Laparoscopic Adrenalectomy
60650
-
60540— Open adrenalectomy -
60545— Open adrenalectomy with excision of adjacent retroperitoneal tumor
Right/left adrenal adenoma / pheochromocytoma / adrenocortical carcinoma / Conn's syndrome / Cushing's syndrome / incidentaloma with indeterminate features
Same
Laparoscopic right/left adrenalectomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with a [right/left] adrenal [mass/pheochromocytoma/adenoma] measuring [___] cm with [biochemical/radiographic] features of [indication]. [For pheochromocytoma: alpha-blockade with phenoxybenzamine was completed preoperatively.] The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
A [___]-cm [right/left] adrenal [mass/adenoma/pheochromocytoma] was identified. The gland was [well-encapsulated/partially adherent to surrounding structures]. The [right adrenal vein entering the IVC / left adrenal vein entering the left renal vein] was identified and controlled early. [No evidence of local invasion or lymphadenopathy.] [Additional findings or none].
The patient was brought to the operating room and placed in the [right/left] lateral decubitus position with the affected side up and the table flexed. General endotracheal anesthesia was induced. Foley catheter was placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics. [For pheochromocytoma: anesthesia was alerted for hemodynamic monitoring and prepared with phentolamine and nitroprusside for hypertensive crises and norepinephrine for hypotension after ligation.]
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established to 15 mmHg. A 12-mm trocar was placed and three additional 5-mm trocars were placed under direct visualization in the [right/left] upper quadrant.
[For right adrenalectomy:] The right triangular hepatic ligament was incised to reflect the right lobe of the liver medially. The right adrenal gland was identified superior and medial to the right kidney. The retroperitoneal fat was dissected to expose the adrenal gland. The right adrenal vein was carefully identified at its entry into the inferior vena cava (IVC), clipped with [hem-o-lok clips (x2 proximally, x1 distally)], and divided. Remaining adrenal vessels were divided with [energy device]. The gland was dissected from the retroperitoneum circumferentially with care to avoid entering the gland capsule. The specimen was placed in a retrieval bag and extracted.
[For left adrenalectomy:] The splenocolic ligament was divided and the spleen was reflected medially. The tail of the pancreas was identified and reflected anteriorly. The left adrenal gland was identified superior to the left kidney. The left adrenal vein was identified at its entry into the left renal vein, clipped with [hem-o-lok (x2 proximally, x1 distally)], and divided. Remaining adrenal vessels were divided with energy device. The gland was dissected circumferentially and placed in a retrieval bag.
The operative bed was inspected. Hemostasis was confirmed. The specimen was extracted intact through the 12-mm port site. The trocars were removed under direct visualization. The 12-mm fascia was closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl]. Sterile dressings were applied.
None
Adrenal gland sent to pathology
Minimal (less than 30 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** adrenal ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic *** adrenalectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a *** adrenal mass *** cm. *** preoperative alpha blockade. Informed consent obtained.
FINDINGS: *** cm *** adrenal ***. Gland ***. Adrenal vein identified and controlled.
DESCRIPTION OF PROCEDURE:
*** lateral decubitus, affected side up. Foley placed. General anesthesia. Surgical timeout per protocol.
Four trocars placed. *** Adrenal vein identified, clipped x3, and divided. Gland dissected circumferentially without capsule entry. Specimen extracted in retrieval bag. Hemostasis confirmed.
Fascia closed at 12-mm site. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Adrenal gland to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Pheochromocytoma — Hemodynamic Management
Given the diagnosis of pheochromocytoma, the adrenal vein was prioritized and ligated early in the dissection to minimize catecholamine release. Anesthesia continuously monitored blood pressure and heart rate. [Several episodes of intraoperative hypertension to ___ mmHg were managed with phentolamine boluses.] After adrenal vein ligation, blood pressure normalized. [Norepinephrine infusion was required after removal for hypotension.] The gland was handled gently and minimal manipulation was performed prior to vein ligation.
Bilateral Adrenalectomy
After completion of the right adrenalectomy, the patient was repositioned to the left lateral decubitus position and the left side was prepped. The procedure was repeated for the left adrenal gland as described. Total operative time was [___] minutes. Given bilateral adrenalectomy, stress-dose hydrocortisone was administered intraoperatively (100 mg IV) and lifelong glucocorticoid and mineralocorticoid replacement was arranged.
Posterior Retroperitoneoscopic Approach
A posterior retroperitoneoscopic adrenalectomy (PRA) was performed with the patient in prone jack-knife position. A small incision was made in the posterior flank below the 12th rib. The retroperitoneal space was developed with a balloon dilator and a 12-mm trocar was placed. Two 5-mm trocars were placed laterally. The adrenal gland was identified directly without peritoneal entry and resected as described, with early adrenal vein ligation.
Charting Tips
- Document that the adrenal vein was ligated and divided early — for pheochromocytoma, this is the key operative step that prevents catecholamine surge. For all cases, early vein ligation reduces intraoperative bleeding and is a technical quality indicator.
- Document that the adrenal capsule was intact on extraction — capsule disruption has oncologic implications for adrenocortical carcinoma (upstaging to stage III) and should be noted if it occurs.
- For pheochromocytoma, document the hemodynamic events and management during the case — intraoperative hypertensive crises, the antihypertensive agents used, and the drop in pressure after vein ligation are clinically important for the ICU team and for future reference.
Billing Tips
- Bill 60650 for laparoscopic adrenalectomy (20.21 wRVU, 90-day global). Use for both transabdominal and retroperitoneoscopic approaches — technique does not change the code.
- 60650 covers unilateral adrenalectomy. For bilateral laparoscopic adrenalectomy, bill 60650 twice with modifier -50 (bilateral). Document each side separately with individual gland weight, appearance, and pathologic findings.
- 90-day global period: endocrine follow-up labs (cortisol, aldosterone, catecholamines) and office visits within 90 days are bundled. Steroid taper management is bundled — do not bill a separate E/M for routine hormonal follow-up within the global period.
- For pheochromocytoma, document preoperative alpha-blockade, hemodynamic events during manipulation, and post-resection hypotension — these support medical complexity and are essential for payer audit defense.
- Open adrenalectomy uses 60540 (unilateral) or 60545 (with excision of adjacent retroperitoneal tumor). Document conversion from laparoscopic to open if applicable.