Laparoscopic Adrenalectomy (Adrenal Gland Removal)*

The adrenal glands are two small organs located at the top of each kidney. They are triangular in shape and about the size of a thumb. These glands – also known as endocrine glands – secrete hormones 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.

What problems occur in the adrenal glands?

Adrenal gland diseases are relatively rare. The most common reason for adrenal gland removal is excess hormone production by a tumor located within the adrenal. Most tumors are small, benign growths that usually can be removed with laparoscopic techniques. Adrenal gland removal also may be needed for some tumors that don’t produce excess hormones, such as very large tumors or tumors suspected of being cancerous. Fortunately, malignant adrenal tumors are rare.

What are symptoms of adrenal gland problems?

Excess hormone production in the adrenal glands may produce a variety of symptoms. Adrenal tumors associated with excess hormone production include:

  • Pheochromocytomas. These tumors produce an excess of hormones that can cause very high blood pressure and spells characterized by severe headaches, excess sweating, anxiety, palpitations and rapid heart rate.
  • Aldosterone-producing tumors. These cause high blood pressure and low serum (blood) potassium levels. The result may be symptoms of weakness, fatigue and frequent urination.
  • Cortisol-producing tumors. These cause Cushing’s syndrome characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin and prominent stretch marks. However, most cases of Cushing’s syndrome are caused by small pituitary tumors and are not treated by adrenal gland removal. Overall, adrenal tumors account for about 20 percent of cases of Cushing’s syndrome.

An incidentally found mass in the adrenal gland may be any of these types of tumors or may produce no hormones at all. Most incidentally found adrenal masses produce no excess hormones, cause no symptoms, are benign and do not require removal. Surgical removal of incidentally discovered tumors is necessary only if:

  • The tumor produces excess hormones.
  • It is large (more than four to five centimeters or two inches in diameter)
  • The tumor is suspected of being malignant. Adrenal gland cancers are rare tumors that usually are very large at the time of diagnosis and are removed by open adrenal surgery.

How are adrenal gland tumors diagnosed?

Mp>When an adrenal tumor is suspected on the basis of symptoms or has been identified by an X-ray, the patient undergoes blood and urine tests to determine whether the tumor is over-producing hormones. CT, nuclear medicine and MRI scans as well as selective venous sampling can be used to locate a suspected adrenal tumor.

What is laparoscopic adrenalectomy?

In the past, open surgery with a six- to 12-inch incision in the abdomen, flank or back was needed to remove an adrenal gland tumor. Today, laparoscopic removal of the adrenal gland (known as “laparoscopic adrenalectomy”) is possible with the surgeon making three or four ¼- to ½ -inch incisions. The surgeon first places a laparoscope – a scope with a light and camera – through one of the incisions. This allows the surgeon to view the anatomy. The surgeon then performs the operation working with long instruments placed through small tubes in the other incisions.

Results of the surgery vary depending on the type of procedure and the patient’s overall condition. Common advantages of laparoscopic surgery are:

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

Who is a candidate for laparoscopic adrenalectomy?

Laparoscopic adrenalectomy may not be appropriate for some patients. You should undergo a thorough medical evaluation by a qualified surgeon in consultation with your primary care physician or endocrinologist.

What if the procedure cannot be performed laparoscopically?
In a small number of patients who undergo laparoscopic adrenalectomy, the operation is converted to an open procedure. Factors that increase the possibility of choosing or converting to an open procedure may include:

  • Obesity
  • History of past abdominal surgery causing dense scar tissue
  • Inability to visualize the adrenal gland clearly
  • Bleeding problems during the operation
  • Large tumor size (more than three to four inches in diameter)

The decision to perform an open procedure is a judgment made by your surgeon either before or during the actual operation. If the surgeon believes it is safer to convert the laparoscopic procedure to an open surgery, this is not a complication but rather sound surgical judgment based on patient safety.

What happens after surgery?

After the operation, it is important to follow your doctor’s instructions. Although many people feel better within a few days, your body still needs time to heal.

After laparoscopic adrenalectomy, most patients are cared for on a regular nursing unit. Occasionally, a patient with a pheochromocytoma may be admitted to an intensive care unit after surgery to monitor his or her blood pressure. Most patients are discharged from the hospital within one or two days after surgery.

Patients with an aldosterone-producing tumor need to have their serum potassium level checked after surgery and may continue on medications to control their blood pressure.

Patients with cortisol-producing tumors and Cushing’s syndrome must take prednisone or cortisol pills after surgery. The dose is adjusted over time as the remaining normal adrenal gland resumes adequate production of the cortisol hormone.

Patients are encouraged to keep activity light while at home after surgery. They may remove any dressings and shower the day after the operation.

Post-operative pain usually is mild, although some patients may need pain medication. Most patients can resume normal activities – including driving, walking up stairs, light lifting and work – within one or two weeks.

What complications can occur?

As with any operation, there is a risk of complications. Complications during the operation may include:

  • Adverse reaction to general anesthesia
  • High blood pressure
  • Bleeding
  • Injury to other organs

Wound problems, blood clots, heart attacks and other serious complications are uncommon after laparoscopic adrenalectomy.

Washington University in St. Louis minimally invasive surgeons who perform this procedure:

L. Michael Brunt, MD

For a patient appointment with a minimally invasive surgeon, please call (314) 454-8877.

*Source of information: Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) patient information brochure.