinci SI robotic surgical system was docked at a 45º angle to the operating table. Following mobilization of left colon and spleen, lesion was carefully dissected along with left adrenal gland, beginning at the left renal hilum. The most challenging part of the dissection was the medial aspect, due to close relationship of the lesion to the aorta, deepening into the interaortocava space, where care was taken not to damage superior mesenteric artery and due to presumable nervous tissue found protruding towards the spine. _x000D_ Results: Operating time was 325 minutes and blood loss was 50ml. Patient was discharged after 72 hours and there were no post-operative complications. Pathology showed ganglionic cells with neural tissue, adjacent to a normal appearance adrenal. _x000D_ Discussion: Ganglioneuromas are a slow growing rare benign tumors that originate from the neural crest and typically affect young adults, mostly (80%) being diagnosed before 40 years old. There is no incidence rate difference between genders. The most frequent location is the posterior mediastinum followed by retroperitoneum and adrenal gland topography, however it may arise from any sympathetic chain location. As in the present case, ganglioneuromas are usually found to be silent, slow growing tumors that are discovered incidentally or by mass compression effect if they become large. Ultrasound and CT imaging may suggest the diagnosis while MRI findings can be specific for Ganglioneuroma. When further diagnostic work up is needed, fine needle biopsy is an option. Although retroperitoneal ganglioneuroma is a benign lesion, it requires surgical excision for definite treatment, preferable through minimally invasive approach._x000D_
Our case shows that a robotic approach is feasible and allows for meticulous and safe dissection of vascular structures, facilitating adequate hemostasis while maintaining oncological principles.