Plate 146
###### Figure 5

The presence of cortical or medullary tumors of either a malignant or benign adenomatous nature is a well-established indication for unilateral adrenalectomy. In recent years, however, the number of indications for bilateral adrenalectomy has gradually increased. It is occasionally performed to control complex endocrine states after partial or unilateral adrenalectomy has failed to alleviate hyperaldosteronism or hypercortisolism, as in Cushing's syndrome.

The most important preoperative procedure is to establish a firm diagnosis. Clinical findings often indicate the altered pathophysiology, but extensive endocrine studies are usually necessary, not only to establish the disorder within the adrenals but also to rule out associated disorders in other endocrine glands. Unless they are malignant, tumors are seldom large enough to be identified by pyelography, tomography, retroperitoneal gas injection, or aortography. Computed tomography scans may be helpful. 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 a major problem with pheochromocytomas. Problems associated with hypercorticolism include hypokalemia with alkalosis, hypertension, polycythemia, musculoskeletal depletion with osteoporosis and hypercalcemia, abnormal glucose tolerance, multiple areas of skin furunculosis, and, finally, poor wound healing. Thus, the surgeon must be aware that many organ systems and their responses to surgery are profoundly affected by adrenal malfunction.

Preoperative consultation and communication among endocrinologist, surgeon, and anesthesiologist are necessary. The anesthesiologist must be prepared for adequate blood and endocrine replacement and occasionally for a prolonged procedure that may be extended into the chest. Electrolytes should be in optimum condition and the patient prepared with parenteral cortisone the evening before and on the morning of surgery for hypercorticolism or bilateral adrenalectomy. Adequate blood must be available, as hypertension plus increased vascularity and fragile veins about the adrenals all tend to increase blood losses.

General anesthesia with endotracheal intubation is preferred. Patients with pheochromocytomas should have adequate preoperative preparation with a long-acting adrenergic (alpha receptor) blocking agent, such as phenoxybenzamine hydrochloride (Dibenzyline). To minimize wide fluctuations of blood pressure, an intra-arterial line should be placed and hypertension controlled with an intravenous infusion of sodium nitroprusside (Nipride). After assuring that adequate fluid and blood replacement has been accomplished, an infusion of norepinephrine (Levophed) ...

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