A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy

A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy Ali Taghi, Fares Issa, Ahmad Alhamid, Aya Alayyoubi, Mohammad Atia, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7558636/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted 16 You are reading this latest preprint version Abstract Background Adrenal haemangiomas are rare, usually benign vascular growths that tend to be small, found by chance, and easily forgotten. But in rare cases, they can behave more like malignant retroperitoneal masses disrupting normal anatomy and making both diagnosis and surgery a real challenge. Tumours weighing more than 20 kg. (That’s almost unheard of) Case presentation A 67 years old woman presented with six months of progressive abdominal distension on a four years background of intermittent left loin pain. Her medical history include hypertension, type 2 diabetes, atrial fibrillation and heart failure. CT showed a massive retroperitoneal mass 22.3×20.9×24.0 cm extending from diaphragm to pelvis. It was pressing on the bowels, both kidneys, and even the great vessels. It looked like it might be coming from the adrenal gland. After optimisation for anaemia (Hb 9 g/dL) and hypothyroidism (levothyroxine 100 µg), and per‑protocol anticoagulation management, she underwent midline laparotomy. The tumour, densely adherent to aorta, inferior vena cava and ureter, was removed en‑bloc using meticulous dissection and LigaSure. Concomitant umbilical hernia was repaired with a 30×30 cm pre‑peritoneal polypropylene underlay mesh (5 cm overlap). The tumour weighed 20.1 kg. Histology showed adrenal cavernous haemangioma with intact margins. Recovery was uncomplicated. She is well at > 2 months follow‑up. Conclusions This case really highlights how tricky it can be to diagnose and manage these giant adrenal vascular tumours. Despite their size and appearance on imaging, which can mimic malignancy, they are often benign. The key to a good outcome lies in solid pre-operative optimisation and slow, careful dissection around the major vessels. When done right, full excision is curative. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Adrenal haemangiomas are rare and usually < 5 cm and discovered incidentally. When large in size, they can mimic malignant retroperitoneal tumours and displace nearby organs, and make it tough to pinpoint their origin or decide on surgical approach. Most of what we know comes from isolated case reports and a few scattered reviews, which repeatedly highlight the same themes of how rare they are, how non-specific the imaging is, and how often the diagnosis is only made after surgery. 1 , 3 , 6 , 8 Case presentation Patient: 67 years old female with HTN, T2DM, atrial fibrillation and heart failure. Medications: amiodarone, furosemide, rivaroxaban, SGLT2 inhibitor (gliflozin), newly started levothyroxine 100 µg for hypothyroidism. Symptoms: 4 years intermittent left loin pain, rapid abdominal enlargement with sharp pain over 6 months. Examination: markedly distended abdomen with a palpable mass > 20 cm centred between umbilicus and left iliac fossa, clear displacement of abdominal and pelvic viscera. Optimisation: anaemia (Hb 9 g/dL, O+), hypothyroidism treated, surgery deferred 3 weeks. The patient received 4 units PRBC and 4 units plasma pre‑operatively. Investigations CT imaging (chest, abdomen, pelvis with contrast in arterial and venous phases) revealed a 22.3 × 20.9 × 24.0 cm retroperitoneal mass, stretching from diaphragm to pelvis. It displaced both kidneys and the bowel anteriorly, with the pancreas, aorta, and inferior vena cava also pushed forward. The mass was heterogeneous, with coarse calcifications measuring 2–6 cm, and there was minor perisplenic fluid. The left adrenal gland appeared to be the origin. There were no enlarged lymph nodes or lung lesions. Differentials included: Retroperitoneal sarcoma Adrenal cortical carcinoma Myelolipoma Pheochromocytoma/paraganglioma Large haemangioma or vascular lesion Less likely: lymphoma or GIST Labs showed treated hypothyroidism and anaemia. Other values were within normal range. Treatment Anaesthesia: general (halothane, propofol, Atracurium, Fentanyl). Approach: long midline laparotomy above and below the umbilicus. Intra‑operative findings: giant, encapsulated retroperitoneal mass with dense adhesions to abdominal aorta, inferior vena cava and left ureter displacement of left kidney, pancreas and spleen. No peritoneal disease. Procedure: careful avascular‑plane dissection with LigaSure, protection of ureter and great vessels, and