Partial adrenalectomy (tumor resection) and total adrenalectomy 1. Indications for partial adrenalectomy (tumor resection) Total adrenalectomy used to be the preferred method for the treatment of occupying adrenal lesions. Although the first partial adrenalectomy was performed as early as 1934, it has only become a routine procedure in the last 10 years or so, thanks to the spread of modern imaging technology, the updating of surgical equipment, and the improvement of surgical skills. The main indications for partial adrenalectomy are lesions occurring in isolated adrenal glands, bilateral adrenal lesions, and adrenal lesions in patients with familial or genetic background. For adrenocortical carcinoma, metastases, unilateral adrenal multiple functional adenomas or nodules, total adrenalectomy should be chosen. Pheochromocytoma (PHEO) In 2014, the “Clinical Guidelines for Pheochromocytoma and Paraganglioma” jointly published by the American and European Endocrine Society pointed out that for hereditary PHEO, partial adrenalectomy is recommended for small tumors that have been completely resected contralaterally to preserve part of the adrenal cortex and avoid permanent corticosteroid The guidelines state that for hereditary PHEO, partial adrenalectomy is recommended to preserve part of the adrenal cortex to avoid permanent hypocorticism. In patients with total contralateral adrenalectomy, partial adrenalectomy preserves enough adrenal cortex that glucocorticoid and salt corticosteroid supplementation is not required in approximately 90% of patients. However, the larger the tumor size, the less cortical space is preserved, and the greater the likelihood of requiring postoperative hormone supplementation. The recurrence of adrenal tumors after partial excision should not be ignored, as the recurrence rate of VHL patients is 10%-15% at 10 years after surgery. year recurrence rate of residual glandular tumors was 7%, of which 78% did not require hormone supplementation. Complications of re-operative resection of recurrent tumors are higher than those of initial surgery, and open surgery may be an option. 3, ACTH non-dependent Cushing’s syndrome (CS) Cortisol-secreting adrenal primary adenomas are recommended for laparoscopic resection of adrenal preserved tumors. Large nodular adrenal hyperplasia (AIMAH) and primary pigmented nodular adrenal disease (PPNAD) were once considered to be preferred to bilateral adrenalectomy with lifelong postoperative corticosteroid replacement. However, Takata observed that even with postoperative corticosteroid supplementation, there is still a risk of acute adrenocortical insufficiency and hormone oversupplementation in 23% of patients. Therefore, considering that AIMAH and PPNAD are benign lesions, preserving the adrenal glands for surgery is not a relatively reasonable option, despite the risk of secondary surgery. For those with moderately elevated urinary free cortisol (UFC) and disparity in adrenal volume between the two adrenal glands, resection of the adrenal gland with significant hyperplasia is recommended; total adrenalectomy on one side and partial resection on the opposite side is recommended for those with significant CS symptoms and significantly elevated UFC. The surgery can be done bilaterally in one phase or in stages, and laparoscopic surgery is recommended. 4.Primary aldosteronism (PHA) For aldosterone adenoma (APA), the CUA guidelines recommend laparoscopic adrenal tumor resection, preserving adrenal tissue as much as possible, and if multiple APA is suspected, total adrenalectomy on the affected side is recommended. In unilateral adrenal hyperplasia (UAH), total laparoscopic adrenalectomy on the aldosterone-dominant side is recommended. Yang Qing et al. performed posterior laparoscopic adrenal adenoma enucleation (145 cases) or partial adrenalectomy on the affected side (51 cases) in 196 patients with APA, and none of the 196 cases showed cortical insufficiency such as panic, malaise, fever, and decreased blood pressure after surgery. At a follow-up of 6 months to 3 years (mean 1.8 years), blood pressure returned to normal in 168 cases (85.7%) and was higher than the normal range in 27 cases (13.8%). The safety and efficacy of posterior laparoscopic partial adrenalectomy (tumor enucleation) were confirmed, and the corresponding adrenal cortical function could be preserved. The American and European Endocrine Society guidelines recommend laparoscopic total adrenalectomy for APA and unilateral adrenal hyperplasia (UAH). Idiopathic hyperaldosteronism (IHA) and familial hyperaldosteronism (FH/GRA) are mainly treated with medications. However, surgery can be considered when patients are unable to adhere to medical treatment due to side effects of medications. The cure rate for hypertension after unilateral or bilateral adrenalectomy is only 19%. Partial adrenalectomy is not always easy to perform. First, the possibility of intraoperative bleeding and the amount of bleeding are higher than in total resection. Second, partial adrenalectomy is more difficult for central tumors, and it remains controversial whether to preserve the adrenal vein. Third, it remains a challenge for surgeons to determine how much of the adrenal gland to preserve in order to maintain normal hormonal function in different patients, and how to accurately estimate the volume of the adrenal gland to be preserved intraoperatively.