Salient Feature

History

Hypertensive
(130/90 to 200/110)
(+) Hypokalemia
Upper and lower
extremity weakness
Elevated
aldosterone:renin
ratio
CT scan finding of
unilateral left
adrenal mass

Physical
Examination

(-) Abdominal
Striae
(-) Hirsutism
(-) Buffalo Hump
(-) Moon Facies

Salient Feature
Review of System

Headache
Nape pain
Paresthesia
Muscle cramps
Upper and Lower
extremity weakness

(-) Palpitation
(-) Diaphoresis

Differential Diagnosis

PHEOCHROMOCYTOMA

Phaios greek word meaning duskycolored tumor

Catecholamine-producing tumor of the
chromaffin cells located in the center of
the adrenal gland, the adrenal medulla.

Pheochromocytoma
Rule In

Hypertension
refractory to
medical
management
Headache
Unilateral left
adrenal mass in CT
scan

Rule
Out
Elevated
aldosterone:renin ratio
Absence of palpitation
and diaphoresis
Screening test:
plasma-free
metanephrine not
done
24-hr urine level of
catecholamine within
normal range

PRIMARY ADRENAL CUSHINGS

SYNDROME
aka ACTH-independent Cushings
Syndrome
Caused by autonomous production of
adrenal cortisol with subsequent
undetectable ACTH level (<5pg/ml)
because of feedback inhibition
90% Adrenal adenoma

Primary Adrenal Cushings

Syndrome
Rule In

Hypertension
Unilateral adrenal
mass on CT scan

Rule
Out
(-) Obesity
(-) Hirsutism
(-) plethora
(-) moon facies
(-) buffalo hump
(-) purple abdominal
striae

24-hour urine collection

for free cortisol
Late evening cortisol
measurement

PRIMARY HYPERALDOSTERONISM/
CONNS DISEASE
a disease in which one or both adrenal
glands produce excess amount of
aldosterone most commonly due to
unilateral adrenal gland adenoma (60%)
and bilateral adrenal gland hyperplase
(35%).

Primary Hyperaldosteronism /
Conns Disease
Rule In

Hypertension refratory
to medical therapy
Hypokalemia
Elevated aldosteroneto-renin ratio
Unilateral adrenal
mass on CT scan
Upper and lower
extremity weakness
Muscle cramps and
paresthesia

Rule
Out

Cannot rule out

FINAL DIAGNOSIS
Primary Hyperaldosteronism
secondary to unilateral left
aldosteronoma

OPERATIVE TECHNIQUE
Indication
Presence of cortical or medullary tumors
of a benign nature

Pre-Operative Preparation
Control of hypertension pre-operatively

Anesthesia
General anesthesia with endotracheal
intubation

 Position
Lateral position with
the left arm crossing
the chest and
supported on a
padded arm board
The abdomen and
flank area should be
exposed and left knee
flexed with padding of
blankets or pillow
between legs

 Incision and exposure

A 10mm 30degree laparoscope is placed
above the umbilicus or in the left lateral
midsubcostal position in the midclavicular line
just above the umbilicus using Hassons open
technique
Abdominal space is inflated with 15cm
pressure and the laparoscope is introduced
A 5mm port is placed in the far left lateral
subcostal position and a 5mm port just left of
midline thru the upper rectus muscle sheath
just left of round ligament, reducing the
chance of lacerating the epigastric artery.
a 3rd 5mm port is placed at anterior axillary
line midway between the costal margin and
the iliac crest

COURSE IN THE WARD

IMMEDIATE POST-OP
To PACU for 2 hours then
back to room with stable VS,
fully awake, (-) pain, (-) N/V
VS q15 x 2hrs, q30 x 2hrs, q1
x 4hrs then q4
NPO
IVF D5LR 120cc/hr side drip
PNSS 500ml + Tramadol
200mg @ 20cc/hr
Meds
Ofloxacin 200mg IVTT q12
Parecoxib 40mg IVTT single
dose @ 1am

IMMEDIATE POST-OP
Meds
Pantoprazole 40mg IVTT x 1
dose then shift to Pantoprazole
40mg PO OD x 3 days
Paracetamol+Tramadol itab q8
once on clear liquids
Levothyroxine 125mg itab OD
Rosuvastatin 20mg itab OD HS
Caltrate Plus itab OD
Terazosin 2mg itab OD