en‑bloc tumour resection with the capsule intact. Concomitant umbilical hernia repair using 30×30 cm polypropylene underlay (pre‑peritoneal) mesh with 5 cm overlap. Abdominal cavity irrigated with normal saline, closed‑suction (Redon) drain placed. Outcome and follow‑up Immediate course: haemodynamically stable, no intra or post-operative complications. Post-operative regimen included IV fluids (saline/dextrose), levofloxacin 500 mg, metronidazole 500 mg, hydrocortisone, omeprazole 40 mg, furosemide, paracetamol, calcium, plasma as indicated, pethidine PRN, and enoxaparin 40 mg for VTE prophylaxis. Pathology: cavernous haemangioma (adrenal haemangioma), endothelial-lined cavernous vascular spaces, margins intact (R0), no atypia. Specimen weight: 20.1 kg. Follow-up: >2 months, asymptomatic, wounds healed, no recurrence on surveillance. Plan: interval clinical review and imaging. Discussion When adrenal haemangiomas reach this kind of size, they can easily be mistaken for malignancy both on imaging and intraoperatively. Nevertheless, certain imaging clues can offer hints. Anterior displacement of kidneys and bowel, and forward shift of major vessels, can suggest adrenal origin. Some reports describe enhancement patterns like peripheral to centripetal filling, T2 hyperintensity, or phlebolith-like calcifications, but none of these are definitive.³ , ⁶,⁸ From a surgical standpoint, planning is critical. You need early identification of the ureter and major vessels, avoid breaching the capsule, and be prepared for multivisceral resection if needed to achieve clear margins. LigaSure helped tremendously with haemostasis. Despite its threatening appearance, adrenal cavernous haemangioma is benign and complete removal is curative. 1,3 Patient’s perspective My belly kept growing and the pain worsened. After the operation, the pressure disappeared and I can move comfortably again Learning points Giant adrenal haemangioma can mimic malignant retroperitoneal tumours; evaluate origin using organ/vessel displacement. In masses > 20 cm, plan exposure around aorta/IVC/renal pedicle and ureter; preserve capsule and use meticulous haemostasis. Extreme size does not imply malignancy histology is definitive. Optimising thyroid status, anaemia and anticoagulation can be pivotal to safe timing and recovery. Author (year) Side Size (cm) Weight (kg) Presentation Operation Histology Outcome/Follow‑up Ref Present case (2025) Left 24 (CT) 20.1 Loin pain → distension Open en‑bloc mesh hernia repair Cavernous haemangioma > 2 mo, well, no recurrence Alhajri et al. (2011) Left 15×14×18 NR Flank pain Open adrenalectomy Infarcted cavernous haemangioma Uneventful 1 Tarchouli et al. (2015) Right 35×26×22 NR Pain, distension Open resection Cavernous haemangioma Good outcome 2 Feo et al. (2018) Left 8–9 NR Incidental Open adrenalectomy Cavernous haemangioma No recurrence at 53 mo 3 Antar et al. (2023) Left 4.4 NR Incidental with other findings Adrenalectomy Cavernous haemangioma Good outcome 4 Tan et al. (2024) Right 9.5 NR Incidental Adrenalectomy Cavernous haemangioma Good outcome 5 Concomitant abdominal wall defects (e.g., umbilical hernia) can be repaired during index operation when contamination risk is low. Comparative summary of selected adrenal cavernous haemangioma cases NR = not reported. Sizes/clinical details are as reported in the cited articles. Declarations Ethics and Consent Written informed consent was obtained from the patient for publication of this case report. Ethics committee approval was not required for this single patient case report in accordance with institutional policy. Clinical trial number: not applicable. Funding: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector Author Contribution Initials: AT (Ali Taghi), FI (Fares Issa), AAH (Ahmad Alhamid), AAy (Aya Alayyoubi), MA (Mohammad Atia), AG (Areen Glore), BB (Baraa Basbous).Author contributions:AT conceived the study, supervised the project, and is the guarantor. AG served as the operating surgeon, led preoperative planning, performed the operation, and contributed to postoperative management, including providing operative images and annotations. AAH, MA, and BB contributed to perioperative clinical management and data acquisition (clinical records, imaging, and operative details). AAy obtained written informed consent and curated/verified the dataset. AT drafted the manuscript. FI and AAy contributed substantially to the Background and Discussion sections and also conducted the literature review and prepared the figures/illustrations. MA and BB provided critical revision of the manuscript for important intellectual content. