Preoperative Preparation

Patients undergoing adrenal surgery require thorough preparation. Such preparation is especially necessary when one uses an open approach. Venous thromboembolism is not uncommon postoperatively, so intermittent pneumatic compression of the legs or some other method of preventing deep venous thrombosis should be considered. Caution is necessary when using anticoagulants because of the risk of retroperitoneal hemorrhage postoperatively. A modified bowel prep using a clear liquid diet and cathartics should be given the day before surgery so the large intestine will not be filled with feces. The effects of excess hormone secretion should be reversed whenever possible. Patients with aldosteronomas should have potassium deficits corrected. Preoperative use of spironolactone or amiloride may facilitate this. The adverse effects of Cortisol excess can be blunted by giving metyrapone, ketoconazole, or mitotane. Vitamin A can counteract some of the poor wound healing that is seen in Cushing's syndrome; 25,000 to 50,000 IU/day can be given orally for the week before the operation and intramuscularly until the patient is able to resume oral intake. Patients with pheochro-mocytomas should have their hypertension controlled with an a-blocking agent or a calcium channel blocker. Inhibiting the vasoconstrictive effects of catecholamines allows the patient to replenish their intravascular volume deficit. Beta-adrenergic blockade should be used in patients with tachycardia, arrhythmia, or pure epinephrine-secreting tumors but only after a-adrenergic blockade has been achieved. Autologous blood can be obtained if a need for transfusion is anticipated.

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