Adrenal Surgery

Overview

Prior to having adrenal surgery, your doctor will ensure that you have been properly prepared. You should discuss all of your medical problems with your surgeon during your consultation visit. Specific blood work, additional tests or consultation with physicians in a number of specialties may be required depending on your medical problems. In addition, if your adrenal gland is producing an excess of one or more hormones you may need to be on specific medications before, during and/or after your surgery. All adrenalectomies are performed under general anesthesia and most often require at least an overnight stay in the hospital.

There are a number of types of operation to remove the adrenal gland. The appropriate approach will ultimately be determined by: 1) tumor size, 2) patient characteristics (i.e. body size and shape, medical conditions, previous operations, etc), 3) the experience and expertise of the surgeon. The two main types of adrenalectomy are open and laparoscopic. Open adrenalectomy is performed through a larger incision (usually just beneath the ribcage). Laparoscopic or minimally invasive approaches use multiple small incisions, a camera for visulaization and 2-3 additional instruments to remove the adrenal gland. The laparoscopic technique allows for shorter hospital stays, decreased blood loss, less post-operative pain and quicker recovery and has become the standard approach for adrenalectomy in most patients. However, for very large tumors and for tumors with a high risk of cancer, the open approach is preferred. For both open and laparoscopic adrenalectomy, there are a number of different techniques and variations. In general, there is no “best” technique, and which approach is used depends on the experience of your surgeon. For this reason, the most important thing is to find an experienced surgeon. 

Types of operations for adrenalectomy

Laparoscopic adrenalectomy

In experienced hands, laparoscopicadrenalectomy 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. 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.

Laparoscopic Retroperitoneal Adrenalectomy

In the laparoscopic retroperitoneal technique, the patient is positioned prone (i.e. lying face down) and the adrenal gland is approached 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 and removed from the surgical space. 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 or for morbidly obese patients.

Robot-assisted Adrenalectomy

Some institutions offer robot-assisted 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. 

Open adrenalectomy

Open adrenal surgery can be done through three types of approaches: anterior, posterior, and thoracoabdominal.

Open Anterior Approach

The most commonly used approach is the open anterior approach. In this technique the patient is positioned on the bed either lying flat or tilted, with the side of 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).

Posterior Approach

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.

Thoracoabdominal Approach

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.

Partial adrenalectomy

The cortex is the part of the adrenal gland that makes cortisol, a hormone that is crucial for life. If the patient does not have enough adrenal cortex left, he or she may develop adrenal insufficiency and may need to take steroid medication. (See What are the potential complications?) In cases of bilateral adrenal tumors (i.e. a tumor in both adrenal glands) or tumors that are small and clearly not cancer (like aldosterone producing adenomas), some surgeons may perform a cortical-sparing adrenalectomy to keep as much of the normal cortex as possible. This usually involves looking at the entire adrenal gland and cutting out just the tumor with a thin rim of normal tissue.

Partial adrenalectomy can be done through any of the laparoscopic or open approaches mentioned. However, it is unclear if it is of benefit to the patient when compared with the risk of potential cancer, recurrence rates (i.e. disease that comes back), and other possiblecomplications. The decision whether it is safe to perform a cortical-sparing adrenalectomy should be made by an experienced adrenal surgeon.