A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?

Improper supplementation of steroids

Bleeding profusely through the surgical site

Infection involving the suture line

Loss of fluids during the procedure

An endocrine surgeon wants to evaluate the risk of multiple endocrine neoplasia (MEN) type 2 syndromes in patients who experienced surgical hypertension during pheochromocytoma resection. She conducts a case-control study that identifies patients who experienced surgical hypertension and subsequently compares them to the control group with regard to the number of patients with underlying MEN type 2 syndromes. The odds ratio of MEN type 2 syndromes in patients with surgical hypertension during pheochromocytoma removal was 3.4 (p < 0.01). Given the rare disease assumption, this odds ratio can be interpreted as an approximation of the relative risk. The surgeon concludes that the risk of surgical hypertension during pheochromocytoma removal is 3.4 times greater in patients with MEN type 2 syndromes than in patients without MEN syndromes. This conclusion is best supported by which of the following assumptions?

Surgical hypertension associated with pheochromocytoma is rare

The case-control study used a large sample size

The relationship between MEN syndromes and surgical hypertension is not due to random error

Pheochromocytoma is common in MEN type 2 syndromes

The 95% confidence interval for the odds ratio does not include 1.0

A 47-year-old woman complains of weight gain and irregular menses for the past 2 years. She has gained 13 kg (28.6 lb) and feels that most of the weight gain is in her abdomen and face. She has type 2 diabetes and hypertension for 1 year, and they are difficult to control with medications. Vital signs include a temperature of 36.9°C (98.4°F), blood pressure of 160/100 mm Hg, and pulse of 95/min. The patient's late-night salivary cortisol is elevated. Morning plasma ACTH is high. Brain magnetic resonance imaging shows a 2 cm pituitary adenoma. Which of the following is the optimal therapy for this patient?

Transsphenoidal pituitary adenomectomy

Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?

Intravenous isotonic saline infusion

A 27-year-old man is brought to the emergency department by ambulance following a motor vehicle accident 1 hour prior. He appears agitated. His blood pressure is 85/60 mm Hg, the pulse is 110/min, and the respiratory rate is 19/min. Physical examination shows bruising of the left flank and fracture of the left lower thoracic bones. Strict bed rest and monitoring with intravenous fluids is initiated. Urinalysis shows numerous RBCs. A contrast-enhanced CT scan shows normal enhancement of the right kidney. The left renal artery is only visible in the proximal section with a small amount of extravasated blood around the left kidney. The left kidney shows no enhancement. Imaging of the spleen shows no abnormalities. Which of the following is the most appropriate next step in management?

Observation with delayed repair

Renal artery embolization with delayed nephrectomy

A 67-year-old woman with tertiary hyperparathyroidism and end-stage renal disease on hemodialysis has persistent hypercalcemia (calcium 12.8 mg/dL) despite maximal medical management with cinacalcet and vitamin D restriction. She has severe pruritus, calciphylaxis, and vascular calcifications. All four parathyroid glands are enlarged on imaging. Evaluate the optimal surgical strategy considering her complex medical status and need for ongoing dialysis access.

Total parathyroidectomy with forearm autotransplantation

Single adenoma resection guided by sestamibi

Subtotal parathyroidectomy (3.5 gland resection)

Total parathyroidectomy without autotransplantation

Medical management escalation with denosumab

Adrenalectomy approaches for USMLE Step 3: High-Yield Surgery Lessons

🗺️ Anatomy - Location, Location, Adrenal!

Location: Retroperitoneal, superomedial to kidneys.
Key Relations:
- Right Gland (Pyramidal): Posterior to the IVC and liver.
- Left Gland (Crescentic): Medial to the spleen; posterior to the pancreas tail; lateral to the aorta.

Adrenal Gland Blood Supply and Venous Drainage

Arterial Supply (x3):
- Superior Adrenal A. (from Inferior Phrenic A.)
- Middle Adrenal A. (from Aorta)
- Inferior Adrenal A. (from Renal A.)
Venous Drainage (Asymmetric):
- Right Adrenal V. $\rightarrow$ IVC (short, direct)
- Left Adrenal V. $\rightarrow$ Left Renal V. (longer)

⭐ The short Right Adrenal Vein draining directly into the IVC increases the risk of hemorrhage and IVC injury during right adrenalectomy.

🔪 Management - The Surgical Game Plan

The choice of adrenalectomy approach hinges on tumor size, suspicion of malignancy, and patient factors.

Approach	Indications	Patient Factors	Advantages	Disadvantages
Lap Transabdominal	Benign tumors <6-8 cm	Standard anatomy	Familiar view, large space	Bowel handling, visceral risk
Lap Retroperitoneal	Small tumors <5 cm, bilateral	Obesity, prior abd. surgery	Direct access, avoids bowel	Small space, technically hard
Open	ACC, tumors >10 cm, invasion	Driven by tumor	En bloc resection, controls large vessels	↑ morbidity, long recovery

Adrenalectomy: Laparoscopic Port vs Open Incision

⚠️ Complications - When Things Go South

Intra-operative
- Hemorrhage: High risk from the short, friable central adrenal vein, especially on the right (direct IVC entry).
- Organ Injury:
  - Left-sided: Spleen (most common), pancreas tail, kidney.
  - Right-sided: Liver, duodenum, IVC.
- Hypertensive Crisis: Due to catecholamine release from pheochromocytoma manipulation.
Post-operative
- Adrenal Insufficiency: Critical risk after removing a cortisol-producing adenoma (suppressed contralateral gland) or bilateral adrenalectomy. Requires stress-dose steroids.
- Thromboembolism (DVT/PE): Increased risk in Cushing's syndrome.
- General: Atelectasis, wound infection.

⭐ Pheochromocytoma: Intra-op catecholamine surge from tumor handling can cause life-threatening hypertension & tachycardia. Pre-op alpha-blockade (e.g., phenoxybenzamine) is crucial to prevent this.

⚡ Biggest Takeaways

Laparoscopic adrenalectomy is the gold standard for most benign tumors (<6 cm).

Transperitoneal (TLA) is the most common approach, offering a larger working space.

Posterior retroperitoneal (PRA) is ideal for bilateral tumors, obesity, or prior abdominal surgery.

Open adrenalectomy is mandatory for large (>10 cm) or suspected malignant tumors (ACC) to ensure complete resection.

Major risks include spleen/pancreas injury (left) and liver/IVC injury (right).

For pheochromocytoma, preoperative alpha-blockade is crucial to prevent hypertensive crisis.

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