Adrenalectomy

Definition

Adrenalectomy is the surgical removal of one or both of the adrenal glands. The adrenal glands are paired endocrine glands, one located above each kidney, that produce hormones such as epinephrine, norepinephrine, androgens, estrogens, aldosterone, and cortisol. Adrenalectomy is usually performed by conventional (open) surgery, but in selected patients surgeons may use laparoscopy. With laparoscopy, adrenalectomy can be accomplished through four very small incisions.


Purpose

Adrenalectomy is usually advised for patients with tumors of the adrenal glands. Adrenal gland tumors may be malignant or benign, but all typically excrete excessive amounts of one or more hormones. A successful procedure will aid in correcting hormone imbalances, and may also remove cancerous tumors that can invade other parts of the body. Occasionally, adrenalectomy may be recommended when hormones produced by the adrenal glands aggravate another condition such as breast cancer.



Precautions

The adrenal glands are fed by numerous blood vessels, so surgeons need to be alert to extensive bleeding during surgery. In addition, the adrenal glands lie close to one of the body's major blood vessels (the vena cava), and to the spleen and the pancreas. The surgeon needs to remove the gland(s) without damaging any of these important and delicate organs.

Open adrenalectomy

The surgeon may operate from any of four directions, depending on the exact problem and the patient's body type. In the anterior approach, the surgeon cuts into the abdominal wall. Usually the incision will be horizontal, just under the rib cage. If the surgeon intends to operate on only one of the adrenal glands, the incision will run under just the right or the left side of the rib cage. Sometimes a vertical incision in the middle of the abdomen provides a better approach, especially if both adrenal glands are involved. In the posterior approach, the surgeon cuts into the back, just beneath the rib cage. If both glands are to be removed, an incision is made on each side of the body. This approach is the most direct route to the adrenal glands, but it does not provide quite as clear a view of the surrounding structures as the anterior approach.

In the flank approach, the surgeon cuts into the patient's side. This is particularly useful in massively obese patients. If both glands need to be removed, the surgeon must remove one gland, repair the surgical wound, turn the patient onto the other side, and repeat the entire process. The last approach involves an incision into the chest cavity, either with or without part of the incision into the abdominal cavity. It is used when the surgeon anticipates a very large tumor, or if the surgeon needs to examine or remove nearby structures as well.

Laparoscopic adrenalectomy

This technique does not require the surgeon to open the body cavity. Instead, four small incisions (about 1/2 in diameter each) are made into a patient's flank, just under the rib cage. A laparoscope, which enables the surgeon to visualize the inside of the abdominal cavity on a television monitor, is placed through one of the incisions. The other incisions are for tubes that carry miniaturized versions of surgical tools. These tools are designed to be operated by manipulations that the surgeon makes outside the body.

Preparation

Most aspects of preparation are the same as in other major operations. In addition, hormone imbalances are often a major challenge. Whenever possible, physicians will try to correct hormone imbalances through medication in the days or weeks before surgery. Adrenal tumors may cause other problems such as hypertension or inadequate potassium in the blood, and these problems also should be resolved if possible before surgery is performed. Therefore, a patient may take specificmedicines for days or weeks before surgery.

Most adrenal tumors can be imaged very well with a CT scan or MRI, and benign tumors tend to look different on these tests than do cancerous tumors. Surgeons may order a CT scan, MRI, or scintigraphy (viewing of the location of a tiny amount of radioactive agent) to help locate exactly where the tumor is. The day before surgery, patients will probably have an enema to clear the bowels. In patients with lung problems or clotting problems, physicians may advise special preparations.

Aftercare

Patients stay in the hospital for various lengths of time after adrenalectomy. The longest hospital stays are required for open surgery using an anterior approach; hospital stays of about three days are indicated for open surgery using the posterior approach or for laparoscopic adrenalectomy.

The special concern after adrenalectomy is the patient's hormone balance. There may be several sets of lab tests to define hormone problems and monitor the results of drug treatment. In addition, blood pressure problems and infections are more common after removal of certain types of adrenal tumors.

As with most open surgery, surgeons are also concerned about blood clots forming in the legs and traveling to the lungs (venous thromboembolism), bowel problems, and postoperative pain.With laparoscopic adrenalectomy, these problems are somewhat less difficult, but they are still present.

Risks

The special risks of adrenalectomy involve major hormone imbalances, caused by the underlying disease, the surgery, or both. These can include problems with wound healing itself, blood pressure fluctuations, and other metabolic problems. Other risks are typical of many operations. These include:

  • bleeding
  • damage to adjacent organs (spleen, pancreas)
  • loss of bowel function
  • blood clots in the lungs
  • lung problems
  • surgical infections
  • pain
  • extensive scarring