Adrenal Surgery Principles
Adrenalectomy is safe only when the tumour is correctly characterised first — block a phaeochromocytoma, replace steroids for a cortisol tumour, and choose laparoscopic for benign functioning tumours but OPEN en-bloc when malignancy is suspected.
The big picture
Adrenalectomy is indicated for functioning tumours (phaeochromocytoma, aldosteronoma, cortisol-secreting adenoma), for masses suspicious of malignancy or large (commonly >4 cm), and for selected metastases. The approach is usually laparoscopic/retroperitoneoscopic for benign functioning tumours; open en-bloc resection is reserved for suspected adrenocortical carcinoma or locally invasive disease.
Characterise then prepare tumour-specifically (block the phaeo, cover the cortisol tumour), and match the approach to pathology — laparoscopic for benign, open en-bloc for suspected cancer.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Safe adrenalectomy is tumour-specific preparation plus the right approach; the operation follows the endocrine plan, not the reverse.
Procedure chooser
- Laparoscopic/retroperitoneoscopic adrenalectomy for benign functioning tumours
- Open en-bloc adrenalectomy for suspected adrenocortical carcinoma or local invasion (manage IVC involvement)
- Cortical-sparing surgery in selected bilateral/hereditary disease
Complications
- Uncontrolled hormone excess if poorly prepared
- Malignant recurrence after capsule breach
- Hypertensive crisis / post-resection hypotension (phaeo)
- Adrenal crisis if steroid cover omitted (cortisol tumour)
- Tumour spillage with laparoscopic resection of carcinoma
- Bleeding, adjacent organ/vascular injury
- Tumour-specific preparation
- Open en-bloc resection for suspected cancer; preserve capsule
- Glucocorticoid cover for cortisol tumours
- Phentolamine/fluids for haemodynamic swings
- Steroids for adrenal crisis
- Oncological management of recurrence
Follow-up
- Haemodynamics and (for phaeo) post-resection hypotension/glucose
- Cortisol axis recovery and steroid replacement
- Potassium/BP after aldosteronoma removal
- Biochemical cure and recurrence
- Immediate postoperative endocrine monitoring; longer-term biochemical surveillance per tumour
- Resolved hormone excess with stable haemodynamics and recovering axis
- Persistent hormone excess (residual/wrong-side/recurrent disease) or adrenal insufficiency
- Recurrence or tumour-specific surveillance
- Steroid dependence during axis recovery; recurrence (especially ACC); hereditary surveillance
Memory hooks
Characterise, then prepare, then operate.
Phaeo: alpha before beta, fill the tank.
Cortisol tumour: steroid cover.
Benign → laparoscopic; cancer → open en-bloc.
Don't breach the capsule of a cancer.
Board traps
Generic 'adrenalectomy' answer that ignores tumour-specific preparation.
Cortisol tumour removed without steroid cover → postoperative crisis.
Suspected ACC done laparoscopically → spillage.
Clinical cases
A surgeon is asked how the operative plan differs for a phaeochromocytoma, a cortisol-secreting adenoma, and a suspected adrenocortical carcinoma.
Give the key difference in preparation/approach for each.