How is adrenal surgery performed?
In experienced hands, laparoscopic adrenalectomyAdrenalectomy - an operation to remove the adrenal gland allows for quick recovery and minimal post-operative pain.20, 21, 24 However, laparoscopic adrenalectomy is not recommended for very large tumors and those with a high likelihood of malignancy (cancer). The decision to perform an open or laparoscopic operation will be made on an individual basis by your surgeon. Approximately 3% of operations that are started laparoscopically will need to be converted to an open operation.25, 26 Conversion to an open operation is based on the judgment of the surgeon. Common reasons for conversion to an open approach include the tumor being stuck to surrounding structures, signs of malignancy (cancer), and tumors too large to be safely removed laparoscopically. Laparoscopic adrenalectomy can be done using one of three different techniques: transabdominal (i.e. through the belly), retroperitoneal (i.e. through the back), and robotic.
Laparoscopic Transabdominal Adrenalectomy:
The transabdominal approach was the first technique described for this operation. For this procedure the patient is positioned either supine (i.e. lying flat on the back) or on the side. Three or four small incisions (less than an inch each) are made below the rib cage. The cavity is then inflated with carbon dioxide gas. For left adrenalectomies, typically 3 operating ports are used. For right adrenalectomies, one additional port is usually needed to hold the liver out of the way. On the left side, the spleen, tail of the pancreas, and often the colon must be carefully moved out of the way to see the gland. On the right side, the liver and often the colon and duodenum (first part of the small intestine) are carefully moved out of the way to see the adrenal gland. The adrenal vein is tied off and the adrenal gland is separated from the surrounding kidney and muscles. The adrenal is placed into a bag for removal. Often the gland can be morcellated (i.e. broken into smaller pieces) while in the bag so it can be removed through the small incision. However, one of the small incisions may be made bigger at the end of the operation in order to remove the gland in one piece.
Video: Laparoscopic transabdominal right adrenalectomy
Video: Laparoscopic transabdominal left adrenalectomy
Laparoscopic Retroperitoneal Adrenalectomy:
In the laparoscopic retroperitoneal technique, the patient is positioned prone (i.e. lying face down) and the adrenal gland is approach through the back. Three small incisions are made beneath the ribcage. This cavity is then inflated, with carbon dioxide gas. The top of the kidney is identified and the adrenal vein is tied off. As with the anterior technique the gland is placed into a bag but usually the tumor does not need to be morcellated and the incisions do not need to be made bigger in order to remove the adrenal gland. The major benefit of the retroperitoneal approach is that the surgeon does not need to move any other organs out of the way (i.e. spleen, liver, pancreas, colon, etc) because the adrenal gland lies right against the ribcage in the back. This technique means that it can be performed much faster than the transabdominal approach. In addition, this may be a better technique for patients having both adrenal glands removed (because the patient does not need to be "flipped over" in order to get to the other side) and for those with extensive scar tissue in their abdomen from previous surgery. 27-29 In addition, some surgeons feel that patients have less post-operative pain. This approach is not recommended for tumors over 6 cm in size and for morbidly obese patients.
Video: Laparoscopic retroperitoneal right adrenalectomy
Robotic Adrenalectomy: A handful of institutions offer a robotic adrenalectomy. This operation is similar to the laparoscopic transabdominal approach, but it uses a surgical robot to assist in the operation. The surgical robot provides potential advantages including enhanced 3-dimensional visualization and increased freedom of movement for laparoscopic instruments. Studies suggest that this approach can be done safely, however, no studies have shown that this approach is any better that the standard laparoscopic techniques.30, 31