| Laparoscopy Adrenalectomy |
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 What
are Adrenal glands? |
| What
is Adrenalectomy? |
| What
are the indications of Adrenalectomy? |
| What
are the symptoms? |
| How
is it diagnosed? |
| What
are the treatment options? |
| What
are the benefits and drawbacks? |
| What
are the risks and complications? |
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| What
are Adrenal Glands? |
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 Adrenal
glands are a part of our endocrine system. They are two
small organs, located one above each kidney. They are
triangular in shape and about the size of a thumb. These
glands produce hormones which 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). |
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| What
is Adrenalectomy? |
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The procedure of removal of an
adrenal gland is called an Adrenalectomy. The adrenal
gland may be removed on one side or both sides at the
time of surgery depending on the nature of disease. An
Adrenalectomy is the surgical removal and this procedure
can be performed using an open incision or laparoscopic
technique.
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. |
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| What
are the indications of Adrenalectomy? |
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| Diseases of the adrenal gland are
relatively rare. The most common reason that a patient
may need to have the adrenal gland removed is because
of tumour within adrenal gland. Most of these tumours
are small and not cancers. They are known as benign growths
that can usually be removed with surgery. 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. Occasionally, Adrenalectomy may be recommended
when hormones produced by the adrenal glands aggravate
another condition such as breast cancer. Let us see the
common indications for removal of the adrenal gland are
the following: |
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- Benign adrenal tumours such as Cushing disease and
Cohn syndrome
- Pheochromocytoma
- Metastatic disease (spread) from lung, breast and
other cancers. This is an uncommon reason for removal
of the adrenal gland. The adrenal gland would only
be considered for removal in metastatic disease if
this were the only site of metastatic disease
- Adrenal mass (enlargement) of uncertain origin.
If the adrenal gland is more than 4cm large then there
is a higher risk of cancer than a smaller mass.
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| What
are the symptoms? |
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| 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. |
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- 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
or 2 inches 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.
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| How
is it diagnosed? |
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| If an adrenal tumour is suspected
based on symptoms or has been identified by X-ray, the
patients are advised to undergo blood and urine tests
to determine if the tumour is over-producing hormones.
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 tutors that appear
malignant. |
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| What
are the treatment options? |
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| Although laparoscopic Adrenal gland
removal has many benefits, it may not be appropriate for
some patients. One must obtain a thorough medical evaluation
by a surgeon qualified in laparoscopic adrenal gland removal.
Aastha is a state-of-art health centre attended by distinguished
and experienced surgeons from different fields We have
dedicated endocrine surgeons with a great deal of experience
with adrenal surgery who are nationally recognized experts
in performing and teaching laparoscopic procedures. They
are among the most experienced laparoscopic surgeons in
the world. |
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| The surgeon may evaluate the patient
and suggest either of the two options: Adrenalectomy by
laparoscopy or by open incision. Let us see both the options
in details: |
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| Open procedure |
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| It is generally accepted that for
adrenal cancer and for conditions where there is a high
risk of adrenal cancer, such as for large (4-7 cm) tumours
or for those associated with multiple endocrine neoplasia,
an "open" operation is better because both sides
can be examined carefully and dealt with in the event
of spread. |
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| The surgeon may operate from any
of four directions, depending on the exact problem and
the patient's body type. Let us see how the surgeon may
approach: |
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| 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. |
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| 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. |
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| 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 tumour,
or if the surgeon needs to examine or remove nearby structures
as well. |
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| Laparoscopic Adrenalectomy |
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Adrenal glands are two in number
and are situated in the abdomen and lie just over each
kidney. They produce chemicals that control several important
processes in the body. Tumours of the adrenal glands are
very rare, and most are non-cancerous (benign) and are
treated by an operation to remove the gland called 'Adrenalectomy'.
This operation used to be carried out routinely through
a long incision in the loin or abdomen (open operation),
but is now performed in a considerable proportion of patients
through a few small 'keyhole' incisions of 0.5-1.5 cm
long.
Laparoscopic surgery refers to the technique in which
a surgeon operates within the abdominal cavity with small
telescopes and long instruments. Instead of making a large
incision which allows the surgeon access to the abdominal
contents where he/she operates with conventional instruments
and their hands, a series of small (~ 1/4 to 3/4 inch)
incisions are made and specialized instruments are used.
One of these instruments fills air into the abdominal
cavity to blow it up (like a balloon but only under modest
pressure). This instillation of air makes it easier to
work since the intestines and other organs will fall away
from the tissues which are being examined. A camera is
then place into the abdominal cavity which allows the
surgeon to see what he/she is doing. The remainder of
the small holes (ports) have long instruments (forceps,
scissors, etc.) placed through them into the abdomen for
the actual dissecting of tissues. The patient on the right
is positioned on his side for a laparoscopic Adrenalectomy.
