Operations on the adrenal glands are performed for primary hyperaldosteronism,
pheochromocytoma, hypercortisolism (Cushing disease or Cushing syndrome),
and adrenocortical carcinoma. These conditions are usually characterized
by hypersecretion of one or more of the adrenal hormones. Less commonly,
surgery may also be performed for nonfunctioning tumors or metastases.
The normal combined weight of the adrenals is 7–12 g.
The right gland lies posterior and lateral to the vena cava and superior
to the kidney (Figure 33–1). The
left gland lies medial to the superior pole of the kidney, just
lateral to the aorta and immediately posterior to the superior border
of the pancreas. An important surgical feature is the remarkable constancy
of the adrenal veins. The right adrenal vein, 2–5 mm long
and several millimeters wide, connects the anterior aspect of the
adrenal gland with the posterolateral aspect of the vena cava. The
left adrenal vein is several centimeters long and travels inferiorly
from the lower pole of the gland, joining the left renal vein after
receiving the inferior phrenic vein. The adrenal arteries are small,
multiple, and inconstant. They usually come from the inferior phrenic
artery, the aorta, and the renal artery.
Anatomy of the adrenals, showing venous return.
With the exception of rare nonsecreting cancers, indications
for adrenal surgery result from hypersecretory states. Diagnosis
and treatment begin with confirmation of a hypersecretory state
(ie, measurement of excess cortisol, aldosterone, or catecholamines
in blood or urine). In order to determine whether the problem originates
in the adrenal, levels of the trophic hormone in question (ie, adrenocorticotropic
hormone [ACTH] or renin) must be measured. If levels
of the trophic hormone are suppressed but hormone secretion is excessive,
autonomous secretion is proved. The next step, except in pheochromocytoma,
is to determine the degree of autonomy, a process that usually distinguishes hyperplasias
(which respond to most but not all controlling mechanisms) from
adenomas and adenomas from cancers. In general, cancers are under
little if any feedback control. If the primary problem is not in
the adrenal, as in Cushing disease, treatment must be directed elsewhere
Adrenal masses are usually detected and localized by CT scan
or MRI. Functioning tumors of the adrenal can be localized by adrenal
(NP-59) for cortical tumors and 131I-metaiodobenzylguanidine
(MIBG) for medullary tumors (pheochromocytomas). Functioning adrenal
or pituitary tumors can also be localized by demonstrating a gradient
of hormone levels between their venous drainage and a peripheral
The major principles of adrenal surgery are as follows:
(1) Whenever possible, the surgeon must be certain of the diagnosis
and the location of the lesion before undertaking the operation.
(2) The patient must be thoroughly prepared so he or she can
withstand any metabolic problems ...