The transperitoneal approach is preferred by most surgeons due to the greater working space and familiarity of anatomic landmarks. Retroperitoneoscopic adrenalectomy is generally considered by the more experienced surgeon but may prove useful in patients with significant prior intra-abdominal surgery and/or morbid obesity. Thoracoscopic adrenalectomy was described by Gill et al. (9
) for the treatment of select patients with adrenal pathology and significant abdominal and retroperitoneal scarring from previous surgery through access via the virgin thoracic cavity and transdiaphragmatic approach. In an effort to further minimize operative morbidity and improve cosmesis, the introduction of laparoendoscopic single-site (LESS) adrenalectomy has been evaluated. A systematic review of LESS adrenalectomy versus conventional laparoscopic adrenalectomy revealed equivalent complication, conversion, and transfusion rates despite a longer operative time in those undergoing a single-site procedure, likely related to the early experience of this novel technique (10
). Additionally, there were comparable cosmetic satisfaction scores, although LESS adrenalectomy demonstrated lower visual analog pain scores. The introduction of robotic technology in the minimally invasive arena has proven to be a successful alternative to other surgeries with specific benefits. Robotic systems aid in eliminating surgeon fatigue, tremor, and provide a three-dimensional visualization of the operative field. However, they represent a more costly option to the healthcare system and require additional training by the surgeon. A prospective trial of laparoscopic versus robot-assisted adrenalectomies failed to show significant benefit in the latter (11
). The study demonstrated that robot-assisted adrenalectomy is a feasible alternative to standard laparoscopic surgery with appropriate robotic experience. Ultimately, the choice of surgical technique is dependent on surgeon experience, the patient’s past surgical history, and preoperative findings.
Prior to operative intervention, metabolic abnormalities associated with hormonally active tumors must be addressed to optimize the patient for surgery. A multidisciplinary approach integrating the patient’s primary care provider, endocrinologist, and urologist ensures appropriate care in the preoperative setting and maintains follow-up after surgery. Hypertension and hypokalemia seen with aldosteronomas are managed with spironolactone. The patient should be maintained normoglycemic with cortisol-secreting adenomas, and stress-dose steroid administration must occur perioperatively. The preoperative management of pheochromocytomas requires special consideration, as inadequate blockade of circulating catecholamines can trigger hypertensive crises secondary to anesthesia or intraoperative manipulation. Patients should receive 14 days of blockade with phenoxybenzamine hydrochloride titrated to control blood pressure. Additional blockade may be indicated if arrhythmias persist or prior treatment proves insufficient.
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