Adrenalectomy: Indications, Types & What to Expect

Adrenalectomy is the surgical removal of one (unilateral) or both (bilateral) adrenal glands. It is performed for hormone-secreting tumors, malignancy, or, rarely, metastatic disease.

Primary Indications

1. Cushing's Syndrome (Cortisol Excess)

• Adrenal adenoma, carcinoma, or bilateral hyperplasia (ACTH-independent).
• Surgery curative for adrenal-source Cushing's; bilateral for hyperplasia.
• Preoperative medical optimization (antihypertensives, glucose control, thrombosis prophylaxis) is critical.

2. Primary Aldosteronism (Conn's Syndrome)

• Aldosterone-producing adenoma (APA) → unilateral adrenalectomy (laparoscopic preferred).
• Bilateral idiopathic hyperplasia → medical management (mineralocorticoid antagonists); surgery not curative.
• Adrenal vein sampling (AVS) distinguishes unilateral vs. bilateral disease preoperatively.

3. Pheochromocytoma / Paraganglioma

• Catecholamine-secreting tumors (adrenaline/noradrenaline).
• Mandatory preoperative α-blockade (phenoxybenzamine) ± β-blockade to prevent intraoperative hypertensive crisis.
• Genetic testing recommended (up to 35% hereditary: RET, VHL, NF1, SDHx, MAX, TMEM127).

4. Adrenal Cortical Carcinoma (ACC)

• Rare, aggressive. Complete en bloc resection (R0) is only curative chance.
• Open approach often preferred for large/invasive tumors; laparoscopic for small (<6 cm), localized.
• Adjuvant mitotane ± chemotherapy (EDP) considered.

5. Incidentaloma (Non-Functional Mass)

• Surgery indicated if: >4 cm (some guidelines >6 cm), imaging features suspicious for malignancy (heterogeneity, irregular margins, necrosis, HU >10 on non-contrast CT), or hormonal autonomy on workup.
• Smaller, radiologically benign masses: surveillance imaging.

Surgical Approaches

• Laparoscopic (transperitoneal or retroperitoneal): Standard for benign tumors <6 cm. Less pain, shorter stay, faster recovery.
• Open: Large tumors, suspected malignancy, prior extensive abdominal surgery.
• Robotic-assisted: Increasingly used; similar outcomes to laparoscopic.

Postoperative Considerations

• Bilateral adrenalectomy → lifelong glucocorticoid + mineralocorticoid replacement.
• Unilateral: contralateral gland usually compensates; monitor for transient adrenal insufficiency.
• Pheochromocytoma: ICU monitoring postoperatively for hemodynamic lability, hypoglycemia.

Multidisciplinary evaluation (endocrinology, endocrine surgery, genetics) ensures appropriate indication, preparation, and long-term follow-up.