Bilateral robotic transabdominal adrenalectomy in a patient with intestinal malrotation.

Bilateral adrenalectomy is the preferred surgical approach for patients with failed treatments for pituitary-based Cushing's syndrome. Intestinal malrotation (IM) is a rare congenital anatomic variant that rarely affects adults. The abnormal abdominal anatomy is concerning to surgeons planning elective procedures in such patients. Here, we describe a bilateral robotic transabdominal adrenalectomy (RTA) in a patient with IM. A 29-year-old female presented with refractory pituitary-based Cushing's syndrome and was found to have IM on preoperative CT scan. The RTA was performed using one 10-12 mm camera trocar, two 8 mm robotic trocars per side and two midline 5 mm assistant ports. The 8 mm robotic cardiere forceps and the 8 mm robotic cautery hook were used on the left and right ports, respectively. Total operation time was 165 min (62 min on the right, 93 min on the left and 21 min for re-positioning). Total console time was 114 min (45 min on the right and 69 min on the left). Blood loss was minimal and there were no complications. She was discharged on post-operative day one. Anatomic variations were noted and the procedure modified. To our knowledge, this is the first reported case of bilateral RTA in a patient with IM. Surgeons should always review the anatomy on preoperative imaging. During the procedure, care should be taken to avoid damage to the multiple loops of small bowel located in the right upper quadrant. On the left side, the colonic splenic flexure is not encountered making access to the underlying left adrenal and kidney easier. The vascular anatomy was normal.