Adrenalectomy

Overview

An adrenalectomy is a surgical procedure to remove one or both adrenal glands, which are located above each kidney. These glands are crucial components of the endocrine system, responsible for producing hormones that regulate metabolism, the immune system, blood pressure, blood sugar, and other vital functions throughout the body. While small in size, the adrenal glands have a significant impact on overall health.

The primary reason for performing an adrenalectomy is to eliminate tumors, the majority of which are benign, meaning they are not cancerous. It’s rare for cancer to originate in the adrenal glands, but the surgery might be necessary if an adrenal gland is producing excessive amounts of hormones, or if cancer from another part of the body has spread to one of the glands.

When only one gland is removed and it was not overproducing hormones, the remaining gland can typically compensate for both, negating the need for hormone replacement therapy. However, if a gland is removed due to overproduction of hormones, hormone replacement medication may be required temporarily until the other gland adjusts to regulate hormone levels adequately. If both glands are removed, lifelong hormone replacement therapy will be necessary to maintain the body’s hormonal balance.

Types

Adrenalectomy, the surgical removal of one or both adrenal glands, can be performed using two main techniques depending on the size and nature of the tumor:

• Open adrenalectomy: This method is typically reserved for larger or potentially cancerous tumors. It involves a significant incision in the abdomen to provide direct access to the glands for removal.
• Laparoscopic adrenalectomy: This is a minimally invasive approach that has become more common. It involves making several small incisions through which a laparoscope (a thin tube with a tiny video camera) is inserted, allowing the surgeon to see inside the body and perform the surgery with special instruments. Robotic-assisted surgery is a variation of this method, utilizing wristed instruments for enhanced precision, and can be performed through the same small incisions.

The laparoscopic procedure can be conducted via two different approaches:

• • Posterior approach: Incisions are made on the back, offering the advantage of avoiding entrance into the abdomen. This approach is particularly beneficial for patients with previous upper abdominal surgeries or those with bilateral tumors. However, due to limited working space, it is typically only suitable for tumors smaller than 6 cm.
  • Lateral approach: Incisions are made on the side of the body, providing an alternative route for access.

Both laparoscopic approaches—whether posterior or lateral—are effective, with the choice of approach depending on specific patient factors, including previous surgical history and tumor characteristics.

Reasons for undergoing the procedure

Adrenalectomy, the surgical removal of one or both adrenal glands, is considered necessary in several situations:

• Presence of adrenal tumors: Surgery is indicated when tumors are found in the adrenal gland. These tumors can be either malignant (cancerous) or benign (non-cancerous). Most adrenal gland tumors are benign, but surgery may be required if they are at risk of becoming malignant or if they disrupt the body’s hormonal balance.
• Overproduction of hormones: Certain adrenal tumors can cause the glands to produce excessive hormones, leading to significant health issues. This includes tumors such as pheochromocytomas and aldosteronomas, or situations where there is too much cortisol production, resulting in Cushing’s syndrome. If a tumor in the pituitary gland triggers the adrenal glands to overproduce cortisol and cannot be completely removed, an adrenalectomy might be necessary.
• Unclear or suspicious imaging results: If imaging exams of the adrenal glands, such as computed tomography (CT) scans or magnetic resonance imaging (MRI) scans, show findings that are suspicious or not clear, surgery may be advised to prevent potential health complications.

Risk

There are always potential risks associated with surgery. Compared to a laparoscopic adrenalectomy, these are more common with an open procedure.

Laparoscopic adrenalectomy results in smaller scars, reduced pain, and fewer associated risks compared to other methods. Patients undergoing this procedure typically experience a shorter hospital stay and a quicker return to normal activities. The surgical team will closely monitor the patient for:

• Bleeding
• Blood clots.
• Infection.
• Injury or damage to organs that is close to the adrenal gland.
• Hernia.
• Pneumonia.
• Anesthesia reactions.
• Issues with the healing of wounds.

Procedure

During the surgical procedure, the surgeon may choose to remove either the tumor, one adrenal gland, or both. A unilateral adrenalectomy involves the removal of one adrenal gland, whereas a bilateral adrenalectomy involves the removal of both adrenal glands.