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgement This work was conducted under the guidance and framework of the SRs organization , and we are grateful for their contribution to the coordination and resources that helped make this study possible. References Alhajri K, Alhasan I, Alzerwi N, Abudaff N. Adrenal haemangioma. BMJ Case Rep. 2011;2011:bcr1220103604. 10.1136/bcr.12.2010.3604 . Tarchouli M, Boudhas A, Ratbi MB, Essarghini M, Njoumi N, Sair K, et al. Giant adrenal hemangioma: unusual cause of huge abdominal mass. Can Urol Assoc J. 2015;9(11–12):E834–6. 10.5489/cuaj.2967 . Feo CV, De Troia A, Pedriali M, Sala S, Zatelli MC, Carcoforo P, et al. Adrenal cavernous hemangioma: a case report. BMC Surg. 2018;18:103. 10.1186/s12893-018-0429-9 . Antar RM, Farag CM, Youssef K, Xu V, Drouaud A, Panitch N, et al. Rare adrenal cavernous hemangioma: a case report highlighting diagnostic challenges. Front Surg. 2023;10:1293925. 10.3389/fsurg.2023.1293925 . Tan T, Botelho J, Hawthorne GC, McElveen E. An imaging and diagnostic conundrum—the adrenal haemangioma. J Surg Case Rep. 2024;2024(5):rjae286. 10.1093/jscr/rjae286 . Hashimoto A, Yoshino H, Yoshikawa F, Kumashiro N, Ando Y, Yamabe F, et al. Giant cavernous hemangioma of the adrenal gland in an elderly patient. Intern Med. 2018;57(9):1317–9. 10.2169/internalmedicine.9711-17 . Toklu A, Mesa H, Collins K. Incidental adrenal hemangioma clinically suspicious for malignancy: diagnostic considerations and review of the literature. Int J Clin Exp Pathol. 2022;15(11):444–58. PMCID: PMC9729942. Testini V, Stabile Ianora AA, Angelelli G, et al. Imaging findings and 4 years follow-up of adrenal cavernous hemangioma: a case report. Egypt J Radiol Nucl Med. 2021;52:225. 10.1186/s43055-021-00552-8 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 06 Nov, 2025 Reviews received at journal 06 Nov, 2025 Reviews received at journal 06 Nov, 2025 Reviews received at journal 04 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviews received at journal 31 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers agreed at journal 29 Oct, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviewers agreed at journal 23 Oct, 2025 Reviewers invited by journal 23 Oct, 2025 Editor invited by journal 15 Sep, 2025 Editor assigned by journal 13 Sep, 2025 Submission checks completed at journal 13 Sep, 2025 First submitted to journal 07 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":1125079,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal CT, arterial phase: retroperitoneal mass, anterior displacement of bowel (and both kidneys, aorta/IVC anterior; coarse calcifications)\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/0e09bf41321b0d269ac046be.jpg"},{"id":95224501,"identity":"aa3e4a5c-0d6f-48db-9109-9fb06a51d0ef","added_by":"auto","created_at":"2025-11-05 16:23:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162800,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal CT, venous phase: relation to left adrenal region and pancreas, heterogeneous enhancement.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/6c2da4c20988e96dc0c56d86.jpg"},{"id":95087961,"identity":"5f0e38b1-3f53-422f-bf8b-ed16ecf1638d","added_by":"auto","created_at":"2025-11-04 07:43:56","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1321763,"visible":true,"origin":"","legend":"\u003cp\u003ePre‑operative theatre photograph: marked abdominal distension.\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/fc5f44171f96d93001e87f5d.jpg"},{"id":95087934,"identity":"1335c4ea-ef6a-4f05-be15-fff37275d727","added_by":"auto","created_at":"2025-11-04 07:43:54","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":82657,"visible":true,"origin":"","legend":"\u003cp\u003eIntra‑operative view: encapsulated mass occupying left retroperitoneum prior to mobilisation.\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/3e473f0eb48d0a63b1685c32.jpg"},{"id":95087937,"identity":"74d60dfc-1554-47cc-8ac0-e8ef46c6e346","added_by":"auto","created_at":"2025-11-04 07:43:55","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2204011,"visible":true,"origin":"","legend":"\u003cp\u003eGross specimen: 20.1‑kg tumour with intact capsule.\u003c/p\u003e","description":"","filename":"figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/c5a61084691164d7a4c04242.jpg"},{"id":95087942,"identity":"efdf2c46-2354-4a20-b2f5-971a95819b6c","added_by":"auto","created_at":"2025-11-04 07:43:55","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":226876,"visible":true,"origin":"","legend":"\u003cp\u003eCut surface: spongy, blood‑filled spaces consistent with cavernous haemangioma.