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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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Laparoscopic Adrenalectomy

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  • General anesthesia is induced with the patient supine.
  • An orogastric tube and a Foley catheter are placed.
  • The patient is placed in the lateral decubitus position with the ipsilateral side up.
  • The table is gently flexed to widen the angle between the costal margin and iliac wing.
  • An axillary roll is placed and a beanbag used to hold the patient in position.
  • Arms, head, and legs are appropriately padded and not abducted beyond 90 degrees.

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Open Adrenalectomy

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  • A nasogastric tube and a Foley catheter are placed.
  • The patient is placed supine with his or her arms resting on arm boards and with legs padded.

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  • Incentive spirometry should be used to prevent atelectasis and postoperative pneumonia.
  • Laparoscopic procedures often require less fluid replacement than do open procedures.
  • Postoperative DVT prophylaxis should be maintained until the patient is ambulatory.
    • Ambulation should be encouraged as early as possible.
    • Following laparoscopic procedures, subcutaneous heparin prophylaxis is appropriate if no concerns exist about ongoing bleeding.
  • Early resumption of regular diet should be possible.
  • The Foley catheter may be discontinued once hemodynamics, urinary output, and electrolytes are stable and within the normal range.

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Patients with Hyperaldosteronism

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  • Potassium supplementation should be stopped immediately postoperatively.
  • Antihypertensives should be weaned.
  • Electrolytes, including potassium, should be checked the morning after surgery.

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Patients with Pheochromocytoma

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  • Patients should be monitored for signs of postoperative hypotension resulting from vascular relaxation.
    • Significant intravenous fluid resuscitation or pressors may be required, although this is less of a problem following adequate α blockade.
  • α Blockade may be discontinued immediately postoperatively and β blockade weaned, except in cases of residual metastatic ...

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