American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary.

IMPORTANCE: Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications. OBJECTIVE: To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy. EVIDENCE REVIEW: A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included. FINDINGS: Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics. CONCLUSIONS AND RELEVANCE: Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care

Ultrasonido laparosc\uf3pico

El ultrasonido laparosc\uf3pico es un progreso relativamente reciente del campo de la ultrasonograf\ueda quir\ufargica cuya aparici\uf3n puede atribuirse a la necesidad de crear transductores especializados que pudieran hacerse pasar de manera ajustada a trav\ue9s de los trocares laparosc\uf3picos ordinarios. Han evolucionado con rapidez calidad, confiabilidad y facilidad de uso de estas unidades, de modo que es posible efectuar en la actualidad ultrasonograf\ueda laparosc\uf3pica de manera sistem\ue1tica. La ultrasonograf\ueda laparosc\uf3pica permite al cirujano revisar los tejidos que est\ue1 operando, y compensar as\ued su incapacidad para palparlos f\uedsicamente. Por este motivo, no s\uf3lo ha sido de utilidad para imitar a las operaciones abiertas, sino que ha refinado las t\ue9cnicas quir\ufargicas laparosc\uf3picas actuales. Gracias a la disponibilidad creciente de equipo de esta clase, as\ued como a la capacitaci\uf3n de los cirujanos en esta modalidad, el ultrasonido laparosc\uf3pico se est\ue1 convirtiendo con rapidez en un instrumento esencial para el cirujano que pretende llevar a la cirug\ueda laparosc\uf3pica hasta fronteras novedosas