\u003c/p\u003e","description":"","filename":"figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/e0833a794836a23201305801.jpg"},{"id":95087941,"identity":"09c52186-c854-4958-8fe2-22c8c31fde51","added_by":"auto","created_at":"2025-11-04 07:43:55","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":66462,"visible":true,"origin":"","legend":"\u003cp\u003eHistology: cavernous vascular channels within fibrous stroma.\u003c/p\u003e","description":"","filename":"figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/b0bc64c5f84ecb1ea94eade9.jpg"},{"id":95224149,"identity":"4adbdb43-0683-488f-b588-7ad7b4634f0f","added_by":"auto","created_at":"2025-11-05 16:23:24","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":88428,"visible":true,"origin":"","legend":"\u003cp\u003eHistology: endothelial‑lined dilated spaces, no atypia.\u003c/p\u003e","description":"","filename":"figure8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/6591d15905242c250eafadd6.jpg"},{"id":102234259,"identity":"eeb7216d-bff0-42a0-b3aa-d43817b662f7","added_by":"auto","created_at":"2026-02-09 16:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5798572,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7558636/v1/f11394b2-c0f4-47bf-a6e3-762e9e894302.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy","fulltext":[{"header":"Background","content":"\u003cp\u003eAdrenal haemangiomas are rare and usually\u0026thinsp;\u0026lt;\u0026thinsp;5 cm and discovered incidentally. When large in size, they can mimic malignant retroperitoneal tumours and displace nearby organs, and make it tough to pinpoint their origin or decide on surgical approach. Most of what we know comes from isolated case reports and a few scattered reviews, which repeatedly highlight the same themes of how rare they are, how non-specific the imaging is, and how often the diagnosis is only made after surgery.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003ePatient: 67 years old female with HTN, T2DM, atrial fibrillation and heart failure. Medications: amiodarone, furosemide, rivaroxaban, SGLT2 inhibitor (gliflozin), newly started levothyroxine 100 \u0026micro;g for hypothyroidism. Symptoms: 4 years intermittent left loin pain, rapid abdominal enlargement with sharp pain over 6 months. Examination: markedly distended abdomen with a palpable mass\u0026thinsp;\u0026gt;\u0026thinsp;20 cm centred between umbilicus and left iliac fossa, clear displacement of abdominal and pelvic viscera. Optimisation: anaemia (Hb 9 g/dL, O+), hypothyroidism treated, surgery deferred 3 weeks. The patient received 4 units PRBC and 4 units plasma pre‑operatively.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInvestigations\u003c/h2\u003e\u003cp\u003eCT imaging (chest, abdomen, pelvis with contrast in arterial and venous phases) revealed a 22.3 \u0026times; 20.9 \u0026times; 24.0 cm retroperitoneal mass, stretching from diaphragm to pelvis. It displaced both kidneys and the bowel anteriorly, with the pancreas, aorta, and inferior vena cava also pushed forward. The mass was heterogeneous, with coarse calcifications measuring 2\u0026ndash;6 cm, and there was minor perisplenic fluid. The left adrenal gland appeared to be the origin.\u003c/p\u003e\u003cp\u003eThere were no enlarged lymph nodes or lung lesions.\u003c/p\u003e\u003cp\u003eDifferentials included:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eRetroperitoneal sarcoma\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAdrenal cortical carcinoma\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMyelolipoma\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePheochromocytoma/paraganglioma\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLarge haemangioma or vascular lesion\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLess likely: lymphoma or GIST\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eLabs showed treated hypothyroidism and anaemia. Other values were within normal range.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003eAnaesthesia: general (halothane, propofol, Atracurium, Fentanyl). Approach: long midline laparotomy above and below the umbilicus. Intra‑operative findings: giant, encapsulated retroperitoneal mass with dense adhesions to abdominal aorta, inferior vena cava and left ureter displacement of left kidney, pancreas and spleen. No peritoneal disease. Procedure: careful avascular‑plane dissection with LigaSure, protection of ureter and great vessels, and en‑bloc tumour resection with the capsule intact. Concomitant umbilical hernia repair using 30\u0026times;30 cm polypropylene underlay (pre‑peritoneal) mesh with 5 cm overlap. Abdominal cavity irrigated with normal saline, closed‑suction (Redon) drain placed.