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European Endocrinology Highlights Surgical Approach to the Adrenal Glands David Scott-Coombes Consultant in Endocrine Surgery, Department of Endocrine Surgery, University Hospital of Wales, Cardiff, UK Abstract Any surgeon treating a patient with adrenal disease should be a member of a multi-disciplinary team involving dedicated specialists, including an endocrinologist, anaesthetist, radiologist, intensivist and geneticist. In an era of epidemic numbers of adrenal incidentalomas, great care must be taken to determine not only the endocrine diagnosis, but also the benefits (if any) of adrenal surgery. Finally, the surgeon must be competent in both minimally invasive and gross resectional surgical techniques and know when to adopt these two very different surgical approaches. Keywords Adrenal, adrenalectomy, laparoscopic, phaeochromocytoma, outcomes Disclosure: David Scott-Coombes has no conflicts of interest to declare. No funding was received for the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 12 June 2015 Published Online: 10 July 2015 Citation: European Endocrinology, 2015;11(2):98–9 Correspondence: David Scott-Coombes, Department of Endocrine Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK. E: david.scott-coombes@wales.nhs.uk The five surgical tenets of endocrine surgery were set out in the 1980s: 1 • • • • • Confirm the diagnosis; Render the patient safe; Consider localisation studies; Decide if surgery is indicated; and Decide which surgical approach to adopt. Confirmation of the diagnosis is based exclusively on biochemical tests and the surgeon should be able to interpret the results almost as well as an endocrinologist. For functioning tumours, the multi-disciplinary team (MDT) should be content that the patient is as stable as possible prior to surgery. For phaeochromocytoma, in the UK, phenoxybenzamine is the commonest choice of drug to deliver alpha-adrenergic receptor blockade with minimal beta-adrenergic blockade prescribed later if a reflex tachycardia develops. Typical UK practice commences pharmacological blockade as an outpatient and then as an inpatient the dose is titrated upwards in the immediate pre-operative period until a satisfactory postural drop in blood pressure has been achieved. Patients with Cushing’s syndrome may require medication to control excess cortisol production prior to surgery. Hypertension and hypokalaemia are relatively easily controlled in most patients with Conn’s syndrome. 2 phaeochromocytoma when either metastasis is suspected or no primary tumour is identified. For patients with a biochemical diagnosis of Conn’s syndrome, adrenal venous sampling should be undertaken to confirm the laterality of the disease. 3 There are two broad surgical approaches: endoscopic or laparotomy. By the year 2000 laparoscopic adrenalectomy became the gold standard approach. 4 As with cholecystectomy, there has not been a randomised trial, but case series have demonstrated several advantages of laparoscopic over open surgery. These include less pain, shorter inpatient stay and quicker return to work with equivalent morbidity and mortality rates. 5 Endoscopic approaches mirror the open approaches that include retroperitoneal and transperitoneal routes. The advantages of a retroperitoneal approach include the avoidance of repositioning a patient undergoing a bilateral adrenalectomy and the lack of a need to mobilise either the liver or the spleen/pancreas. 6 For huge tumours the open access can be widened using either an extended lateral incision, or a transthoracic approach (either via a midline sternotomy or a lateral approach). The decision about open or ‘keyhole’ surgery is mainly influenced by two factors: tumour size and likelihood of malignancy. Cross-sectional imaging is undertaken in all patients with adrenal disease. It will lateralise the pathology in patients with Cushing’s syndrome and exclude the possibility of a paraganglioma in patients Depending upon the experience of the surgeon, a laparoscopic approach is limited to tumours up to about 10 cm in diameter. Of course the tumour needs to be extracted and large tumours will require a larger incision! There is an option to perform a hand-assisted procedure (popular in renal transplant surgery) where a ‘hand-port’ that admits one (surgeon’s) hand into the peritoneal cavity is used to both dissect and facilitate with a biochemical diagnosis of phaeochromocytoma. Cross-sectional imaging will also indicate the size of the tumour and provide information about the likelihood of malignancy. MIBG is reserved in patients with a tumour extraction. When a malignancy is suspected, laparotomy is the favoured approach. Adrenocortical cancer is highly malignant and the best option for cure is to remove the tumour with a clear margin (R 0 TOU CH MED ICA L MEDIA 119