Laparoscopic Adrenalectomy

Overview

Laparoscopic Adrenalectomy is a minimally invasive approach to remove one or both adrenal glands if it has become cancerous and /or are producing excess hormones. Adrenal glands are tiny triangular-shaped organs just above each kidney that produce certain hormones like aldosterone, adrenaline, sex hormones (androgens), and cortisol, which control and regulate various functions such as growth, development, sexual function, and metabolism. Let us explore laparoscopic adrenalectomy in detail to understand the procedure better. 

What Is Laparoscopic Adrenalectomy?

Laparoscopic Adrenalectomy, or adrenal gland removal using a laparoscope, is a minimally invasive surgical procedure involving removing one or both adrenal glands if it has turned cancerous or if the gland is producing excess hormones. Adrenalectomy can be done by an open or laparoscopic method. 

During a minimally invasive (involves small incisions with minimal bleeding and trauma) technique, your surgeon will use a special scope known as a "Laparoscope” through one of the incisions. It is a flexible fiber-optic instrument with a light source and a tiny camera at the tip. When inserted into the abdominal cavity, it captures interior images and projects them on a large screen that guides the surgeon in performing the procedure. 

Through the remaining incisions, tiny tools are passed that help the surgeon to remove a portion of the adrenal gland or the tumor with the adrenal gland completely. A Laparoscopic approach is the most preferred approach by surgeons due to decreased blood loss, less morbidity, quicker procedure, and increased patient satisfaction. 

Laparoscopic Adrenalectomy can be done as:

• Unilateral Laparoscopic Adrenalectomy- When one adrenal gland is removed. Different approaches can be used here.
• Bilateral Laparoscopic Adrenalectomy- When both the adrenal glands are removed. This is done when a patient has bilateral adrenal hyperplasia (enlargement of the adrenal gland) with Cushing’s syndrome (when your body produces excess steroid hormone, cortisol), not responding to medical treatment. Different approaches can be used here also, but a lateral transperitoneal approach is used, where one kidney is operated on first and then the other.
• Partial Adrenalectomy- It is also known as cortical sparing 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.

When Is A Laparoscopic Adrenalectomy Recommended?

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. Symptoms that mandate the removal of the tumor with/without the adrenal gland are:

• 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 occurs your body produces excess steroid hormone cortisol that leads to obesity, high blood pressure, diabetes, and decreased bone strength (osteoporosis).
  • Primary hyperaldosteronism occurs when your adrenal gland starts producing increased aldosterone, which causes high blood pressure.
  • Pheochromocytoma is a benign adrenal gland tumor that produces excess hormones and causes high blood pressure and headaches.

What Are The Different Surgical Approaches To Laparoscopic Adrenal Gland Removal?

Adrenal surgery can be performed through different techniques requiring an experienced surgeon. 

Transperitoneal Approach

• This approach provides more visualization of the operating area and decreases the risk of intra-operative injuries.
• The patient lies on the lateral side with the affected side up.
• This approach removes the left and right adrenal glands.
• 5 incisions are made on the abdomen for the surgery

Lateral Retroperitoneal Approach

• This approach is used in previously intra-abdominal surgery with adhesions.
• It helps to avoid the intra-abdominal organs and allows direct access to te adrenal gland.
• 4 incisions are made on the abdomen for surgery

Posterior Retroperitoneal Approach

• Here, the incisions are made on the back (flanks)
• It allows direct access to the adrenal gland without disturbing the peritoneal space.
• This is an obsolete approach not used by most surgeons

Transthoracic Approach

• This is used when access to the adrenal gland through the transabdominal and retroperitoneal route has not been successful.

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, 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.
• It uses the combined principles of the posterior approach and the anterior trans-abdominal technique.

How To Prepare For Laparoscopy Adrenal Gland Removal?

You must first consult your doctor when you notice any symptoms associated with adrenal tumors.

Before Surgery:

• 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 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. 
• 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 as it is performed under general anesthesia.
• Mostly, laparoscopic adrenalectomy is an outpatient procedure, and you may be allowed to go home the same day or stay overnight at the hospital. Arrange for someone to drive you home after the procedure, as you will be drowsy from the effect of anesthesia.

How Is A Laparoscopic Adrenalectomy Performed?

Laparoscopic adrenalectomy is a minimally invasive, outpatient, and safe procedure when performed by an experienced general surgeon or a urologist (a doctor specializing in the diseases of the urinary tract and male reproductive system disorders). The procedure takes about 1 to 2 hours and is performed under general anesthesia (you will be asleep and feel no pain).

• 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.
• 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.

Complete Removal Of Adrenal Gland:

• Your surgeon will make multiple (3 to 5) small keyhole-sized incisions (depending upon the approach used), with a scalpel in front of your abdomen. 
• The surgical site will be injected with carbon-dioxide gas to inflate the abdomen to improve visibility for the surgeon.
• 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 tumor with the adrenal glands will be separated and removed completely (unilateral or bilateral) from the surrounding tissues. 
• The wound will be closed with sutures or staples.

Cortical-sparing/ Partial Adrenalectomy:

• The initial steps are similar to complete laparoscopic adrenalectomy but here, a thin rim of normal adrenal tissue is excised that surrounds the adrenal nodule. The cortex is left behind during this procedure, and only a part of the adrenal gland is removed.
• The adrenal vein is left intact to preserve the vascular supply to the adrenal gland. 
• The incision is closed with glue, sutures, or staples.

What To Expect After Laparoscopic Adrenalectomy?

After a laparoscopic 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. You can go home the same day once your vitals are stable or may be kept overnight in the hospital for observation.

After Surgery:

• 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.
• 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 1 to 3 weeks.

What Are The Benefits & Risks of Laparoscopic Adrenalectomy?

Benefits:

Laparoscopic Adrenalectomy is a safe and effective procedure with the added advantage of being minimally invasive. Some of the key benefits of this surgery are listed below.

• Small incisions with minimal scarring.
• Minimized bleeding during the procedure.
• Shorter hospital stay and quick recovery.
• Quick recovery and return to normal activities.
• Minimal postoperative complications. 
• Alleviates symptoms associated with adrenal tumors.
• Improves your quality of life.
• Prevents tumor recurrence.

Since it is mostly a radical surgery, it prevents cancer metastasis (spread) to other organs and tissues.

Risks:

Laparoscopic Adrenalectomy, though a safe procedure, may pose the following risks during or after the surgery:

• Post-op infections - which may delay wound healing.
• Injury to nearby organs and tissues- by the surgeon’s instruments.
• Allergic reactions to anesthesia - may include hives, rash, itching, nausea, dizziness, confusion, and shortness of breath.
• Blood clots in the leg - may develop due to immobility and 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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