Indications for Adrenal Surgery
The main indications for surgery on the adrenal gland are:
- a hormone-producing tumour in the cortex (e.g. adrenal adenomas) or medulla (e.g. phaeochromocytoma)
- a tumour greater than 3-4cm in size, even with no evidence of abnormal hormone production, to prevent missing a possible malignancy
- a primary cancer in the adrenal
- symptoms (e.g. pain) due to an enlarged adrenal gland pressing on adjacent organs
- unsuccessful pituitary surgery, requiring a bilateral laparoscopic adrenalectomy for Cushing's disease
Types of Adrenal Surgery
Either one (unilateral) or both (bilateral) adrenals can be removed, but this decision depends on the nature of the underlying endocrine disease and which gland is affected by the disease process.
The operation of choice for adrenalectomy is now laparoscopic or keyhole (minimally invasive) surgery in most cases. The approaches for the right and left adrenalectomy differ in detail and are covered on the webpage Details of Surgery, although this page contains some pictures you may not wish to view.
Laparoscopic adrenalectomy
Fig.1: Laparoscopic left adrenalectomyThis is minimally invasive or "key-hole surgery", and the operation of choice for most adrenal tumours.
Adrenal surgery is the ideal operation to do laparoscopically as it is the large incision used in open adrenalectomy, rather than the internal dissection of the gland itself that is so traumatic to the patient.
There are two possible approaches for laparoscopic adrenalectomy, which are roughly equal in terms of postoperative discomfort and length of hospital stay:
- anterior transperitoneal approach
This is the more popular technique, crossing the abdominal cavity from the front/side of the abdomen to reach the gland at the back. - posterior retroperitoneal approach
This is becoming a popular option, with the surgeon approaching the adrenal gland directly through the back of the patient, with claimed less discomfort after surgery, but it is more technically challenging and not all patients are suitable, particularly in the obese patient.
Fig.2: Three small scars after left laparoscopic adrenal surgeryIn the laparoscopic operation, rather than one large incision being made, a few (3-4) small holes are made in the abdomen of the patient through which a camera and surgical instruments are introduced (Fig. 1).
The actual operation inside the patient is fairly similar to the open operation, but because the wounds are much smaller (Fig. 2), there is less pain and recovery time is much shorter.
Either one of the laparoscopic approaches can be successfully used for most tumours seen in the adrenal gland, except for very large or malignant tumours. It is now the preferred technique in most cases of adrenal surgery, even for bilateral diseases.
Laparoscopic surgery is also probably a safer operation in phaeochromocytoma in experienced hands as there is less manipulation of the tumour before clipping of the vein and removal of the tumour, compared with the open approaches.
It is important to say that any laparoscopic approach should be abandoned and an open operation performed in the case of difficult anatomy and dissection, evidence of malignancy, or complications such as excessive bleeding.
Anterior open approach
Fig.3: Incision line of a right open adrenalectomyThis is the approach of choice (rather than the laparoscopic approach) when the tumour is very large or is suspected to be malignant. It is much more invasive and traumatic for the patient, but postoperative pain can usually be easily controlled with an epidural catheter or patient-controlled analgesia.
A long subcostal incision (just underneath the rib edge) is made (Fig. 3) in relatively the same position as the ports for laparoscopic surgery, but of course one large wound is made.
Typically the dissection inside the patient proceeds along similar lines to the laparoscopic approach, but the exposure is over a greater area. It provides good access to the adrenal and any involved surrounding structures, allowing more radical surgery when required.
Thoracoabdominal open approach
This is a far more radical version of the anterior approach, requiring opening of the thoracic (chest) cavity, as well as the abdomen, in one large incision, to improve access to the adrenal tumour.
Because of the greater trauma to the patient and greater postoperative pain, this radical technique is only indicated in very large tumours, or in possible or proven malignant tumours, when removal of surrounding tissues as a single block may be needed.
Posterior open approach
In this approach the incision is made on the back of the patient which avoids the hazards of crossing the abdominal cavity to reach the adrenal gland at the back, which to a certain extent makes more intuitive sense as a surgical approach.
It is seldom used nowadays however, as it can only be used for small tumours, which should be removed laparoscopically. It is not appropriate for larger or malignant tumours either, so has now become largely obsolete as a surgical technique.