ADRENALECTOMY (Latin adrenalis — epinephral and Greek ektome — excision, removal; synonym: extirpation of an adrenal gland, epinefrektomiya) — surgery of removal of an adrenal gland.
And. began to make only at the end of 19 century at new growths of adrenal glands; however results of surgical interventions were ineffective because of impossibility of performing replacement hormonal therapy. In 1912 the French surgeon Delbe (P. L.E. Delbet) made And. the left adrenal gland to three patients with an essential hypertension who soon died; after that on adrenal glands at an idiopathic hypertensia refused operative measures.
In 1922 at the XV congress of the Russian surgeons V. A. Oppel proposed to make And. to patients with spontaneous gangrene of the lower extremities (obliterating endarteritis), explaining a spasm of peripheral arteries with the strengthened products of adrenaline adrenal glands. Results of these operations were also not encouraging. And only since the 50th years 20 century, thanks to accumulation of knowledge of function of adrenal glands and achievements of chemistry of the steroid connections providing synthesis of active corticosteroid drugs, And. was widely adopted.
Absolute indications to And. hormone-producing tumors of an adrenal gland (a kortikosteroma, an androsteroma, an aldosteroma, a kortikoestroma, a pheochromocytoma), cancer of an adrenal gland without endocrine manifestations and severe forms of a disease of Itsenko — Cushing are.
At Itsenko's disease — Cushing is made bilateral And., usually in two stages with autotransplantation of sites of bark of an adrenal gland in hypodermic cellulose or without it. The subtotal resection of both adrenal glands at the specified disease was not repaid since a recurrence arises in 25 — 30% of cases, and repeated interventions on adrenal glands are followed by a high postoperative lethality (to 50%).
The relative indication to And. the idiopathic hypertensia is. At the heavy and quickly progressing forms (with diastolic pressure not less than 120 mm of mercury.), if conservative therapy does not give effect, carry out bilateral And. Some surgeons at especially severe forms of an idiopathic hypertensia recommend along with And. to make at the same time sympathectomy (see). Postoperative mortality at patients with an idiopathic hypertensia makes 23 — 47%. However the high lethality is explained not by the nature of surgery, but weight of a basic disease.
Bilateral And. some foreign surgeons at inoperable forms of cancer of milk and prostatic glands since it prolongs life of patients recommend.
Contraindications to And. at patients with an idiopathic hypertensia advanced age, existence of a cardiovascular and renal failure is. At tumors of an adrenal gland And. it is contraindicated in the presence of metastasises.
Technology of operation. All offered approaches to adrenal glands present generally to modification of lumbar, transperitoneal and transthoracic accesses. Adrenal glands operations make under an endotracheal anesthesia.
At the known localization of a tumor of an adrenal gland usually use lumbar or thoracolumbar transphrenic access from the relevant party. If in the presence of a clinical picture of the tumor of an adrenal gland confirmed with datas of laboratory, the topical diagnosis remains not clear, apply a laparotomy (better cross) that allows to examine at the same time both adrenal glands, and also places of a possible arrangement of malrelated tumors (a paraganglion at a pheochromocytoma, ovaries and a wide ligament of a uterus at an androsteroma). At patients kortikostsromy (Cushing's syndrome) as a result of disturbance of reparative processes discrepancy and suppuration of an operational wound is quite often observed; therefore use of transthoracic or transabdominal accesses is not shown them because of danger of development of a pyothorax or eventration. In these cases lumbar extra peritoneal access is shown. All above concerns also to patients with a disease of Itsenko — Cushing (adrenal struma). Small benign tumors should be deleted by enucleation, trying to keep whenever possible fabric of bark, adjacent to a tumor. At suspicion on a malignant new growth the tumor is deleted together with an adrenal gland and surrounding cellulose according to the principles accepted during removal of malignant tumors. The right
adrenal gland operations because of a possibility of germination are especially dangerous by a tumor of the lower vena cava therefore at the disposal of the surgeon always there has to be the corresponding tools and a set of atraumatic needles for an angiorrhaphy in case of wound of a wall of the lower vena cava.
Technology of removal of the adrenal gland which is not affected with a tumor (Itsenko's disease — Cushing and other diseases), consists in gradual careful allocation in its way of consistently imposed styptic clips on the cellulose surrounding an adrenal gland with the subsequent alloying.
The technique of an adrenalectomy is developed, edges consists in allocation and the isolated bandaging of an average adrenal vein without alloying of arterial vessels. After crossing between ligatures of an average vein of an adrenal gland the last is vyslaivat in the stupid way from surrounding cellulose. At the specified technique, as a rule, there is no bleeding since the arterial bed of an adrenal gland is presented by a set of small vessels which are quickly thrombosed. Operation is finished with leading of a rubber drainage which is taken in 2 — 3 days.
In the postoperative period at patients with an androsteroma, kortikoestromy, aldosteromy, a pheochromocytoma, and also after removal of one adrenal gland at Itsenko's disease — Cushing corticosteroid and angiotonic hormones do not appoint.
After removal of a kortikosteroma administration of corticosteroid drugs has crucial importance since the second, the adrenal gland which is not affected with a tumor is in a condition of an atrophy.
The scheme of administration of hormonal drugs at patients kortikosteromy, and also after removal of the second adrenal gland at Itsenko's disease — Cushing — see. Kortikosteroma .
Bibliography: Alexandrov N. N. and Pantyushenko T. A. Adrenal glands operation at patients with far come breast cancer, Minsk, 1071, bibliogr.; Nikolaev O. V. and Keriman V. I. Kortikosteroma, M., 1970. bibliogr.; Nikolaev O. V. and E. I Cockroaches. Hormonal and active tumors of bark of an adrenal gland. M, 1963, bibliogr.; Onpel V. A. Spontaneous gangrene as hyperadrenalemia, L., 1928.
V. I. Kertsman, O. V. Nikolyev.