Surgical Treatment Of Primary Hyperaldosteronism

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The treatment of choice for patients with primary hyperaldosteronism caused by an aldosterone-secret-ing adrenal adenoma is surgical resection. Preopera-tive preparation of patients for adrenalectomy should include correction of hypokalemia and control of hypertension. Spironolactone, a competitive antagonist of aldosterone, is an effective agent for controlling blood pressure and also helps to increase serum potassium levels; oral potassium supplements can be used in conjunction with spironolactone to achieve normokalemia. A good blood pressure response to spironolactone is also an excellent predictor of a good

Figure 8-4. Algorithm for the diagnosis of primary hyperaldos-teronism and differentiation between adenoma and hyperplasia. CT = computed tomography.
Figure 8-5. Intraoperative photograph of a laparoscopic adrenalectomy.

response to adrenalectomy. An alternative medication to spironolactone is amiloride, which is a potassium-sparing diuretic. Patients may require other antihypertensive medications if their hypertension is refractory to spironolactone or amiloride. Some patients may benefit from a sodium-restricted diet.

In previous decades, the favored surgical approach to resection of aldosterone-secreting adenomas was unilateral open adrenalectomy, using either a posterior (Hugh-Young) or lateral flank incision. The introduction of laparoscopic adrenalectomy in 1992 dramatically altered the surgical approach to primary hyperaldosteronism.4-61213 Currently, unilateral laparoscopic adrenalectomy is the procedure of choice for resection of aldosteronomas (Figure 8-5). These tumors are well suited for laparoscopic resection because they are relatively small and are almost always benign, and their location is usually known prior to operation from CT or other localization studies. The advantages of laparoscopic adrenalectomy include smaller incisions, decreased postoperative pain, fewer incisional hernias, and shorter duration of hospitalization. In our recent study comparing patients who underwent laparoscopic adrenalectomy with patients who underwent open adrenalectomy for primary hyperaldosteronism, we found that laparo-scopic adrenalectomy resulted in fewer postoperative complications than open adrenalectomy.6 In addition, patients undergoing laparoscopic adrenalectomy were equally likely to improve in blood pressure (= 75%) and hypokalemia (98%) when compared with patients treated with the open technique.

The technique for laparoscopic adrenalectomy has been well described in other publications. Aldos-

teronomas may be resected laparoscopically either by the posterior or the lateral approach.14 The choice of approach depends largely on surgeon preference and experience. Regardless of the approach that is selected for laparoscopic adrenalectomy, this operation should be performed by an experienced laparoscopic surgeon.

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