Adrenalectomy (Non-Pheo)
Patient phenotype
Cushing's syndrome (cortisol excess), Conn's (aldosteronoma → HTN, hypokalemia), incidentaloma, metastasis. Each has distinct preop physiology. Cushing's = obese, fragile skin, hyperglycemia, HTN; Conn's = HTN + low K.
Procedure
Laparoscopic (preferred) or open. Lateral decubitus. ~2-3 hours. Adrenal vein ligated early — vessels are short + fragile.
Anesthetic plan
GETA. A-line for HTN management. Stress-dose steroids if Cushing's or bilateral (or suppressed contralateral). K replacement for Conn's. Standard for incidentaloma after pheo workup negative.
Setup
- ·A-line if HTN + Cushing's
- ·1-2 PIVs
- ·Type & screen
- ·Hydrocortisone 100 mg available (Cushing's)
- ·K + Mg available (Conn's)
- ·Forced air warmer
Biggest concerns by phase
Confirm pheo ruled out
ANY adrenal mass needs pheo workup (plasma metanephrines, 24h urine) BEFORE OR. Missed pheo + induction = catastrophic hypertensive crisis.
Cushing's-specific issues
Glucose intolerance, HTN, fragile skin (careful positioning, padding), proximal myopathy (NMB sensitivity), osteoporosis (positioning fractures), psych issues. Stress-dose steroids day-of + taper.
Conn's — K + BP correction
K should be > 3.5 before induction. Spironolactone 4-6 weeks preop normalizes K + BP. Avoid succinylcholine if K low.
Adrenal vein injury + bleeding
Right adrenal vein drains directly to IVC, very short — injury can cause significant bleeding. Have blood available, large-bore access.
Adrenal insufficiency post-removal
After Cushing's adrenalectomy, contralateral adrenal is suppressed → adrenal insufficiency. Hydrocortisone replacement IV → PO taper over months.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-yo F with Cushing's syndrome from L adrenal adenoma. BP 165/95, BMI 38, BG 230 fasting. Scheduled for laparoscopic L adrenalectomy. Plan?
What an examiner probes for
- ▹Confirms metanephrines normal (no pheo)
- ▹Stress-dose hydrocortisone day-of
- ▹Glucose management — insulin scale
- ▹Careful positioning given osteoporosis + skin
- ▹Postop steroid taper plan
Sources
- Miller's Ch 35
- Stoelting/Hines Ch 24
Anatomy reference
Sourced reference images. 4 matches for "adrenal kidney endocrine".
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