Editing Surgery of the Adrenals (section)

== Approach ==

=== Options ===
#'''Open adrenalectomy''' 
#'''Laparoscopic/robotic adrenalectomy'''

==== Laparoscopic Adrenalectomy ====

===== Contraindications =====
* '''Absolute'''
*# '''Local recurrence of a previously resected adrenal mass'''
*# '''Invasive adrenal cortical carcinoma with evidence of invasion of neighboring organs or renal artery or vena caval involvement'''
*# '''Contraindications to establishment of pneumoperitoneum§'''
*## '''Cardiac failure'''
*## '''Pulmonary failure'''
*## '''Renal failure'''
*## '''Hemodynamic instability/shock'''
*## '''Increased intracranial pressure'''
*## '''Acute intestinal obstruction with dilated bowel loops'''
*## '''Large pelvic mass'''
*## '''Soft tissue infection at port sites'''
*## '''Acute glaucoma'''
*## '''Recurrent spontaneous pneumothorax'''
*## '''Vascular endocranial malformation'''
*## '''Hypertensive retinopathy'''
*## '''Expected (extensive) adhesions from a previous abdominal surgery'''
*## '''Abdominal aortic aneurysm (may be associated with increased risk of vascular rupture)'''
*Relative
*# Large tumor (>6 cm)
*# Localized adrenal cortical carcinoma without adrenal vein or vena caval involvement
*# Morbid obesity
*# Malignant pheochromocytoma
*# Virilizing adrenal tumor (70-80% of these tumors are actually functional adrenal cortical carcinoma)
*# Significant abdominal adhesion
*# History of recurrent pyelonephritis
*# Pregnancy
==== Open Adrenalectomy ====

* '''Broadly classified into transperitoneal and retroperitoneal approaches'''

===== Transperitoneal =====
* '''Include the anterior transabdominal and thoracoabdominal approaches'''
* '''Advantages'''
*# '''Excellent surgical exposure'''
*# '''Better access to the hilum and great vessels'''
* '''Disadvantage'''
*# '''Higher risk of intra-abdominal organ injury and ileus'''

===== Retroperitoneal =====
* '''Include the flank and posterior lumbodorsal approaches'''
* '''Advantages'''
*# '''Reduced risk of visceral and bowel injuries by avoiding entry into the peritoneum'''
*# '''Less ileus and shorter hospitalization'''
*# '''Ideal for the morbidly obese patient in whom the abdominal panniculus will fall forward in a flank or prone position'''
*# '''Reduced hemodynamic and respiratory morbidity in the absence of pneumoperitoneum'''
*# '''Dense intraperitoneal adhesions arising from previous surgery or inflammation are averted by operating in the retroperitoneum'''
* '''Disadvantage'''
** '''Smaller operative field''' which makes dissection of large tumors difficult
* '''Posterior lumbodorsal approach should not be used for large tumors or adrenal cortical carcinoma'''
* '''The main advantage of the flank approach over the posterior approach is the ease of conversion into the transperitoneal approach should difficulties be encountered. In contrast, the prone posterior lumbodorsal approach allows for bilateral adrenalectomy without patient repositioning.'''