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INDICATIONS

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The presence of cortical or medullary tumors of a benign nature is a well-established indication for unilateral laparoscopic adrenalectomy. These tumors may be functional and produce cortisol, aldosterone, catecholamines, and rarely testosterone and other sex hormones. In many cases the tumors are nonfunctional and are removed because of the concern for cancer. In these situations the adrenal mass is frequently found during abdominal imaging done for unrelated indications. These so-named adrenal “incidentalomas” should generally be removed if they have a cross-sectional diameter 4 cm or greater or if they are proven to be functional. Patients with nonfunctional adrenal masses less than 4 cm should be followed with periodic imaging to monitor changes in the size of the mass. A benign adenoma on CT is typically a homogeneous mass with a low attenuation value (less than 10 HU on a noncontrast image or a greater than 50% washout on an adrenal protocol CT). It is recommended that patients with an incidentaloma should have a 1-mg dexamethasone suppression test and a measurement of plasma-free metanephrines. In addition, patients with hypertension should have determinations of serum potassium and plasma aldosterone concentrations to plasma renin activity for an activity ratio. Surgery is considered in all patients with functional adrenal cortical tumors. All patients with biochemical evidence of pheochromocytoma should undergo surgery except in rare instances. Although size is not an absolute contraindication to laparoscopic adrenalectomy, the procedure may be difficult on lesions greater than 10 cm. Open adrenalectomy with en bloc excision is the mainstay for primary and recurrent adrenocortical carcinoma due to the lack of effective adjuvant therapy and the difficulty of maintaining oncologic principles with laparoscopy.

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PREOPERATIVE PREPARATION

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The most important preoperative procedure is to establish a firm diagnosis. Accordingly, the reader should refer to current texts on diagnostic endocrinology for the required procedures. When adrenalectomy is decided upon, the surgeon should investigate and, if possible, correct many of the secondary systemic and metabolic effects that are the direct result of the altered functional activity of the adrenal. The management of the hypertension and its cardiovascular sequelae is the major problem with pheochromocytomas. Preoperative treatment with an alpha-receptor antagonist such as phenoxybenzamine hydrochloride or doxazosin (Cardura) and volume expansion is necessary in patients with pheochromocytoma in order to control the associated hypertension. This may take 2 weeks or more. Beta-blockers are reserved for patients with tachycardia or cardiac arrhythmias. Problems associated with hypercortisolism have been reviewed in the section on bilateral adrenalectomy.

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ANESTHESIA

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Preoperative consultation and communication among endocrinologist, surgeon, and anesthesiologist are necessary. A type and screen is acceptable for small tumors. Autologous donation or type and cross to ensure the availability of blood products is recommended for tumors greater than 6 cm and for a right-sided tumor due to its proximity to the inferior vena cava. General anesthesia with endotracheal intubation is preferred in all cases. A catheter ...

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