Chapter 3. Adrenalectomy

General Indications

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

Specific Conditions and Disease States

• 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).

Laparoscopic Adrenalectomy

Absolute

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

Relative

• 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.

Open Adrenalectomy

Absolute

• Refractory coagulopathy.
• Comorbidities precluding safe general anesthesia.

Relative

• Suboptimal medical preparation for pheochromocytoma resection.

Expected Benefits

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

Potential Risks

• 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.

Laparoscopic Adrenalectomy

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

Open Adrenalectomy

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

General Preparation

• 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).

Disease-Specific Preparation

• 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 ...