\u003c/p\u003e\n\u003ch3\u003eOutcome and follow‑up\u003c/h3\u003e\n\u003cp\u003eImmediate course: haemodynamically stable, no intra or post-operative complications. Post-operative regimen included IV fluids (saline/dextrose), levofloxacin 500 mg, metronidazole 500 mg, hydrocortisone, omeprazole 40 mg, furosemide, paracetamol, calcium, plasma as indicated, pethidine PRN, and enoxaparin 40 mg for VTE prophylaxis. Pathology: cavernous haemangioma (adrenal haemangioma), endothelial-lined cavernous vascular spaces, margins intact (R0), no atypia. Specimen weight: 20.1 kg. Follow-up: \u0026gt;2 months, asymptomatic, wounds healed, no recurrence on surveillance. Plan: interval clinical review and imaging.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhen adrenal haemangiomas reach this kind of size, they can easily be mistaken for malignancy both on imaging and intraoperatively. Nevertheless, certain imaging clues can offer hints. Anterior displacement of kidneys and bowel, and forward shift of major vessels, can suggest adrenal origin. Some reports describe enhancement patterns like peripheral to centripetal filling, T2 hyperintensity, or phlebolith-like calcifications, but none of these are definitive.\u0026sup3;\u003csup\u003e,\u003c/sup\u003e⁶,⁸\u003c/p\u003e\u003cp\u003eFrom a surgical standpoint, planning is critical. You need early identification of the ureter and major vessels, avoid breaching the capsule, and be prepared for multivisceral resection if needed to achieve clear margins. LigaSure helped tremendously with haemostasis. Despite its threatening appearance, adrenal cavernous haemangioma is benign and complete removal is curative. \u003csup\u003e1,3\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003ePatient’s perspective\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMy belly kept growing and the pain worsened. After the operation, the pressure disappeared and I can move comfortably again\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eLearning points\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eGiant adrenal haemangioma can mimic malignant retroperitoneal tumours; evaluate origin using organ/vessel displacement.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn masses\u0026thinsp;\u0026gt;\u0026thinsp;20 cm, plan exposure around aorta/IVC/renal pedicle and ureter; preserve capsule and use meticulous haemostasis.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExtreme size does not imply malignancy histology is definitive.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOptimising thyroid status, anaemia and anticoagulation can be pivotal to safe timing and recovery.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor (year)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSide\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSize (cm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOperation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHistology\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOutcome/Follow‑up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresent case (2025)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (CT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLoin pain \u0026rarr; distension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOpen en‑bloc mesh hernia repair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 mo, well, no recurrence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlhajri et al. (2011)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u0026times;14\u0026times;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFlank pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOpen adrenalectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eInfarcted cavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUneventful\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTarchouli et al. (2015)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u0026times;26\u0026times;22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePain, distension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOpen resection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeo et al. (2018)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncidental\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOpen adrenalectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo recurrence at 53 mo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAntar et al. (2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncidental with other findings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdrenalectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTan et al. (2024)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncidental\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdrenalectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCavernous haemangioma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eConcomitant abdominal wall defects (e.g., umbilical hernia) can be repaired during index operation when contamination risk is low.