How is adrenal surgery performed?
Open adrenal surgery can be done through three types of approaches: anterior, posterior, and thoracoabdominal.
The most commonly used approach is the anterior approach. In this technique the patient is positioned on the bed either lying flat or tilted, with the gland to be removed up, on the operating room bed. This approach may use a vertical midline incision or more commonly, a subcostal incision (i.e. diagonal incision just under the ribcage). Just as with a laparoscopic operation, surrounding structures need to be moved aside to get at the adrenal gland. For operations on the left adrenal gland, the spleen, pancreas and often the colon must be moved aside. On the right side, the liver, colon and duodenum (first part of the small intestine) must be moved aside. The open anterior approach is ideal for very large adrenal tumors, particularly when a malignancy (cancer) is suspected since excellent exposure can be obtained and other organs can be removed with the adrenal if necessary (due to invasion of the cancer).
Open surgery on the adrenal gland can also be performed from a posterior approach. In this technique the patient is positioned prone (i.e. face down) on the operating room table. A curved incision is made on the side of the gland to be removed, muscles are moved out of the way with retractors and a part of the lowest (12th) rib may be removed. This technique does have some limitations. For example, it does not allow as wide or complete a view as the anterior approach, making it less than ideal for larger tumors. In addition, it is harder to remove surrounding organs that the tumor may have grown into in cases of cancer. As a result, this approach is generally not used for tumors bigger than 6cm and those suspected to be malignant (cancerous) in which the removal of additional organs may be required.
For very large tumors or cancers growing into other organs or spreading into the veins that drain the adrenal gland, the thoracoabdominal approach is likely the best approach. This technique uses an incision that runs through both the abdomen and the chest. This approach may cause more post-operative pain and pulmonary (lung) complications and is typically only used for very large, advanced cancers.