Adrenalectomy

Introduction to Procedure

We know that undergoing any procedure is a scary experience. We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd. We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

The adrenal glands are paired retroperitoneal organs situated superior to the kidneys. They consist of two functional units, the adrenal cortex (secreting glucocorticoids (cortisol), mineralocorticoids (aldosterone), and sex hormones) and the adrenal medulla (secreting catecholamines, e.g. noradrenaline, adrenaline and dopamine).

Adrenal masses can be classified into functioning and non-functioning tumours. In over 5% of routine cross-sectional imaging, an incidental adrenal mass (incidentaloma) may be found. Benign adrenal adenomas represent the commonest adrenal tumours (>60%). Adrenocortical carcinoma is rare and carries a dismal prognosis. Metastases to the adrenal gland from melanoma, lung, breast, and renal carcinoma can be found in up to 73% of cases.

Operative techniques

Laparoscopic adrenalectomy represents the standard of care for resection of benign functioning of non-functioning adrenal tumours.

Approach to the adrenal glands requires clear appreciation of anatomy and the relationship of the glands to other retroperitoneal organs. The laparoscopic transperitoneal adrenalectomy is carried out with the patient in the lateral decubitus position. A four-port technique is commonly used for approach to the right adrenal gland with the most medial port being used for insertion of a liver retractor.

The right adrenal gland is exposed by rotating the liver medially by dividing the triangular ligament. On the left, a three-port technique is used. Exposure of the left adrenal gland requires division of the lienophrenic ligament and medial rotation of the spleen. It is of paramount importance to ensure minimal traction on the liver or the spleen to prevent problematic haemorrhage from capsular tears.

The right adrenal vein has a short drainage course into the inferior vena cava. In up to 20% of cases, the adrenal vein may drain into an accessory right hepatic vein. Incision of the peritoneal layer over the right adrenal gland is followed by dissection along the course of the retrohepatic inferior vena cava to its confluence with the adrenal vein. The adrenal vein is skeletonised and ligated. Blood supply to the adrenal gland is segmental and individual feeding arteries need to be accurately controlled.

Exposure to the left adrenal gland follows the same principles. Care is required to preserve the left renal vein, particularly if an accessory adrenal vein drains into it. Dissection of the adrenal gland is carried out within the peri-adrenal fat with careful attention to haemostasis and minimal manipulation of the gland. Where tumour infiltration into the surrounding tissues is encountered, conversion from a laparoscopic to open technique may be required with view to en-bloc resection of involved organs.

Close postoperative monitoring is specifically required following resection of pheochromocytomas as large fluctuations in blood pressure are anticipated. Peri- and postoperative glucocorticoid and mineralocorticoid supplementation is initiated as required.

Additional procedures that may become necessary

Abdominal drain insertion
Chest drain insertion
Nephrectomy

Benefits

Diagnostic: Provide histological diagnosis for underlying adrenal tumour development.
Therapeutic: Treatment of symptomatic adrenal pathology, remove tumour from adrenal gland whether primary or secondary, restore hormonal equilibrium after surgery with medication as required.

Alternative procedures/conservative measures

Medical: Conservative watchful waiting with serial radiological follow-up, analgesia, hormonal and steroid therapy as necessary.
Surgical: Open, laparoscopic, RFA (currently in research phase).

Serious/frequently occurring risks

Intra/postoperative haemorrhage from adrenal vein stump, accessory adrenal veins or accessory hepatic veins
Inadvertent injury to adjacent organ; liver capsule or parenchymal injury, splenic injury requiring splenectomy, bowel injury (especially splenic flexure during left adrenalectomy), damage to the tail of the pancreas, injury to bowel during laparoscopic port insertion
Pleural effusion/lower lobe pneumonia
DVT/pulmonary embolism
Pneumothorax
Postoperative adrenal insufficiency (Addisonian crisis)
Death (2009 national crude mortality rate 0.6%)

Blood transfusion necessary

Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions.

Type of anaesthesia/sedation

General anaesthesia with appropriate invasive and non-invasive monitoring (central venous pressure (CVP)/arterial line)
Routine postoperative surgical follow-up to ensure satisfactory healing
Endocrinological follow-up for clinical and biochemical confirmation of cure (e.g. reduction in antihypertensive requirements and potassium supplementation in Conn's syndrome)
Short Synacthen test – indicated following unilateral adrenalectomy in Cushing's syndrome as predictor of return of contralateral adrenal function