What is the priority surgical procedure for an elderly female patient with a hernia and an adrenal gland disorder, such as Cushing's syndrome or an adrenal tumor, requiring both hernia repair and adrenal gland removal?

Surgical Priority: Adrenal Gland Removal First

The adrenal gland removal must be performed first, before hernia repair, if the patient has a functional adrenal lesion (Cushing's syndrome, pheochromocytoma, or aldosterone-secreting adenoma). The presence of active hypercortisolism, catecholamine excess, or hyperaldosteronism creates life-threatening perioperative risks including cardiovascular complications, poor wound healing, and metabolic crises that would make elective hernia repair extremely dangerous 1, 2.

Decision Algorithm Based on Adrenal Pathology

If Functional Adrenal Lesion (Priority: Adrenalectomy First)

Cushing's Syndrome/Hypercortisolism:

• Patients with clinically apparent Cushing's syndrome require unilateral adrenalectomy of the affected gland before any elective surgery 1. Hypercortisolism causes severe metabolic derangements including hypertension, hyperglycemia, immunosuppression, and impaired wound healing that dramatically increase surgical morbidity and mortality 2.
• The presence of severe complications like left ventricular hypertrophy or cirrhosis indicates end-organ damage requiring rapid cortisol normalization through bilateral adrenalectomy before considering other procedures 2.
• Minimally-invasive surgery should be performed when feasible for adrenalectomy 1, 3.

Pheochromocytoma:

• Adrenalectomy must be performed for confirmed pheochromocytomas before any elective procedure 1. Uncontrolled catecholamine excess creates catastrophic intraoperative hypertensive crises, arrhythmias, and cardiovascular collapse during anesthesia induction or surgical manipulation 1.

Aldosterone-Secreting Adenomas:

• Unilateral aldosterone-producing adenomas require adrenalectomy as definitive treatment 1. Severe hypertension and hypokalemia from hyperaldosteronism increase perioperative cardiovascular risk and must be addressed surgically before elective procedures 1.

If Non-Functional Adrenal Lesion (Priority: Depends on Size and Characteristics)

Benign Non-Functional Adenomas <4 cm:

• These lesions do not require surgery and the hernia repair can proceed as the primary procedure 1. No further follow-up imaging or functional testing is required for benign non-functional adenomas <4 cm 1.

Indeterminate or Larger Lesions (≥4 cm):

• Suspected adrenocortical carcinoma requires adrenalectomy first 1. Minimally-invasive adrenalectomy can be offered if the tumor can be safely resected without rupturing the capsule 1.
• Open adrenalectomy should be considered for larger adrenocortical carcinomas or locally advanced tumors 1.
• For indeterminate non-functional lesions, shared decision-making should guide whether to proceed with repeat imaging versus surgical resection before hernia repair 1.

Critical Perioperative Considerations

Why Functional Adrenal Lesions Take Priority:

• Hypercortisolism causes immunosuppression, poor wound healing, increased infection risk, and metabolic instability that make hernia repair outcomes significantly worse 2, 4.
• Uncontrolled pheochromocytoma during hernia surgery can cause fatal intraoperative cardiovascular events 1.
• The elderly population has reduced physiologic reserve, making them particularly vulnerable to the compounded stress of untreated adrenal hyperfunction during surgery 2.

Post-Adrenalectomy Considerations:

• Following adrenalectomy for functional lesions, patients require glucocorticoid replacement and close monitoring for adrenal insufficiency before proceeding with hernia repair 2, 5.
• If bilateral adrenalectomy is performed, lifelong glucocorticoid and mineralocorticoid replacement is necessary, with risk of Nelson syndrome requiring regular pituitary MRI monitoring 2, 5.
• Hernia repair can typically proceed 4-6 weeks after adrenalectomy once hormonal status is stabilized and surgical recovery is complete 6, 3.

Common Pitfalls to Avoid

• Never proceed with elective hernia repair in a patient with undiagnosed or untreated functional adrenal pathology 1, 2. All elderly patients with adrenal masses should be screened for autonomous cortisol secretion using 1 mg dexamethasone suppression testing 1, 7.
• Do not assume small adrenal lesions are benign without functional testing 1, 8. Even relatively small tumors can harbor malignancy or produce excess hormones 8.
• Avoid performing hernia repair under general anesthesia in patients with undiagnosed pheochromocytoma 1. Screen patients with adrenal incidentalomas displaying ≥10 HU on non-contrast CT for pheochromocytoma with plasma or 24-hour urinary metanephrines 1.