Adrenalectomy

Definition

Adrenalectomy is the surgical removal of one or both adrenal glands. The adrenal glands are paired endocrine glands—one located above each kidney—that produce hormones such as epinephrine, norepinephrine, androgens, estrogens, aldosterone, and cortisol. Adrenalectomy is usually performed by conventional (open) surgery; however, in selected patients, surgeons may use laparoscopy . With laparoscopy, adrenalectomy can be accomplished through four very small incisions.

Purpose

Adrenalectomy is usually advised for patients with tumors of the adrenal glands. Adrenal gland tumors may be malignant or benign, but all typically excrete excessive amounts of one or more hormones. When malignant, they

To remove the adrenal glands, an incision is made below the patient's ribcage (A). The adrenal gland, which sits on top of the kidney (B), is visualized (C). The vein emerging from the gland is tied off and cut (D), and the adrenal gland is removed (E). (

Illustration by GGS Inc.

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Demographics

Neuroblastoma is one of the few cancer types known to secrete hormones. It occurs most often in children, and it is the third most common cancer that occurs in children. In the united States, approximately 7.5% of the childhood cancers diagnosed in 2001 were neuroblastomas, affecting one in 80,000 to 100,000 children. Close to 50% of cases of neuroblastoma occur in children younger than two years old. The disease is sometimes present at birth, but is usually not noticed until later. Approximately one-third of neuroblastomas start in the adrenal glands. According to some reports, African-American children develop the disease at a slightly higher rate than Caucasian children (8.7 per million compared to 8.0 per million cases diagnosed).

Description

Open adrenalectomy

The surgeon may operate from any of four directions, depending on the exact problem and the patient's body type.

In the anterior approach, the surgeon cuts into the abdominal wall. Usually the incision will be horizontal, just under the rib cage. If the surgeon intends to operate on only one of the adrenal glands, the incision will run under just the right or the left side of the rib cage. Sometimes a vertical incision in the middle of the abdomen provides a better approach, especially if both adrenal glands are involved.

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.

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.

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 tumor, or if the surgeon needs to examine or remove nearby structures as well.

Laparoscopic adrenalectomy

This technique does not require the surgeon to open the body cavity. Instead, four small incisions (about 0.5 in [1.27 cm] diameter each) are made into a patient's flank, just under the rib cage. A laparoscope enabling the surgeon to visualize the inside of the abdominal cavity on a television monitor is placed through one of the incisions. The other incisions are for tubes that carry miniaturized versions of surgical tools. These tools are designed to be operated by manipulations that the surgeon makes outside the body.

Diagnosis/Preparation

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 tumors 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.

Most adrenal tumors can be imaged very well with a CT scan or MRI, and benign tumors tend to look different on these tests than do cancerous tumors. 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 tumor is located.

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.

Aftercare

Patients stay in the hospital for various lengths of time after adrenalectomy. The longest hospital stays are required for open surgery using an anterior approach; hospital stays of about three days are indicated for open surgery using the posterior approach or for laparoscopic adrenalectomy.

The special concern after adrenalectomy is the patient's hormone balance. There may be several sets of required lab tests to define hormone problems and monitor the results of drug treatment. In addition, blood pressure problems and infections are more common after removal of certain types of adrenal tumors.

As with most open surgery, surgeons are also concerned about blood clots forming in the legs and traveling to the lungs (venous thromboembolism), bowel problems, and postoperative pain. With laparoscopic adrenalectomy, these problems are somewhat less prevalent, but they are still present.

Risks

The risks of adrenalectomy include major hormone imbalances, caused by the underlying disease, the surgery, or both. These can include problems with healing, blood pressure fluctuations, and other metabolic problems.

Other risks are typical of many operations. These include:

• bleeding
• damage to adjacent organs (spleen, pancreas)
• loss of bowel function
• blood clots in the lungs
• lung problems
• surgical infections
• pain
• scarring

Normal results

The outcome of an adrenalectomy depends on the condition for which it was performed. For example, in the case of hyperaldosteronism, the surgical removal of the adrenal glands provides excellent results, with the majority of patients being cured. In the case of patients diagnosed with pheochromocytoma, long-term cures are rare in cases of malignant pheochromocytomas. In cases of metastatic disease, five-year survival rates as high as 36% have been reported.

