Adrenalectomy or adrenal gland removal is a surgical procedure that involves removing one or both adrenal glands if it has turned cancerous or if a tumor produces excess hormones. Adrenal glands produce hormones like aldosterone, adrenaline, sex hormones (androgens), and cortisol, which control and regulate various functions such as growth, development, sexual function, and metabolism.
Tunours of adrenal glands normally do not affect any hormones and are symptomless, but at times may cause an increase in the production of these hormones, resulting in dysregulation of the various functions of the body.
Symptoms of increased hormone production due to adrenal tumors include:
- Hypertension (increased blood pressure)
- Hyperhidrosis (excessive sweating)
- Urinary frequency (frequent urination)
- Obesity (excess weight)
- Anxiety, rapid heart rate
- Headaches and muscle weakness
- Associated syndromes
- Cushing's syndrome (high cortisol levels)
- Primary hyperaldosteronism (increased aldosterone)
- Pheochromocytoma (increased catecholamines and metanephrines).
Adrenal surgery can be performed through different techniques requiring an experienced adrenal surgeon.
Mini Back Scope Adrenalectomy (MBSA):
- Also known as posterior retroperitoneoscopic adrenal operation.
- It is the preferred operation for more than 95% of patients with adrenal tumors.
- Small 0.5 to 1.1 cm incisions behind your abdomen.
- A laparoscope is used to guide the surgeon during the procedure.
Laparoscopic Transabdominal Adrenalectomy (LTA):
- The incisions in this technique are made in front of the abdomen.
- Though not the best, it is performed by most less experienced surgeons.
- Disadvantages- Longer hospital stay, more post-op pain, and slow recovery.
Laparoscopic Hand-Port Assisted Transabdominal Adrenalectomy:
- This approach is appropriate for large (> 7 to 12 cm), aggressive adrenal tumors.
- The incisions are made in front of the abdomen.
Open-Standard Transabdominal Adrenalectomy:
- This traditional surgical method involves a single large incision (about 10 inches) in front of the abdomen.
- It is used for large adrenal tumors (>12 cm) and those that are suspected to be malignant (cancerous).
Open Thoraco-Abdominal Adrenalectomy:
- This approach is used for large (>12 cm) malignant (cancerous) adrenal tumors and allows the greatest exposure to the gland.
- A large incision passes through the abdominal and thoracic (chest) cavities, including the diaphragm (the muscle that separates the abdomen and the chest).
Open Posterior Adrenalectomy:
- This involves a large incision in the back overlying the kidney's top.
Open Retroperitoneal Adrenalectomy:
- It involves a single large incision behind the abdomen.
- It uses the combined principles of the posterior approach and the anterior trans-abdominal technique.
- This is a surgical technique that is performed using a robotic arm.
- It involves a similar approach to LTA and MBSA.
- However, this has been abandoned for many years.
Adrenalectomy is a radical (complete/total) surgery recommended to remove the tumor cells along with the adrenal glands to stabilize hormone production and prevent further recurrence. It helps to alleviate symptoms caused due to increased hormones, namely cortisol, adrenaline, and sex hormones. However, adrenalectomy is also recommended for large, aggressive adrenal tumors, even without hormone fluctuations.
You must first consult your doctor when you notice any symptoms associated with adrenal tumors. A urologist (doctor specializing in urinary tract diseases), a general surgeon, or a laparoscopic surgeon can perform an adrenalectomy.
- Discuss your medical history about conditions such as asthma, diabetes (increased blood sugar levels), hypertension (high blood pressure), thyroid, heart, or lung diseases.
- Hormonal imbalance is seen in many other disorders; hence, your surgeon must rule out certain medical conditions.
- You will be advised to get a few imaging tests like CT (Computed Tomography), and MRI (Magnetic Resonance Imaging) scan to locate and check the size of the adrenal tumor.
- You need to undergo the following tests to confirm the presence of an adrenal tumor:
- Blood and urine analysis for elevated levels of hormones.
- Ultrasound scan to check if there is any adrenal tumor present.
- Image-guided needle biopsy to confirm if the tumor is benign or malignant.
- CT (Computed Tomography) scan to evaluate the tumor's exact location.
- Positron Emission Tomography (PET) scan to confirm the size and type of tumor.
- MRI (Magnetic Resonance Imaging) scan to determine the location and extent of metastasis.
- Once the diagnosis is confirmed, your surgeon will schedule surgery for you.
- You will be advised to discontinue medications like blood thinners, anti-inflammatory medications, and other herbal supplements for at least 2 weeks before the procedure.
- You must minimize salt intake to control your blood pressure before the adrenal surgery.
- Certain medications must be taken before the surgery depending on the type of adrenal tumor you have:
- If you have pheochromocytoma, you must take medications to control your blood pressure and heart rate.
- If you have aldosteronoma, you will need to take potassium.
