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INDICATIONS

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 or growth. In these situations, the adrenal mass is frequently found during abdominal imaging done for unrelated indications. These so-named adrenal incidentalomas generally should be removed if they have a cross-sectional diameter of 4 cm or greater or if they are proven to be functional. Patients with nonfunctional adrenal masses smaller than 4 cm without concerning radiographic features should be followed with periodic imaging to monitor changes in the size of the mass.

A benign adenoma on computed tomography is typically a homogeneous mass with a low attenuation value (<10 HU on a non-contrast-enhanced image or a greater than 50% washout on an adrenal protocol computed tomography scan). A functional workup of all incidentalomas should include measuring plasma-free metanephrines and either a 1-mg dexamethasone suppression test or a 24-hour urine analysis for cortisol and creatinine. In addition, patients with hypertension should have determinations of plasma aldosterone concentrations to plasma renin activity or direct renin concentration 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 larger than 10 cm. Open adrenalectomy with en bloc excision is the mainstay for primary and recurrent adrenocortical carcinoma because of the lack of effective adjuvant therapy and the difficulty in maintaining oncologic principles with laparoscopy.

PREOPERATIVE PREPARATION

The most important preoperative procedure is to establish a firm diagnosis. Accordingly, readers should refer to current texts on diagnostic endocrinology for the required procedures. When adrenalectomy is decided on, 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. 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 are absolutely necessary in patients with pheochromocytomas in order to control the associated hypertension during surgery. This may take several weeks or more. Patients are ideally titrated to a point of orthostatic hypotension. Frequently, nasal congestion is a sign of alpha blockade. Beta-blockers are reserved for patients with tachycardia or cardiac arrhythmias. Problems associated with hypercortisolism were reviewed in Chapter 121.

ANESTHESIA

Preoperative consultation and communication among endocrinologist, surgeon, and anesthesiologist are necessary. A type and screen is acceptable for small tumors. A type and cross to ensure ...

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