Laparoscopic surgery has proved to be a major advancement
for the management of adrenal tumours. Patients that
have undergone laparoscopic surgery have much shorter
hospitalization, more rapid recovery (approximately
2 weeks compared to 4 to 8 weeks after open surgery)
and earlier return to work. The postoperative pain is
markedly reduced after laparoscopic surgery and the
general feeling of physical well being returns at a
much faster rate.
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| At Aastha we offer specialized
expertise in laparoscopic Adrenalectomy. We perform the
procedure utilizing both standard laparoscopic techniques
and with a laparoscopic hand-access device. Two new devices
that allow the surgeon to insert a hand inside the abdomen
during laparoscopic surgery have recently been developed.
The procedure called hand-assisted laparoscopic surgery
(HALS) allows better retraction and easier dissection
of abdominal organs since the advantages of using the
human hand that is present during open surgery is now
also available during laparoscopic surgery. We have pioneered
HALS techniques for laparoscopic Adrenalectomy and offer
this procedure for large tumours in the adrenal gland
that otherwise would require an open surgical procedure.
We have found the use of the hand assist-device to be
advantageous during laparoscopic surgery since the operative
time is markedly reduced. Furthermore manipulation of
the tumour with surgical instruments is reduced thus decreasing
the risk of fracturing the tumour or having an incomplete
excision of the tumour. In larger tumours, standard laparoscopic
procedures are less desirable, due to the risk of cancer.
With hand-assisted laparoscopic surgery large adrenal
tumours can be safely removed intact and with a rim of
surrounding normal tissue to obtain clean microscopic-free
margins around the tumour tissue. Furthermore the ability
to intraoperatively palpate the tumour allows the surgeon
to make an early assessment as to whether the lesion is
benign (non-cancerous) or malignant (cancer) and therefore
convert to an open procedure if cancer of the adrenal
gland is suspected. |
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| Patient is positioned on the inflatable
"bean bag" in the modified flank position (60-70°).
We prefer to flex the operative table. The umbilicus can
be used as an entrance point, and the camera can be placed
in this trocar.· CO2 is insuflated up to a pressure
of 18mm/Hg to create pneumoperitoneum. Under laparoscopic
guidance, two or three additional working ports are inserted
below the rib cage. |
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Identification
of landmarks and trocar insertion.
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| 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: |
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- 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 3 or 4 inches in diameter)
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| 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, these are not a complication,
but rather sound surgical judgment. The decision to convert
to an open procedure is strictly based on patient safety.
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| Before the surgery |
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| 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
tumours 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 specific medicines
for days or weeks before surgery. |
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| Most adrenal tumours can be imaged
very well with a CT scan or MRI, and benign tumours tend
to look different on these tests than do cancerous tumours.
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 tumour 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.
Some patients may need medications to control the symptoms
of the tumour, such as high blood pressure. 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. |
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| After the surgery |
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| Once the surgery is completed,
you will be taken to a post-operative or recovery unit
where a nurse will monitor your progress. You will be
scheduled for a follow-up appointment two weeks after
the procedure. It is important that your bandages be kept
clean and dry. Mild discomfort may occur at the incision
site so your surgeon may prescribe pain medication. The
laparoscopic method results in less pain than the open-procedure
method. After the operation, it is important to follow
your doctor's instructions. Although many people feel
better in just a few days, remember that your body needs
time to heal. Post-operative pain is generally mild and
patients may require a pain pill or pain medication. |
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| Recovery |
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| Patients are encouraged to engage
in light activity while at home after surgery. Patients
can remove any dressings and shower the day after the
operation. Most patients can resume normal activities
within one week, including driving, walking up stairs,
light lifting, and work. You should call and schedule
a follow-up appointment within 2 weeks after your operation.
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| Benefits
and drawbacks |
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| In the past, making a large 6 to
12 inch 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 1/4-1/2 inch incisions. Patients may leave the hospital
in one or two days and return to work more quickly than
patients recovering from open surgery. |
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| Laparoscopic Adrenalectomy can
de performed safely in a cost-effective manner. Given
the benefits of this minimally invasive technique, the
laparoscopic approach is quickly gaining popularity as
the treatment of choice for Adrenalectomy. Results of
surgery may vary depending on the type of procedure and
the patients overall condition. Common advantages are:
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- Less postoperative pain
- Shorter hospital stay
- Quicker return to normal activity
- Improved cosmetic result
- Reduced risk of herniation or wound separation
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| Complications
and risks |
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| As with any operation, there is
a risk of a complication. Complications during the operation
may include: |
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- Adverse reaction to general anaesthesia
- High blood pressure
- Bleeding
- Injury to other organs
- Wound problems, blood clots, heart attacks, and
other serious complications are uncommon after laparoscopic
Adrenalectomy
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| For those carefully selected patients
who are well-suited for the procedure, people who undergo
laparoscopic Adrenalectomy have done much better than
those receiving the standard, "open" operations,
with a much quicker return to normal activity, a shorter
hospital stay, less need for pain medication, and a markedly
lower incidence of complications. |
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