## **Core Concept**
Bilateral adrenalectomy is sometimes performed for the management of Cushing's disease, particularly when other treatments fail or are not feasible. This surgical procedure involves the removal of both adrenal glands, which are responsible for producing cortisol. After removal, patients will require lifelong corticosteroid replacement therapy. Intraoperative administration of hydrocortisone is crucial to prevent acute adrenal insufficiency.

## **Why the Correct Answer is Right**
The correct timing for administering hydrocortisone during bilateral adrenalectomy is **after the removal of both adrenal glands**. This is because the body's natural source of cortisol (the adrenal glands) is being surgically removed, and exogenous cortisol (hydrocortisone) needs to be given to prevent acute adrenal crisis. Administering hydrocortisone after the glands are removed ensures that the patient has sufficient cortisol levels to avoid a potentially life-threatening crisis.

## **Why Each Wrong Option is Incorrect**
- **Option A:** Administering hydrocortisone before the surgery starts does not directly address the immediate need for replacement therapy post-removal of the glands. It might help in reducing surgical stress but does not accurately reflect the critical moment for replacement therapy initiation.
- **Option B:** Giving hydrocortisone during the surgery but before removal of the glands might help with surgical stress response but does not accurately address the immediate post-operative need for cortisol replacement therapy.
- **Option D:** Delaying hydrocortisone administration until post-operatively but not specifying it needs to be after gland removal could lead to a delay in providing essential cortisol replacement.

## **Clinical Pearl / High-Yield Fact**
A crucial point to remember is that patients undergoing bilateral adrenalectomy require lifelong corticosteroid replacement therapy. The dose of hydrocortisone should be adjusted according to the patient's needs, and typically, a dose of 100-200 mg per day is started post-operatively, divided into multiple doses.

## **Correct Answer:** C. after removal of both adrenal glands.