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eComparative summary of selected adrenal cavernous haemangioma cases\u003c/h3\u003e\n\u003cp\u003eNR\u0026thinsp;=\u0026thinsp;not reported. Sizes/clinical details are as reported in the cited articles.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eEthics and Consent\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report. Ethics committee approval was not required for this single patient case report in accordance with institutional policy.\u003c/p\u003e\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003ethis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eInitials: AT (Ali Taghi), FI (Fares Issa), AAH (Ahmad Alhamid), AAy (Aya Alayyoubi), MA (Mohammad Atia), AG (Areen Glore), BB (Baraa Basbous).Author contributions:AT conceived the study, supervised the project, and is the guarantor. AG served as the operating surgeon, led preoperative planning, performed the operation, and contributed to postoperative management, including providing operative images and annotations. AAH, MA, and BB contributed to perioperative clinical management and data acquisition (clinical records, imaging, and operative details). AAy obtained written informed consent and curated/verified the dataset. AT drafted the manuscript. FI and AAy contributed substantially to the Background and Discussion sections and also conducted the literature review and prepared the figures/illustrations. MA and BB provided critical revision of the manuscript for important intellectual content. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis work was conducted under the guidance and framework of the SRs organization , and we are grateful for their contribution to the coordination and resources that helped make this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlhajri K, Alhasan I, Alzerwi N, Abudaff N. Adrenal haemangioma. BMJ Case Rep. 2011;2011:bcr1220103604. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bcr.12.2010.3604\u003c/span\u003e\u003cspan address=\"10.1136/bcr.12.2010.3604\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTarchouli M, Boudhas A, Ratbi MB, Essarghini M, Njoumi N, Sair K, et al. Giant adrenal hemangioma: unusual cause of huge abdominal mass. Can Urol Assoc J. 2015;9(11\u0026ndash;12):E834\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5489/cuaj.2967\u003c/span\u003e\u003cspan address=\"10.5489/cuaj.2967\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeo CV, De Troia A, Pedriali M, Sala S, Zatelli MC, Carcoforo P, et al. Adrenal cavernous hemangioma: a case report. BMC Surg. 2018;18:103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12893-018-0429-9\u003c/span\u003e\u003cspan address=\"10.1186/s12893-018-0429-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAntar RM, Farag CM, Youssef K, Xu V, Drouaud A, Panitch N, et al. Rare adrenal cavernous hemangioma: a case report highlighting diagnostic challenges. Front Surg. 2023;10:1293925. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2023.1293925\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2023.1293925\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan T, Botelho J, Hawthorne GC, McElveen E. An imaging and diagnostic conundrum\u0026mdash;the adrenal haemangioma. J Surg Case Rep. 2024;2024(5):rjae286. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jscr/rjae286\u003c/span\u003e\u003cspan address=\"10.1093/jscr/rjae286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHashimoto A, Yoshino H, Yoshikawa F, Kumashiro N, Ando Y, Yamabe F, et al. Giant cavernous hemangioma of the adrenal gland in an elderly patient. Intern Med. 2018;57(9):1317\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2169/internalmedicine.9711-17\u003c/span\u003e\u003cspan address=\"10.2169/internalmedicine.9711-17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eToklu A, Mesa H, Collins K. Incidental adrenal hemangioma clinically suspicious for malignancy: diagnostic considerations and review of the literature. Int J Clin Exp Pathol. 