Improving diagnostic techniques has lead to the increase of incidental and non-incidental adrenal tumor detection. When incidentally discovered, adrenal tumors necessitate thorough work-up to determine if they are hormonally functional, malignant, or metastatic. Patients with hormonally functional adrenal tumors should have targeted preoperative optimization, in addition to routine age-appropriate optimization.
The right and left adrenal glands are located within Gerota fascia adjacent to the kidneys. The arterial supply of the adrenal glands consists of small arterial branches arising from the inferior phrenic artery, the aorta, and the renal arteries. Venous drainage of the left adrenal gland is to the left renal vein through the left adrenal vein, while the right adrenal vein drains directly into the inferior vena cava.
The adrenal gland is comprised of two distinct layers, the outer adrenal cortex, and the inner adrenal medulla, which have distinct hormonal production.
The adrenal medulla is made up of ectodermal cells of neural crest origin and is the site of catecholamine production, which includes dopamine, norepinephrine, and epinephrine.
The adrenal cortex is divided into three zones, from superficial to deep being the zona glomerulosa, zona fasiculata, and the zona reticularis. The zona glomerulosa is the site of mineralocorticoid (aldosterone) production. The zona fasciculata is the site of glucocorticoid (cortisol) production. The zona reticularis is the site of androgen production (DHEA-S, DHEA, and androstenedione).
Severe coagulopathy and poor cardiopulmonary performance status are absolute contraindications adrenalectomy by any technique. Minimally-invasive contraindications included: large tumor size (>6cm) and adrenocortical carcinoma.
Laparoscopic equipment includes the following:
Collaboration between an experienced adrenal surgeon and an anesthesiologist is important in adrenal surgery, given the potential for abrupt changes in hemodynamics throughout the case.
Preoperative preparation for the patients undergoing adrenalectomy is of the utmost importance. Workup should include biochemical workup to determine if a nodule or mass secreting aldosterone, cortisol, or catecholamines is present.
In cases of increased catecholamine secretion (pheochromocytoma), patients should be initialed on alpha-blockade until orthostasis is achieved, with the addition of beta-blockade as needed. Preoperative hydration and electrolyte repletion should also be done through a high-sodium diet and increase fluid intake the week prior to surgery. Patients with hyperaldosteronism on biochemical workup should undergo adrenal venous sampling to confirm lateralization of the affected adrenal gland as preoperative imaging can be misleading in many cases.
Laparoscopic Transabdominal Adrenalectomy
Lateral decubitus with affected gland upward, flex bed at the lower chest. The surgeon and assistant stand facing the front of the patient. No need for foley or preoperative antibiotics.
Posterior Retroperitoneoscopic Adrenalectomy
Prone, gel rolls to lift the pelvis and at the chest to allow the abdomen to hang freely if Cloward Prone Positioner is not available. Hip and knees flexed at 110°. No need for foley or preoperative antibiotics.
Primary adrenal insufficiency occurs after bilateral adrenalectomy. Signs and symptoms are volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. Patients are managed by replacement therapy based on glucocorticoids (hydrocortisone or cortisone), mineralocorticoids (fludrocortisone) in cases of confirmed corticoids or aldosterone deficiency, respectively.
Only women with androgens deficiency, which presents low libido, depressive symptoms, and/or low energy levels despite otherwise optimized glucocorticoid and mineralocorticoid replacement, are candidates for dehydroepiandrosterone (DHEA) replacement. Other consequences of bilateral adrenalectomy include hypercortisolism due to excess ACTH stimulation of residual adrenal tissue, adrenal crisis, and the development of an aggressive corticotropic tumor called Nelson’s syndrome. Nelson’s syndrome is less common and is typically associated with skin hyperpigmentation due to hypersecretion of proopiomelanocortin (POMC) products.
Diagnosis requires one of the following: 1) expanding pituitary mass lesion compared with pre-bilateral adrenalectomy imaging or 2) plasma level of ACTH more than 200 ng/mL in addition to progressive elevations of ACTH (an increase of >30%) on at least three consecutive occasions. Adrenal crisis is a life-threatening complication of adrenal insufficiency. Patients in the adrenal crisis typically present with profoundly impaired well-being, hypotension, nausea and vomiting, and fever responding well to parenteral hydrocortisone administration. Infections are the major precipitating causes of adrenal crisis.
Adrenal causes of hypertension, diabetes, hyperlipidemia, and obesity are potentially underdiagnosed and may go untreated. Additionally, there has been an increase in the number of incidentally found adrenal masses with improvements in axial imaging over time.
The clinician must be able to work-up and manage patients with adrenal masses, both functional and non-functional, to treat these patients with minimal morbidity. When planning for adrenalectomy, considerations of hormonal changes and preoperative preparation for these changes is as important and demands as much of the surgeon's attention as the technical aspects of the case.
Adrenalectomy has been shown to have a relatively low risk of postoperative complications, with an overall rate of 3.6%.. Improved patient outcomes and decreased hospital costs have been demonstrated when adrenalectomy is performed by a high-volume adrenal surgeon (>/=6 adrenalectomies/year).
An interprofessional approach to adrenalectomy aids in the prevention and avoidance of intraoperative and postoperative complications, and in some cases, allows for same-day discharge. These improvements are only achieved with close communication across the care team-which includes the patient's endocrinologist, surgeon, anesthesiologist, nurses, and all additional health professionals that may be involved in the patient's care.
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