Many of the adrenal masses encountered in children can be resected laparoscopically, including pheochromocytomas, most ganglioneuromas, and even some neuroblastomas. The size of the mass might be a limiting factor depending on the experience of the surgeon. Tumors for which spillage is potentially disastrous, such as adrenocortical carcinomas, should probably not be approached using a minimally invasive approach. In most cases, a lateral, transabdominal approach can be used for both right and left adrenal lesions. The majority of the operation can be performed using blunt dissection, dividing small vessels with the harmonic scalpel or hook electrocautery. Control of the adrenal vein can be particularly hazardous, especially on the right where it is typically very short and enters directly into the IVC. It is easily torn by overly aggressive dissection but once identified can be clipped near its origin and divided.
Newborns with incidentally identified adrenal masses have neuroblastoma or adrenal hemorrhage. These are difficult to differentiate but the distinction is usually irrelevant, because either lesion, if small, can be safely observed. Resection is rarely necessary but sometimes demanded by anxious parents. Careful surveillance with serial ultrasound appears to be safe, but should probably be done as part of a clinical trial.
Adrenal ganglioneuromas are often found incidentally in teenagers who undergo CT or MRI for unrelated symptoms or as part of a trauma evaluation. The vast majority of these lesions are benign and could theoretically be safely observed indefinitely, however because a very small percentage of these will turn out to harbor a tiny neuroblastoma (ganglioneuroblastoma) resection is usually recommended. In fact, although most “incidentalomas” in children are benign, size and imaging characteristics do not necessarily predict the likelihood of malignancy. In practice then, a pediatric surgeon is asked to resect almost every adrenal mass identified in a child beyond the newborn period. Fortunately, these lesions can almost always be removed laparoscopically.
All but the smallest adrenocortical carcinomas should be resected using an open approach through a generous incision in order to make every effort to avoid breach of the capsule and even the slightest degree of tumor spillage. These tumors are generally unresponsive to chemotherapy and therefore complete resection offers the greatest (and sometimes only) chance for cure. Spillage upstages the tumor and can significantly diminish survival. The tumor capsule is often very delicate and tears easily. A meticulous and very gentle approach is imperative. Locally invasive tumors should be resected en bloc, including portions of adjacent spleen, liver, stomach or diaphragm if necessary to achieve negative margins. All patients should undergo an extensive ipsilateral retroperitoneal lymph node dissection for staging purposes. Unlike the case with Wilms tumor, adrenocortical carcinoma with tumor thrombus extension into the IVC or atrium almost never shrinks in response to neoadjuvant chemotherapy. If, even after complete mobilization of the primary tumor, the thrombus cannot be pulled down into the infrahepatic IVC to allow placement of a vascular clamp above it, cavotomy on cardiopulmonary bypass must be used.