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Laparoscopic Adrenalectomy

The adrenal glands are two small organs, one located above each kidney. They are triangular in shape and about the size of a thumb. The adrenal glands are known as endocrine glands because they produce hormones. These hormones are involved in control of blood pressure, chemical levels in the blood, water use in the body, glucose usage, and the “fight or flight” reaction during times of stress. These adrenal-produced hormones include cortisol, aldosterone, the adrenaline hormones and a small fraction of the body’s sex hormones (oestrogen and androgens).

Adrenal glands

Diseases of the adrenal gland are relatively rare. The most common reason that a patient may need to have the adrenal gland removed is excess hormone production by a tumour located within the adrenal. Most of these tumours are small and not cancers. They are known as benign growths that can usually be removed with laparoscopic techniques. Removal of the adrenal gland may also be required for certain tumours even if they aren’t producing excess hormones, such as very large tumours or if there is a suspicion that the tumour could be a cancer, or sometimes referred to as malignant. Fortunately, malignant adrenal tumours are rare. An adrenal mass or tumour is sometimes found by chance when a patient gets an X-ray study to evaluate another problem.

Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. Adrenal tumours associated with excess hormone production include pheochromocytomas, aldosterone-producing tumours, and cortisol-producing tumours. Some of these tumours and their typical features are given below.

  • Pheochromocytomas produce excess hormones that can cause very high blood pressure and periodic spells characterized by severe headaches, excessive sweating, anxiety, palpitations, and rapid heart rate that may last from a few seconds to several minutes.
  • Aldosterone producing tumours cause high blood pressure and low serum (blood) potassium levels. In some patients this may result in symptoms of weakness, fatigue, and frequent urination.
  • Cortisol producing tumours cause a syndrome termed Cushing’s syndrome that can be characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Most cases of Cushing’s syndrome, however, are caused by small pituitary tumours and are not treated by adrenal gland removal. Overall, adrenal tumours account for about 20% of cases of Cushing’s syndrome.
  • An incidentally found mass in the adrenal may be any of the above types of tumours, or may produce no hormones at all. Most incidentally found adrenal masses do not make excess hormones, cause no symptoms, are benign, and do not need to be removed. Surgical removal of incidentally discovered adrenal tumours is indicated only if:
    • The tumour is found to make excess hormones
    • Is large in size (more than 4-5 centimetres in diameter)
    • If there is a suspicion that the tumour could be malignant.
  • Adrenal gland cancers (adrenal cortical cancer) are rare tumours that are usually very large at the time of diagnosis. Removal of these tumours is usually done by open adrenal surgery.

If an adrenal tumour is suspected based on symptoms or has been identified by X-ray, the patient should undergo blood and urine tests to determine if the tumour is over-producing hormones. Special X-ray tests, such as a CT scan, nuclear medicine scan, an MRI or selective venous sampling are commonly used to locate the suspected adrenal tumour.

Surgical removal of the adrenal gland is the preferred treatment for patients with adrenal tumours that secrete excess hormones and for primary adrenal tumours that appear malignant.

In the past, making a large 20-30cm incision in the abdomen, flank, or back was necessary for removal of an adrenal gland tumour. Today, with the technique known as minimally invasive surgery, removal of the adrenal gland (also known as “laparoscopic adrenalectomy”) can be performed through three or four 1-2cm incisions. Patients may leave the hospital in one or two days and return to work more quickly than patients recovering from open surgery.

Results of surgery may vary depending on the type of procedure and the patients overall condition.

Common advantages are:

  • Less postoperative pain
  • Shorter hospital stay
  • Quicker return to normal activity
  • Improved cosmetic result
  • Reduced risk of herniation or wound separation

Although laparoscopic Adrenal gland removal has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by a surgeon qualified in laparoscopic adrenal gland removal in consultation with your primary care physician or endocrinologist to find out if the technique is appropriate for you.

Prior to the operation, some patients may need medications to control the symptoms of the tumour, such as high blood pressure.

  • Patients with a pheochromocytoma will need to be started on special medications several days prior to surgery to control their blood pressure and heart rate.
  • Patients with an aldosterone-producing tumour may need to have their serum potassium checked and take extra potassium if the level is low.
  • Patients with Cushing’s syndrome will need to receive extra doses of cortisone medication on the day of surgery and for a few months afterwards until the remaining adrenal gland has resumed normal function
  • Preoperative preparation includes blood work, medical evaluation, chest x-ray and an ECG depending on your age and medical condition.
  • After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
  • Blood transfusion and/or blood products may be needed depending on your condition.
  • Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
  • It is recommended that you shower the night before or morning of the operation.
  • After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
  • Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and large doses of Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
  • Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
  • Quit smoking and arrange for any help you may need at home.
  • The surgery is performed under a complete general anaesthesia, so that the patient is asleep during the procedure.
  • A cannula (a narrow tube-like instrument) is placed into the abdominal cavity in the upper abdomen or flank just below the ribs.
  • A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula. This gives the surgeon a magnified view of the patient’s internal organs on a television screen.
  • Other cannulas are inserted which allow your surgeon to delicately separate the adrenal gland from its attachments. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. It is almost always necessary to remove the entire adrenal gland in order to safely remove the tumour.
  • After the surgeon removes the adrenal gland, the small incisions are closed.

In a small number of patients the laparoscopic method cannot be performed. In that situation, the operation is converted to an open procedure. Factors that may increase the possibility of choosing or converting to the “open” procedure may include:

  • Obesity
  • A history of prior abdominal surgery causing dense scar tissue
  • Inability to visualize the adrenal gland clearly
  • Bleeding problems during the operation
  • Large tumour size (over 8cm in diameter)

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.