Adrenalectomy
What the Examiner Expects
Surgical removal of the adrenal gland, most commonly performed laparoscopically. The examiner expects you to know the indications: functional tumors (pheochromocytoma, Cushing's adenoma, aldosteronoma, sex-hormone producing), nonfunctional tumors > 4 cm or with imaging features suspicious for carcinoma, metastases (solitary), and incidentalomas meeting size or functional criteria. For pheochromocytoma, adequate preoperative alpha-blockade (phenoxybenzamine or doxazosin for 10–14 days, followed by beta-blockade if tachycardic, and volume resuscitation with salt loading) is essential to prevent intraoperative hypertensive crisis.
Key Examiner Focus Points
- Laparoscopic approach is standard for most adrenal pathology
- Pheochromocytoma: alpha-blockade (phenoxybenzamine) for 10–14 days BEFORE surgery
- Cortisol-producing adenoma (Cushing's): postop steroid replacement — contralateral gland is suppressed
- Aldosteronoma (Conn's): confirm lateralization with adrenal vein sampling before unilateral adrenalectomy
- Open approach for large tumors (> 6 cm) or suspected adrenocortical carcinoma (avoid morcellation)
Common Curveballs
During laparoscopic adrenalectomy for pheochromocytoma, BP spikes to 250/130 during tumor manipulation
This is expected despite alpha-blockade. Anesthesia team should administer IV phentolamine (alpha-blocker), nitroprusside, or nicardipine for acute BP control. Minimize tumor manipulation. Ligate the adrenal vein early to reduce catecholamine release. Once the vein is ligated, watch for rebound hypotension — be ready with vasopressors and fluids.
Patient with Cushing's syndrome due to adrenal adenoma — what happens postoperatively?
The contralateral adrenal gland is suppressed from chronic cortisol excess. The patient will have adrenal insufficiency postoperatively and requires stress-dose steroids (hydrocortisone) tapered gradually over months as the hypothalamic-pituitary-adrenal axis recovers. This can take 6–12 months.
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