Li HuanGe Lu QiaoXian Nur Izzati

Adrenal Glands - Lie retroperitoneally beneath the diaphragm - Capping the medial aspects of the superior pole of each kidney - Produce various hormones
- Regulate metabolism - Immune system - Blood pressure - Blood sugar - Other essential functions

Suspicion

of malignancy Functional adrenal mass Isolated adrenal metastasis Cushings syndrome

 Uncontrolled

coagulopathy Severe cardiopulmonary disease Presence of a locally advanced tumor, and medically untreated pheochromocytoma. Extensive previous abdominal surgery Pregnant patients

 Major

hormone imbalances

problems with healing, blood pressure fluctuations, and other metabolic problems.

Other

risks are typical of many operations. These include:

bleeding damage to adjacent organs (spleen, pancreas) loss of bowel function blood clots in the lungs lung problems surgical infections pain scarring

 Preoperative

management and control of the physiologic effects of hormonally or vasoactive tumors

Patients with Pheochromocytoma: should undergo alpha blockade at least 7-10 days before surgery Hypercortisolism: stress doses of steroids should be administered before and following surgery Aldosteronomas: should have hypokalemia corrected, and blood pressure should be adequately controlled

Three different surgical approaches

Transabdominal lateral flank approach( most often used) Anterior transabdominal approach Retroperitoneal approach

 Port

positioning and laparoscopic access Liver retraction and dissection

with a blunt grasper, a fan retractor, kite or snake-type retractors, or a Nathanson liver retractor

Adrenal

vein dissection and ligation

use a right-angle dissector or Maryland dissector to gently dissect the vessel

Adrenal

gland dissection Adrenal gland removal and completion

placed in a specimen retrieval bag and removed through a 10-mm trocar

 Physical

exam Blood tests Urine tests Abdominal ultrasound CT scan of the abdomen and head MRI scan Nuclear scan (MIBG or NP-59)

a test in which a small amount of radioactive material is injected and pictures are taken of the inside of the body to determine if the tumor is cancerous

Investigation
CBC,GXM Chest

x-ray, ECG PT/PTT Renal function test(K+ level) General

Urinary

catheter Nasogastric tube Sequential compression devices Appropriate antibiotics

Lateral or semi-lateral position, ranging from 45-70 ( transperitoneal approach) Using a beanbag mattress, but a gel roll will suffice. Umbilicus should be near the joint in the table to allow for flexing of the table to improve flank exposure Safety straps and tape are used to securely position the patient All pressure points should be padded to prevent nerve compression injuries. The patients arm is placed on an arm rest and should be adequately padded. A shoulder roll is also placed. Reverse Trendelenburg positioning can also help with exposure.

Laparoscopic Instruments
right angle dissector, hook electrocautery laparoscopic suction/irrigator

Other useful instruments

liver retractor specimen retrieval bag electrosurgical instrument: Harmonic Scalpel or LigaSure vascular-load endoscopic stapling device

In PACU
Monitor

Bleeding Manage pain Monitor vital signs Nausea and Vomiting

Provide routine post-op care. Monitor serial blood sugars, serum electrolytes is very important.

Surgical stress may aggravate the glucose intolerance associated with Cushing's syndrome. Moreover, postadrenalectomy there is a tendency towards hypoglycemia because of impaired hepatic gluconeogenesis especially if steroid replacement is inadequate. Monitor vital signs, I&O. Administer IV therapy and vasopressors as ordered.

Observe for hemorrhage and shock.

Prevent infections (suppression of immune system makes clients especially susceptible).

Encourage coughing and deep breathing to prevent respiratory infection. Use meticulous aseptic technique during dressing changes.

Administer cortisone or hydrocortisone as ordered to maintain cortisol levels. Provide general care for the client with abdominal surgery

Diet

Follow the diet recommended by your doctor. To avoid retaining fluid, you may need to monitor and reduce salt intake. You may also need to restrict your fluids. Ask your doctor when you will be able to return to work. Do not drive for the first week unless your doctor has given you permission to do so. No strenuous activity for 2 weeks eg. no exercise, heavy lifting, shovelling, or sports. Avoid activity that may stress any of the surgical incisions. If you had to stop taking medicines before the procedure, ask your doctor when you can resume taking them. Medicines that are commonly stopped include: Anti-inflammatory drugs (eg, aspirin) Blood thinners, such as clopidogrel (Plavix) or warfarin (Coumadin)

Physical Activity

Medications

Home Care

Monitor your weight daily. Report a weight gain of more than 2 lbs per day to your doctor. This may mean you are retaining fluid. You may shower, but no swimming or tub baths for 2wks. Gently wash the part of your body that has the stitches. Pat the area gently with a clean towel. When the area is dry, put on a clean, new bandage as directed. Keep the incision area clean and dry. Wash your hands before changing the dressing. Ask your doctor about when it is safe to shower, bathe, or soak in water. Monitor your blood pressure daily or as ordered by your doctor. If your doctor instructs you to, wear compression stockings until you are able to walk on a regular basis. The compression stocking will help to decrease blood clots from forming in your legs.

 Fludrocortisones

is prescribed for transient aldosterone deficiency (common after adrenelectomy). The symptoms are postural hypotension and hyperkalemia. On maintenance therapy can develop addisonian crisis when under stress The symptoms of fever, abdominal pain, and hypotension.

 http://www.sages.org/publication/id/PI14/ http://www.thirdage.com/hc/p/14760/adre

nalectomy-what-to-expect http://www.mountsinai.org/patientcare/health-library/treatments-andprocedures/adrenalectomy-open-surgery https://www.wnyurology.com/content.aspx? chunkiid=561998