Morbidity and mortality rates

There is wide agreement that laparoscopic approaches decrease operative morbidity. The laparoscopic approach is commonly used to treat smaller adrenal tumors. At many laparoscopic centers, the laparoscopic adrenalectomy has become the standard practice. Several centers recommend a particular approach or laparoscopic method, but regardless of which approach is preferred, the cure and morbidity rates are similar for laparoscopic and open adrenalectomy (in the case of small tumors). No method is suitable for all patients. In general, selecting the approach based on patient and tumor characteristics while considering the familiarity of the surgeon yields the best results.

Alternatives

Alternatives to adrenalectomy depend on the medical condition underlying the decision to perform the surgery. In some cases, drug therapy may be considered as an alternative when the condition being treated in benign.

Resources

BOOKS

Bradley, Edward L., III. The Patient's Guide to Surgery. Philadelphia: University of Pennsylvania Press, 1994.

Fauci, Anthony S., et al., ed. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 1997.

Little, M., and D. C. Garrell. The Endocrine System: The Healthy Body. New York: Chelsea House, 1990.

PERIODICALS

Del Pizzo, J. J. "Transabdominal laparoscopic adrenalectomy." Current Urology Reports 4 (February 2003): 81–86.

Desai, M. M., I. S. Gill, J. H. Kaouk, S. F. Matin, G. T. Sung, and E. L. Bravo. "Robotic-assisted laparoscopic adrenalectomy." Urology 60 (December 2002): 1104–1107.

Hawn, M. T., D. Cook, C. Deveney, and B. C. Sheppard. "Quality of life after laparoscopic bilateral adrenalectomy for Cushing's disease." Surgery 132 (December 2002): 1068–1069.

Ikeda, Y., H. Takami, G. Tajima, Y. Sasaki, J. Takayama, H. Kurihara, M. Niimi. "Laparoscopic partial adrenalectomy." Biomedical Pharmacotherapy 56 (2002) suppl.1: 126s–131s.

Martinez, D. G. "Adrenalectomy for primary aldosteronism." Annals of Internal Medicine 138 (January 2003): 157–159.

Munver, R., J. J. Del Pizzo, and R. E. Sosa. "Adrenal-preserving Minimally Invasive Surgery: The Role of Laparoscopic Partial Adrenalectomy, Cryosurgery, and Radiofrequency Ablation of the Adrenal Gland." Current Urology Reports 4 (February 2003): 87–92.

ORGANIZATIONS

American Association of Clinical Endoctrinologists. 1000 Riverside Ave., Suite 205, Jacksonville, FL 32204. (904) 353-7878. http://www.aace.com .

American College of Surgeons. 633 N. Saint Clar St., Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org .

OTHER

"Adrenalectomy." <2000 [cited April 7, 2003]. http://www.dundee.ac.uk/medicine/tayendoweb/images/adrenalectomy.htm� 3E;

"Laparoscopic Adrenalectomy: The preferred operation for benign adrenal tumors." [cited April 7, 2003]. http://www.endocrineweb.com/laparo.html

"Laparoscopic Removal of the Adrenal Gland." 2001 [cited April 7, 2003]. <http://mininvasive.med.nyu.edu/urology/adrenalectomy.html> .

Richard H. Lampert Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Adrenalectomies are performed by general or endocrine surgeons. Surgeons work closely with their medical colleagues (endocrinologists) who are often the doctors who are responsible for both the initial diagnosis and investigation of endocrine disorders. Endocrinologists may also be involved in long-term follow-up care after the adrenalectomy. Endocrine surgeons also work with nuclear medicine physicians, radiologists, pathologists, geneticists, and anesthetists to provide the best possible patient care.

QUESTIONS TO ASK THE DOCTOR

• What procedure do you intend to use for my adrenalectomy?
• What do I need to know about my adrenalectomy?
• How long is the procedure?
• How long will it take to recover from the surgery?
• What are the major risks of the surgery?
• Why must my adrenal gland(s) be removed?
• What restrictions can I expect on my physical activity after the surgery?
• How many adrenalectomies do you perform each year?