Adrenalectomy

An adrenalectomy is the surgical removal of the adrenal gland . It can be unilateral or bilateral.

indication

Adrenalectomy is always indicated for primary tumors of the adrenal gland such as:

• hormonally active adrenal adenomas (e.g. in Conn's disease , adrenal Cushing's syndrome )
• Pheochromocytoma
• Adrenal carcinoma
• hormonally inactive tumors ( incidentaloma ) if the diameter is more than 4 cm and growth is proven

In the case of reactive enlargements of the adrenal glands, such as those observed in Cushing's pituitary disease, adrenalectomy should be considered as the last option if the causal therapy fails (removal of the pituitary adenoma, etc.).

A subtotal adrenalectomy is reserved for single, small, eccentrically located and benign tumors.

Procedure

The standard method is endoscopic adrenalectomy (laparoscopic or retroperitoneoscopic), which is associated with faster recovery and less pain for the patient.

Depending on the findings, alternative access routes may be cheaper. In the case of multiple preliminary abdominal interventions, the laparoscopic technique is a risk due to adhesions in the abdominal wall, so that the lateral approach (flank access) or the posterior approach is preferable.

In the case of adrenal carcinomas, the transabdominal or thoracoabdominal approach is favorable for reasons of clarity and the possible need to expand the procedure ( para-aortic lymph node dissection ) . In this way, the radical nature of the operation can be varied according to the intraoperative findings.

Perioperative measures

Precautions must be taken before and after surgery to minimize the risk and improve the feasibility of the procedure.

Preoperative measures

In the case of pheochromocytomas, alpha-blockers ( phenoxybenzamine ) must be administered preoperatively and usually in combination with beta-blockers ( propranolol ).

In the case of hyperaldosteronism , the administration of aldosterone antagonists and possibly other antihypertensive drugs is necessary.

Before the operation of patients with hypercortisolism , imbalances of the electrolyte balance and metabolism ( steroid diabetes ) should be corrected and the high blood pressure should be adjusted .

Post-operative measures

In principle, any patient can suffer from an Addison's crisis after an adrenalectomy . The Addison's crisis is inevitable after bilateral adrenalectomy. In unilateral adrenalectomy, the adrenal gland on the opposite side is often atrophied and is not capable of sufficient cortisol synthesis on its own.

Therefore, a substitution of cortisol (for example with hydrocortisone ) should already start during the operation. In the case of bilateral adrenalectomy, this must be continued for life.

In the case of unilateral adrenalectomy and non-cortisol-producing tumors, the substitution can be ended rapidly and gradually. If there is pronounced atrophy of the opposite side, substitution must be made slowly and gradually over a longer period of time until the remaining adrenal gland adapts.

complication

A bilateral adrenalectomy for Cushing's syndrome can lead to Nelson’s tumor .

literature

• M. Brauckhoff, P. Nguyen Thanh, A. Bär, and H. Dralle: Subtotal bilateral adrenalectomy with maintenance of adrenocortical function . In: The surgeon . Springer Berlin / Heidelberg. February 19, 2004. Retrieved October 7, 2010.

Individual evidence

1. ↑ Bernfried Leiber (founder): The clinical syndromes. Syndromes, sequences and symptom complexes . Ed .: G. Burg, J. Kunze, D. Pongratz, PG Scheurlen, A. Schinzel, J. Spranger. 7., completely reworked. Edition. tape 2 : symptoms . Urban & Schwarzenberg, Munich et al. 1990, ISBN 3-541-01727-9 .

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