Patients diagnosed with cortisol excess, such as in the case of Cushing’s syndrome, may need to take a hydrocortisone supplement for approximately a year after the surgery. This supplementation is necessary until the remaining adrenal gland starts producing a sufficient amount of hormones independently.

For individuals who have undergone this surgery, further tests are conducted to determine whether they require steroid replacement therapy.

Before the procedure

The following instructions will be provided to the patient by the healthcare provider. This may include the following.

• Patient might have to refrain from eating and drinking for a specific amount of time before to the procedure.
• As some medications might affect blood clotting, patient are advised to stop using them, particularly nonsteroidal anti-inflammatory drugs (NSAIDs).
• Patient will be instructed to take blood pressure medication to manage it before the surgery.
• Prepare for someone to bring the patient home after the procedure.
• In order to help the medical team get ready for the surgery, the patient could also require imaging testing. In order to ensure the safety of the process, patients may need to take particular precautions before to surgery if their body is producing an excessive amount of hormones.

During the procedure

Adrenalectomy, the surgical removal of one or both adrenal glands, is performed under general anesthesia, rendering patients in a sleep-like state for the duration of the procedure. Surgeons can opt for either a minimally invasive approach or open surgery, depending on various factors including the condition affecting the adrenal gland, the patient’s health, and medical history.

Minimally invasive surgery: Minimally invasive surgery, known for its benefits such as smaller scars, reduced pain, and quicker recovery times compared to open surgery, is often preferred for adrenalectomy due to the small size of the adrenal glands. This category includes:

• Laparoscopic surgery: Utilizing a laparoscope, a small camera inserted through an incision in the abdomen, this method allows the surgeon to view internal organs and guide the removal of the adrenal gland with instruments inserted through additional small incisions.
• Posterior retroperitoneoscopic surgery (PRA): Similar to laparoscopic surgery, but the small incisions are made in the back, allowing for the removal of the adrenal gland through these entry points.
• Robotic surgery: A variation of laparoscopic surgery where the surgeon controls mechanical arms attached to surgical instruments from a computer console. This method may require fewer incisions.

Open surgery: Open surgery involves removing the adrenal gland through a single, larger incision in the front of the abdomen. The decision to use open surgery is typically based on factors such as the size and type of the tumor, spread to other tissues, the presence of scar tissue from previous surgeries, or obesity. This approach is generally reserved for larger tumors or those that have spread to adjacent tissues.

The choice between minimally invasive surgery and open surgery for adrenalectomy is influenced by the specifics of the adrenal gland condition, as well as the patient’s overall health and history of surgeries. Discussing with your healthcare team is crucial to determine the most suitable surgical approach for your situation.

After the procedure

Hospital stay duration following an adrenalectomy varies based on the surgical method employed. Patients undergoing minimally invasive surgery typically are discharged on the same day or may require an overnight hospital stay. Conversely, those who undergo open surgery can expect a hospitalization period ranging from 3 to 5 days.

Outcome

After an adrenalectomy, the removed adrenal gland is sent for laboratory analysis, where pathologists examine the gland and its tissues to provide insights to your healthcare provider. Following the surgery, discussions with your provider about the findings and any necessary follow-up care are essential. Often, only one adrenal gland is removed, allowing the remaining gland to compensate for both. If the surgery was to address hormone overproduction, hormone replacement therapy might be required until the remaining gland adjusts. However, if both adrenal glands are removed, lifelong hormone replacement medication becomes necessary to substitute for the hormones previously produced by these glands.

Make sure to attend all follow-up visits so your surgical team can monitor your recovery and remove stitches if you had open adrenal surgery.

If you experience any of the following between appointments, contact your surgical team immediately:

• Persistent pain unrelieved by medication.
• Loose stitches or an opening at the incision site.
• Symptoms of infection such as warmth, redness, swelling, bleeding, pus, or significant pain at the incision.
• Fever.
• Irregular bowel movements.

In case of an emergency, such as fainting, severe breathing difficulties, chest pain, or coughing up blood, call emergency services immediately.