MHBR
Monitor I&O, refer if <40cc/hr

POST-OPERATIVE DAY1
S
Abdominal discomfort at
operative site
(-) BM
(+) Flatulence X 3

Alert awake conscious

N/A AS PPC
ECE CBS
AP DHS
Flat NABS non distended
non tender
CRT <2 sec, full pulses

A
Primary
Hyperaldosteronism

C/D IVF
May remove Foley
Catheter

POST-OPERATIVE DAY2
S
(+)BM

BP = 130/90
NA AS PPC
ECE CBS
AP DHS
Soft NABS
nontender

A
Primary
hyperaldosteronism

MGH
Ff-up after 1 week with
repeat S. K, Lipid profile,
SGPT
Home Meds
Levothyroxine 125mg itab
OD
Rosuvastatin 20mg itab
OD HS
Caltrate Plus itab OD

JOURNALS

MacGillivray, et.al.
BACKGROUND:
To compare the outcome of patients who underwent laparoscopic
transabdominal adrenalectomy (LA) with those who had open adrenalectomy
(OA).
METHODS:
A retrospective review of consecutive adrenalectomies performed by a single
surgical team at a university hospital. Outcome measurements were
operative time, operative blood loss, procedure-related complications,
postoperative stay, and return to regular activity.
RESULTS:
Twenty-nine adrenalectomies were done in 23 patients during a 54-month
period. There were 12 OAs performed in nine patients and 17 LAs were done
in 14 patients. Both groups were similar in their demographics and their
indications for operation. All attempted LAs were successfully completed. The
mean operative time was longer for LA than for OA (289 vs 201 min; p =
0.042). Resumption of oral intake (1.0 vs 3.0 days; p = 0.002), postoperative
hospital stay (3.0 vs 7.9 days; p = 0.002), and return to regular activity (8.9
vs 14.6 days; p = 0.002) were significantly shorter after LA than after OA.
There were no postoperative deaths and there was no difference in operative
blood loss between the two groups. Procedure-related complications occurred
in three patients having LA and in five patients having OA.
CONCLUSIONS:

Brunt, et.al.
BACKGROUND
Laparoscopic adrenalectomy has recently been used for removing a variety of adrenal
neoplasms. The purpose of the present study was to compare results and outcomes in
patients who underwent either laparoscopic or open adrenalectomy at our institution from
1988 to the present.
STUDY DESIGN:
The records of 66 consecutive patients with benign adrenal neoplasms who underwent
adrenalectomy from 1988 through 1995 were retrospectively reviewed. Patients were divided
into three groups based on the operative approach: group I (n = 25), open anterior
transabdominal approach; group II (n = 17), open posterior retroperitoneal approach; and
group III (n = 24), laparoscopic transabdominal flank approach. Various parameters were
compared and statistical analyses were performed.
RESULTS:

UNILATERA
L

BILATERAL

1 Open Ant Transabdominal

Approach

142 +/- 38
minutes

205 +/- 71
minutes

2 Open Post Retroperitoneal

Approach

136 +/- 34
minutes

328 +/- 11
minutes

3 Lap Transabdominal Flank

Approach

183 +/- 35
minutes

422 +/- 77
minutes

 Patients who underwent laparoscopic adrenalectomy had significantly less

operative blood loss (mean, 104 mL compared to 408 mL in group I and 366
mL in group II, p < 0.001) and a lower incidence of perioperative blood
transfusion. Laparoscopic adrenalectomy was also associated with
significantly reduced parenteral pain medication requirements (p < or =
0.001) and more rapid resumption of a regular diet (p < or = 0.01) compared
to open adrenalectomy. Postoperative length of stay was significantly longer
in group I (8.7 +/- 4.5 days) and in group II (6.2 +/- 3.9 days) after open
adrenalectomy than after laparoscopic adrenalectomy (3.2 +/- 0.9 days) (p <
0.01). Total hospital charges were similar for groups II and III but somewhat
higher for group I. Patients were able to resume 100 percent activity an
average of 10.6 +/- 4.9 days after laparoscopic adrenalectomy and returned
to work a mean of 16.0 +/- 6.1 days postoperatively.
CONCLUSIONS:
Laparoscopic adrenalectomy is a safe and effective procedure and has several
advantages over open adrenalectomy. Laparoscopic adrenalectomy should
become the preferred operative approach for the treatment of patients with
small, benign adrenal neoplasms.