LAUSR

chest and hip supports placed to allow the abdominal contents to hang freely. Ports were inserted at the tip of the 11th and 12th ribs and one further port medial to the 12th rib approximately a finger breath below the posterior costal margin. The retroperitoneal space was insufflated with CO2 to a pressure of 20 mmHg. The initial dissection was difficult given the extent of adipose tissue within the retroperitoneum and friability of the tissues as a result of the cortisol excess. Intraoperative ultrasound using a BK Medical 5000 (BK Medical, Peabody, Massachusetts, USA) laparoscopic probe was used to assist in identifying the adrenal lesion and relevant landmarks such as the superior pole of the kidney and adrenal vein. The identification of the tumour significantly increased the speed and confidence of the operating team and the procedure was completed successfully with no intraoperative complications. The patient had an unremarkable post-operative recovery period. The causes of Cushing’s syndrome can be divided into ACTH (Adrenocorticotropic hormone) dependent (80%) or ACTH independent (20%). ACTH-dependent causes include ACTH-secreting pituitary adenomas, ectopic secretion of ACTH by a secreting nonpituitary tumour and non-hypothalamic CRH (corticotrophin-releasing hormone) secreting tumours. ACTH-independent causes include iatrogenic causes, adrenal cortical adenomas or carcinomas, bilateral macronodular adrenal hyperplasia and primary nodular adrenocortical disease. Biochemical work-up for the suspected Cushing’s patient should commence, after a thorough history and examination ensuring to exclude glucocorticoid intake. Secondary causes of hypercortisolism include pregnancy, poorly managed diabetes, alcohol dependence and physical stress. Investigative approach is to confirm the diagnosis of Cushing’s syndrome and then differentiate between ACTH-dependent and -independent causes. Initial investigations include midnight salivary cortisol (two samples taken at different dates), 24-h urinary free cortisol and 1 mg dexamethasone suppression test. This case illustrates the value of intraoperative ultrasound during PRA in obese or Cushing’s patients, in assisting in tumour localization where a large volume of retroperitoneal fat obscures the usual anatomical landmarks. Patient consent was obtained prior to the writing of this article.