Surgical Treatment

We believe that virtually all patients who prove to have a unilateral aldosteronoma or unilateral excessive aldosterone

FIGURE 68-5. CT scans of the abdomen revealed a 10-mm nodular lesion (arrow) in the right adrenal gland (A) and thickened limb (arrowhead) of the left adrenal gland (B) in a 48-year-old patient with primary hyperaldosteronism (a ratio of plasma aldosterone concentration to plasma renin activity of 370). Adrenal venous sampling lateralized excessive secretion of aldosterone to the right gland (see Table 68-1), and this was confirmed at surgery.

FIGURE 68-5. CT scans of the abdomen revealed a 10-mm nodular lesion (arrow) in the right adrenal gland (A) and thickened limb (arrowhead) of the left adrenal gland (B) in a 48-year-old patient with primary hyperaldosteronism (a ratio of plasma aldosterone concentration to plasma renin activity of 370). Adrenal venous sampling lateralized excessive secretion of aldosterone to the right gland (see Table 68-1), and this was confirmed at surgery.

production are acceptable candidates for adrenalectomy. The treatment of choice for aldosterone-producing adenoma and primary adrenal hyperplasia is unilateral adrenalectomy. To decrease the surgical risks, hypokalemia should be corrected before the operation by the administration of spironolactone, oral potassium, or both. Several studies have shown that normalization of blood pressure with spironolactone before the operation is a good predictor of the successful treatment of hypertension after unilateral adrenalectomy.14,15,19,23 We are, however, often unable to evaluate an isolated response to spironolactone because other antihypertensive medications have usually been

TABLE 68-1. Adrenal Venous Sampling in a Patient with a Right Aldosterone-Producing Adenoma

Adrenal Venous Sampling Aldosterone (ng/dL) Cortisol (|ig/dL)

Ratio of Aldosterone to Cortisol

Aldosterone Ratio*

Basal Right Left

IVC below RV After ACTH stimulation Right Left

IVC below RV

520 120 54

4300 330 120

104.7 208.6

20.4

320.8 345.2

35.5

'Ratio of aldosterone to Cortisol divided by the ratio of aldosterone to Cortisol in the left adrenal vein. ACTH = adrenocorticotropin; IVC - inferior vena cava; RV - renal veins.

previously administered. In addition, spironolactone is equally effective in controlling arterial pressure in patients with aldos-terone-producing adenoma and those with idiopathic hyperal-dosteronism, irrespective of the different responses of the blood pressure in patients with these two conditions after unilateral adrenalectomy.35 We, therefore, do not use the response to spironolactone alone as a criterion for selection of adrenalectomy in patients with primary hyperaldosteronism.

Laparoscopic adrenalectomy is currently recommended as the optimal approach for primary hyperaldosteronism, although traditionally unilateral adrenalectomy by either a flank or posterior approach was the procedure of choice. The details of the operative technique for laparoscopic adrenalectomy are given elsewhere in this text as well as in the literature.62 64 Laparoscopic adrenalectomy has been used since 1992.65 67 Many studies have shown that this procedure has several advantages over open adrenalectomy, such as less postoperative blood loss, earlier recovery, and a smaller wound.68"73 The operative time and operative complications are not significantly different from those of open adrenalectomy. During the past 6 years, we have performed 75 laparoscopic adrenalectomies for aldosterone-producing adenomas. The average total operating time was 181 minutes, and the average blood loss was 27 mL—similar to that reported by others.

Most laparoscopic adrenalectomies for aldosterone-producing adenomas involve total removal of the adrenal gland. Several studies have reported that laparoscopic adrenal-sparing surgery is feasible and effective in the treatment of patients with primary hyperaldosteronism.74 76 The idea of adrenal-sparing surgery or partial adrenalectomy was initially advocated in open surgery.77 The need for adrenal preservation by partial adrenalectomy for patients with aldosterone-producing adenoma is unclear because long-term adrenal problems are rare after unilateral adrenalectomy.

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