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laparoscopic adrenalectomy is emerging as a standard of care approach for extirpation of adrenal neoplasms .
albeit , due to technical constraints , this approach is seldom utilized for management of lesions with a definitive or presumed diagnosis of invasive adrenal cortical carcinoma or very large adrenal tumors .
we report a case of a large adrenal ganglioneuroma ( gn ) measuring 17  11  7.5 cm that was removed completely by the laparoscopic approach and evaluate the feasibility of this approach for managing large adrenal neoplasms .
a 33-year - old female presented to us with left flank pain and ultrasonography suggestive of left suprarenal mass .
computed tomography ( ct ) scan revealed a large left suprarenal mass which was well - marginated with homogenous low ct attenuation , non - enhancing , and free from surrounding structures [ figure 1 ] .
ct scan showing non - enhancing large left suprarenal mass patient was positioned in right lateral decubitus .
a large suprarenal mass was identified encroaching medially beyond the medial border of aorta , superiorly abutting the diaphragm , laterally extending up to the parietal wall and displacing the kidney inferiorly [ figure 2 ] .
spleenopancreatic complex was released from lateral attachments and surface of tumor using harmonic scalpel through 5 mm lateral port .
the adrenal vein was identified and control was achieved at the confluence with left renal vein . a plane of cleavage was defined between the aorta and the neoplasm and the attachments were freed along this plane .
drain was removed on the second day and the patient was sent home on the following day . on gross inspection , the specimen appeared bosselated with intact capsule measuring 17  11  7.5 cm [ figure 4 ] .
intraoperative image showing large suprarenal mass intraoperative image showing dissection of tumor using harmonic scalpel cut section of tumor showing bosselated surface with intact capsule
gn is a rare benign , slow - growing tumor that may arise anywhere along the paravertebral sympathetic plexus and occasionally from the adrenal medulla and accounts for 0 - 6% of incidentalomas .
these neoplasms are usually hormonally nave and the clinical symptoms are chiefly attributable to their size / location .
although certain radiological features like presence of discrete calcifications and a low non - enhanced t1-weighted signal with a late and gradual enhancement on dynamic magnetic resonance imaging ( mri ) may suggest gn , definitive diagnosis depends of histopathological features .
the management of adrenal gn is essentially complete surgical resection through either an open or laparoscopic approach .
this is chiefly attributable to the appealing morbidity profile and outcome obtained following this approach .
however , few authors have reported laparoscopic adrenalectomy for larger lesions without any significant morbidity .
shah et al . , reported successful laparoscopic removal of 8.5  7 cm adrenal neoplasm in a 12-year - old girl . 
 
zografos et al . , successfully resected a 13 cm gn of adrenal gland in a 23-year - old female with laparoscopic approach .
extensive experience in advanced laparoscopic techniques and reports of successful laparoscopic extirpation of large adrenal tumors motivated us to embark on this approach for definitive management in this case .
transperitoneal approach was preferred in view of the larger workable space and the procedure could be completed conveniently .
additionally , in view of nonfunctioning characteristics , no hemodynamic fluctuations were encountered during tumor manipulation at laparoscopy . to the best of our knowledge
, we are reporting the largest adrenal neoplasm which has been removed laparoscopically till date .
laparoscopic removal of large benign , nonfunctioning adrenal tumor is possible with minimal morbidity , however requires expertise in advanced laparoscopy .
laparoscopic adrenalectomy is the standard of care for management of adrenal neoplasms . 
 however , large sized adrenal lesions are considered as relative contraindication for laparoscopic extirpation 
 . we report laparoscopic excision of giant ganglioneuroma of adrenal gland in a 33-year - old female patient . 
 patient was presented with left loin pain of 2 months duration . 
 computed tomography ( ct ) scan was suggestive of non - enhancing left suprarenal mass measuring 17  10 cm . 
 preoperative endocrine evaluation ruled out functional adrenal tumor . 
 patient underwent transperitoneal excision of suprarenal mass . 
 the lesion could be completely extirpated laparoscopically . 
 duration of surgery was 250 minutes . estimated blood loss was 230 milliliters . 
 specimen was extracted through pfannenstiel incision . 
 no significant intraoperative or postoperative happenings were recorded . 
 microscopic features were suggestive of ganglioneuroma of adrenal gland .