Adrenal pseudocysts are rare, benign lesions often mistaken for hepatic pathology due to their size and location, posing diagnostic challenges.

A 50-year-old male with poorly controlled type 2 diabetes, hypertension, and a prior cerebrovascular accident presented with two months of dyspepsia and right upper quadrant discomfort. Initial ultrasound and contrast-enhanced CT (CECT) suggested a 17 x 15 cm hepatic hydatid cyst. CEMRI revealed a 17.3 x 12.6 x 15.2 cm suprarenal cyst splaying the right adrenal gland. Laboratory results (normal metanephrines, cortisol) and echocardiography (LVEF 60%) guided preoperative planning. Open right adrenalectomy was performed using a modified Makuuchi incision on 07/02/2025.

Intraoperative findings confirmed a 17 x 20 x 15 cm cyst arising from the adrenal gland, excised intact with minimal blood loss in 2.5 hours. Histopathology identified a unilocular pseudocyst with fibrocollagenous walls and calcifications, no epithelial lining or malignancy. The patient recovered uneventfully, discharged on postoperative day 5.

This case underscores CEMRI’s critical role in correcting diagnostic mimicry and the efficacy of open surgery with a Makuuchi incision for giant cysts in complex patients .