Is the tumor co-secreting additional hormones?

Could the tumor be malignant? Carcinomas of the adrenal gland commonly present with corticosteroid excess, often in combination with other hormones. It is important not to miss a carcinoma of the adrenal gland presenting as Cushing’s syndrome, as the planned surgical approach may need to be adjusted if this is the likely diagnosis.

Achieve optimal preoperative control of hypertension, diabetes, and improving muscle strength where possible.

Patients are susceptible to infection with high doses of circulating steroids; wound healing will also be inhibited. It is often advisable, therefore, in these circumstances to block the effect of the steroids with drugs such as ketoconazole before surgery, aiming to allow the operation to take place in a patient who is not suffering from the gross metabolic consequences of hypercortisolism.

Patients should receive thromboprophylaxis according to NICE guidelines.

Patients with Cushing’s are susceptible to peptic ulcers, and prophylaxis should be considered.

Very careful (gentle) positioning of the patient who may have skin that easily bruises as well as severe osteoporosis. All pressure points must be carefully protected.

Prophylactic antibiotics should be prescribed.

Laparoscopic surgery (via either a transperitoneal or a posterior approach) for an adrenal adenoma is the ideal approach. Open surgery should be the approach if malignancy is suspected (see Chap.​ 5).

Platelet function is suppressed in the presence of high steroid levels. Be aware that the liver bruises easily and subcapsular hematomas can readily develop during dissection.