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General Indications

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  • Clinically or biochemically apparent adrenal hormonal hyperfunction.
  • Possible or certain malignant adrenal mass.
  • Adrenal mass of uncertain significance.

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Specific Conditions and Disease States

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  • Primary hyperaldosteronism.
    • Unilateral cortical adenoma causing Conn's syndrome.
    • Bilateral hyperplasia with unilateral dominance (established by adrenal vein sampling).
  • Hypercortisolism.
    • Unilateral cortical adenoma.
    • Refractory Cushing's syndrome (from Cushing's disease, primary adrenal hyperplasia, or ectopic adrenocorticotropic hormone [ACTH] syndrome).
  • Pheochromocytoma.
  • Unilateral cortical adenoma causing virilization.
  • Myelolipoma (in selected situations).
  • Adrenal cyst (if refractory or symptomatic).
  • Adrenocortical carcinoma.
  • Incidentaloma with indeterminate or concerning imaging characteristics.
  • Adrenal metastases of other primary cancers (in selected situations).

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Laparoscopic Adrenalectomy

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Absolute

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  • Adrenocortical carcinoma (certain or likely).
  • Refractory coagulopathy.
  • Comorbidities precluding safe general anesthesia.

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Relative

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  • Previous ipsilateral partial adrenal resection.
  • Previous extensive upper abdominal or retroperitoneal surgery.
  • Very large adrenal tumors (> 6–8 cm).
  • Suboptimal medical preparation for pheochromocytoma resection.

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Open Adrenalectomy

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Absolute

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  • Refractory coagulopathy.
  • Comorbidities precluding safe general anesthesia.

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Relative

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  • Suboptimal medical preparation for pheochromocytoma resection.

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Expected Benefits

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  • Resolution of clinical symptoms related to adrenal hypersecretory function.
  • Treatment of primary or metastatic adrenal malignancies.
  • Treatment of symptomatic benign adrenal masses.

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Potential Risks

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  • For laparoscopic procedure, risk of conversion to an open procedure.
  • Bleeding requiring reoperation.
  • Glucocorticoid insufficiency (most commonly following preoperative hypercortisolism, bilateral adrenalectomy, or previous contralateral adrenalectomy).
  • Recurrence of tumor.
  • Scarring.
  • Infection.
  • Failure of operation to correct hypertension or adrenal hyperfunction.
  • Need for additional tests or procedures.

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Laparoscopic Adrenalectomy

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  • Standard laparoscopic and open instrument trays.
  • Surgical energy device such as harmonic scalpel or LigaSure.

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Open Adrenalectomy

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  • Major exploratory laparotomy instrument tray.
  • Retraction system such as Bookwalter or Thompson retractor.
  • Surgical energy device such as harmonic scalpel or LigaSure.

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General Preparation

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  • Nothing by mouth before surgery.
  • No preoperative antibiotics are necessary before surgery except when the patient has other indications (eg, cardiac valvulopathy, orthopedic hardware).
  • Anesthesiology consultation as needed.
  • Invasive blood pressure monitoring if required for pheochromocytoma or other medical condition.
  • Deep vein thrombosis (DVT) prophylaxis (for laparoscopic cases this should include sequential compression devices).

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Disease-Specific Preparation

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  • Preoperative control of hypertension for patients with pheochromocytoma.
    • α-Adrenergic blockade is achieved using phenoxybenzamine, 10 mg orally three times daily, titrated upward until mild orthostatic symptoms occur.
    • Requires 7–10 days minimum preparation.
    • Phenoxybenzamine should be continued until the morning of the procedure and given with a sip of water.
    • If necessary, β-adrenergic blockade is added after α blockade is established to treat tachycardia and prevent unopposed α blockade.
  • Stress-dose steroids administered to patients having adrenalectomy for hypercortisolism (benign or malignant causes) due to suppression ...

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