2022;15(11):444\u0026ndash;58. PMCID: PMC9729942.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTestini V, Stabile Ianora AA, Angelelli G, et al. Imaging findings and 4 years follow-up of adrenal cavernous hemangioma: a case report. Egypt J Radiol Nucl Med. 2021;52:225. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s43055-021-00552-8\u003c/span\u003e\u003cspan address=\"10.1186/s43055-021-00552-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7558636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7558636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAdrenal haemangiomas are rare, usually benign vascular growths that tend to be small, found by chance, and easily forgotten. But in rare cases, they can behave more like malignant retroperitoneal masses disrupting normal anatomy and making both diagnosis and surgery a real challenge. Tumours weighing more than 20 kg. (That\u0026rsquo;s almost unheard of)\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e\u003cp\u003eA 67 years old woman presented with six months of progressive abdominal distension on a four years background of intermittent left loin pain. Her medical history include hypertension, type 2 diabetes, atrial fibrillation and heart failure. CT showed a massive retroperitoneal mass 22.3\u0026times;20.9\u0026times;24.0 cm extending from diaphragm to pelvis. It was pressing on the bowels, both kidneys, and even the great vessels. It looked like it might be coming from the adrenal gland. After optimisation for anaemia (Hb 9 g/dL) and hypothyroidism (levothyroxine 100 \u0026micro;g), and per‑protocol anticoagulation management, she underwent midline laparotomy. The tumour, densely adherent to aorta, inferior vena cava and ureter, was removed en‑bloc using meticulous dissection and LigaSure. Concomitant umbilical hernia was repaired with a 30\u0026times;30 cm pre‑peritoneal polypropylene underlay mesh (5 cm overlap). The tumour weighed 20.1 kg. Histology showed adrenal cavernous haemangioma with intact margins. Recovery was uncomplicated. She is well at \u0026gt;\u0026thinsp;2 months follow‑up.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis case really highlights how tricky it can be to diagnose and manage these giant adrenal vascular tumours. Despite their size and appearance on imaging, which can mimic malignancy, they are often benign. The key to a good outcome lies in solid pre-operative optimisation and slow, careful dissection around the major vessels. When done right, full excision is curative.\u003c/p\u003e","manuscriptTitle":"A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 07:43:49","doi":"10.21203/rs.3.rs-7558636/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-06T09:18:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T07:51:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T05:37:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-04T16:20:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T18:44:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T10:43:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277334563868432078244541413498364202456","date":"2025-10-29T17:05:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275997482906017844170036608923239037339","date":"2025-10-29T10:37:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186671893634030822858336115144691393568","date":"2025-10-28T18:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137278203174498342707999839294123779955","date":"2025-10-28T15:42:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195088823989669546544739358602165019329","date":"2025-10-23T14:11:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-23T13:51:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-15T09:52:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-13T06:45:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-13T06:45:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-09-07T21:58:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0d8c781-814f-4e6b-b97b-e8f33325b58f","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:04:21+00:00","versionOfRecord":{"articleIdentity":"rs-7558636","link":"https://doi.org/10.1186/s12893-026-03553-4","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-02-02 15:59:12","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-11-04 07:43:49","video":"","vorDoi":"10.1186/s12893-026-03553-4","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03553-4","workflowStages":[]},"version":"v1","identity":"rs-7558636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7558636","identity":"rs-7558636","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}