- If you have Cushing's syndrome, you must take extra cortisone medication on the day of your surgery.
- You must fast for at least 8 to 12 hours before the adrenal surgery as it is performed under general anesthesia.
Adrenal gland removal involves removing the adrenal glands affected by adrenal tumors by an experienced adrenal surgeon.
- On the day of the surgery, you will be asked to sign a consent form that allows the surgeon to perform the procedure on you.
- Your vitals will be checked, and a line will be administered for intravenous (IV) anesthesia and antibiotics.
- A urinary catheter will be placed to drain the urine.
- Once taken to the operating room, the surgical site will be cleansed with an antiseptic solution.
- General anesthesia will be administered Depending on the location of the incision site, you will be made to lie flat on your back or towards your side.
- The surgery is done in the following ways
- Once the adrenal glands are removed, a drainage tube will be inserted to drain excess fluids and any post-op discharge.
- The incisions will be closed with sutures or staples, and a surgical dressing will be placed over it.
1. Open Adrenalectomy:
- Here, the surgeon will make a single large incision of around 10 inches using a scalpel (a surgical blade) either in front or behind the abdomen or between the abdominal and chest cavity.
- The adrenal glands will be removed by separating the blood vessels.
- The incision will be stitched up, and a surgical dressing will be placed.
- The procedure takes around 1 to 2 hours.
2. Laparoscopic Adrenalectomy:
- Your surgeon will make multiple (3 to 4) small keyhole-sized incisions with a scalpel in front of your abdomen.
- The surgical site will be injected with gas to inflate the area to improve visibility.
- A laparoscope will be inserted into one of the incisions to capture images and project them on screen. This guides the surgeon to perform the procedure.
- The adrenal glands will be separated and removed from the surrounding tissues. The wound will be closed with sutures or staples.
- The laparoscopic procedure takes around 2 to 3 hours.
3. Posterior Retroperitoneoscopic Adrenalectomy (PRA):
- It is the same as the laparoscopic approach, but the incisions are made at the back.
- The procedure takes around 2 to 3 hours.
4. Robotic-assisted Adrenalectomy:
- It is the same as a laparoscopic procedure, but the surgeon will make only 2 keyhole-sized incisions near the abdomen.
- Instead of using the instruments manually, a robotic arm handles the instruments.
- The surgeon operates the robotic arm from a distance at the console.
- Robotic adrenalectomy takes around 3 to 4 hours.
5. Cortical-sparing/ Partial Adrenalectomy:
- Removing the cortex (a part of the adrenal gland that makes a hormone, cortisol) leads to adrenal insufficiency. Hence to avoid this, the cortex is left behind during this procedure, and only a part of the adrenal gland is removed.
6. Bilateral Adrenalectomy:
It is a laparoscopic procedure that removes both adrenal glands.
Post adrenal gland removal or adrenalectomy, you will be observed in a PACU (post-anesthesia care unit), to monitor your vitals closely. Once stabilized, you will be shifted to your room for further recovery. Depending on the type of surgery and severity of the condition, you will be either sent home the same day or kept for 2 to 3 days.
- Once you regain complete consciousness, you may experience mild pain and discomfort that will be managed through painkillers.
- A urinary catheter will be placed until you get discharged from the hospital.
- IV antibiotics and fluids will continue until you remain in the hospital to prevent post-op infection.
- Your nutritionist will plan your diet to prevent constipation and accelerate your healing process.
- You will be made to walk the following day post-surgery, to prevent the development of blood clots and improve blood circulation.
- Once you are back home, rest and hydrate well.
- You must:
- Clean and care for the surgical wound.
- Avoid lifting heavy objects and strenuous exercises for 2 to 3 weeks
- Avoid saunas, tub baths, and swimming for 2 weeks to prevent soaking the wound.
- Ensure to be active to prevent blood clots.
- Complete recovery may take around 3 to 4 weeks.
Adrenal gland removal is a safe and effective procedure with an added advantage due to the different surgical techniques. Some of the key benefits of this surgery are listed below.
- Alleviates symptoms associated with adrenal tumors.
- Improves your quality of life.
- Enhanced survival rate.
- The surgery involves several techniques according to your individual condition.
- Laparoscopic and robotic surgeries involve small incisions with minimal scarring.
- Shorter hospital stay and quick recovery.
- Prevents tumor recurrence.
Since it is mostly a radical surgery, it prevents cancer metastasis (spread) to other organs and tissues.
Adrenalectomy, though a safe procedure, may pose the following risks during or after the surgery:
- Excessive bleeding during the surgery (especially in open adrenalectomy).
- Injury to nearby organs and tissues.
- Allergic reactions to anesthesia may include hives, rash, itching, nausea, dizziness, confusion, and shortness of breath.
- Post-op infections may delay wound healing.
- Blood clots may eventually dislodge into the bloodstream and travel to other organs like the lungs, brain, or heart. This can lead to life-threatening complications.
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