Adrenal Surgery

Adrenal body is an endocrine gland that’s located above kidneys, it consists of cortical layer and medullar area that also act as separate endocrine glands. They differ by anatomical peculiarities, secretion of different types of hormones and their origin.

The exterior part (cortical layer) synthesizes so-called steroid hormones that participate in metabolism of proteins and other elements that regulate fluid-and-electrolyte balance, as well as a few sex hormones (that also belong to the class of steroid hormones).

Causes of adrenal diseases

  • hypophysis produces too much adrenocorticotrophin hormone that regulates functioning of adrenal body (also called Cushing syndrome);
  • excessive secretion of hormones by adrenal body itself (for instance, in case pf tumors);
  • deficiency of adrenocorticotrophin hormone secreted by hypophysis (secondary adrenal failure);
  • insufficient secretion of hormones in adrenal body due to its damage or absence (primary acute or chronic adrenal failure).

Adrenal diseases are pretty rare. Damage of this organ (particularly, because of tuberculosis or autoimmune damage) leads to adrenal failure – deficiency of hormones secreted by this organ. Excess of different adrenal hormones is possible in case of adenoid tumors (tumor formations that produce hormones) or redundant stimulation by hypophysis (Cushing syndrome).

Since methods of instrumental diagnosis (computer tomography – CT and magnetic-resonance imaging – MRI) have been improved, pathological changes of adrenal body are revealed more frequently, even if accidentally. Although functional tumors of adrenal body are rare, they still require surgical invasion to be treated.

Symptoms of adrenal diseases

The symptoms of adrenal diseases depend on the type of hormone that’s produced excessively, or not sufficiently. For example, excess of mineralocorticoid hormones causes increased blood pressure and lowering of potassium level, while excess of sex hormones makes up for abnormal sexual development, excessive growth of facial hair, and so on. Acute adrenal failure is a life-threatening condition that takes place when the cortical layer of adrenal body stops secreting hormones, or suddenly produces them in much lower amount.

Methods of adrenal ectomy

Traditional adrenal ectomy is cavernous abdominal incision that’s made by cutting the abdomen (transabdominal) or chest (thoracabdominal). It’s performed when surgeons remove big malignant tumors near organs or tumors more than 10-12 cm in size. After this operation, a 20-30 cm long stitch is left.

Laparoscopic adrenal ectomy. It’s practiced most often, because this operation is minimally invasive. However, it has one disadvantage: the operation lasts 20 min longer than the traditional one. With this approach, a surgeon makes 4 little incisions (about 1,27 cm in diameter) and uses special endovideoscopic instruments. There are two ways to access the adrenal body during operation. Laparoscopic retroperitoneoscopic access. The operation is made from the back side without affecting abdomen.

This type of adrenal ectomy is considered to be the most efficient and safest, because the risk of damaging abdominal organs is minimal. The patient lies on the operating table with face down, and the surgeon makes a cut on retroperitoneum and inflates the area slightly with special gas: it will form space for manipulations. After that, the following actions are done depending on the type of retroperitoneoscopic adrenal ectomy:

  • during common retroperitoneoscopic adrenal ectomy (CORA), a surgeon puts 2-3 trocars inside for operating with endoscopic instruments (videocamera, scissors, constrictors, coagulators, etc).
  • during one-port retroperitoneoscopic adrenal ectomy (SARA), a doctor makes a 3 cm cut, puts endoscope and one instrument inside. After the operation, a patient has one barely visible scar in the zone of loins.

Laparoscopic transabdominal access is made via abdomen with endoscopic instruments. There are two types of operation:

  1. laparoscopic transabdominal lateral access. The patient lies on his side (opposite to the affected adrenal body), the operational table is bent by 30 degrees in the area of loins and is fixed. After that, the surgeon inflates subcostal zone with special gas and inputs trocars for manipulators. The instruments are advanced into the abdominal area, inner organs are moved aside, and when the surgeon accesses the back abdominal wall to remove adrenal body.
  2. laparoscopic transabdominal direct access. The patient lies on his back, and the table is sligtly bent in the zone of loins. This type of operation is convenient for the surgeon, because it provides enough space for work and allows for accessing both adrenal glands.

Robotic assisted laparoscopic adrenal ectomy. This operation is performed with the help of Da Vinci robotized surgical system. The apparatus consists of two parrts – a four-arm machine that performs all manipulations during surgery, and operator’s console allowing surgeon to control all actions of the robot.

Laparoscopic adrenal ectomy

Adrenal ectomy is a surgical operation that presupposes one-lateral removal of adrenal gland (adrenal body). It is usually performed in case of adrenal tumors. The operation allows removing either one adrenal body, or both adrenal bodies (bilateral adrenal ectomy).

In case of benign and non-active adrenal tumors, surgeons perform partial adrenal ectomy, which means the tumor only (cyst, adenoid tumor) is removed, but the adrenal body is preserved. The biopsy material is sent to a laboratory for histological analysis which will show the type and cause of tumor.

Organ-preserving operation is appropriate, if a patient has both adrenal bodies damaged, and there’s a chance to preserve one of them, because in case of removal of both adrenal bodies, a person becomes addicted to hormonal therapy for the rest of life.

Contraindications for laparoscopic adrenal ectomy

The contraindications for any laparoscopic invasion can be divided into absolute and relative, and local or general. The classification depends on the type of invasion during which it’s used. For example, 14-week-long pregnancy won’t be a contraindication for laparoscopic hernia plastics, but is a contraindication for operations to treat acute cholecystitis.

Absolute contraindications:

  • Patient’s terminal states and coma.
  • Progressing decompensation (inability to function normally) of cardiac-vessel system.
  • Sepsis, diffuse purulent peritonitis.
  • Other bad comorbidities that make the risk of surgical invasion unreasonably high.

General contraindications:

  • Extreme obesity (often regarded as a relative contraindication).
  • Disorders of blood clogging (can be revealed with the help of blood analyses).
  • Late pregnancy.
  • Local or diffuse purulent peritonitis or assumption of it.
  • General infectious diseases.

Local contraindications:

  • Infection of front abdominal wall.
  • The history of open abdominal surgeries, profound cohesions in the abdomen, scar deformations of abdominal wall (it’s also a relative contraindication).

Indications for laparoscopic adrenal ectomy

Indications for laparoscopic adrenal ectomy:

  • Aldosterone-producing adenoma of adrenal body, or unilateral hyperplasia of cortical layer of adrenal body.
  • Cushing syndrome caused by adenoma in cortical layer of the adrenal gland (it should be noted that Cushing syndrome developing as bilateral hyperplasia of the adrenal body is not always an indication for adrenal ectomy).
  • Pathological tumor in adrenal body less than 6 cm in diameter that’s combined with other metastatic tumors.
  • Pathological tumor in adrenal body less than 6 cm in diameter that progressed quickly in the last 6 months according to the results of computer tomography or MRI.
  • A small (up to 6 cm in diameter) and clearly pronounced pheochromocytoma. The selection of treatment method should be very accurate. The research of this pathology is still continued.
  • Cancer of adrenal body less than 6 cm in diameter is usually operated with open access, however, doctors research laparoscopic methods of treatment.

Pre-surgery preparation

In case of laparoscopic operation, a patient is prepared as accurately as for an open one (the point of operation stays the same, besides, surgeons never exclude the chance of conversion – switching to the open type of operation). When medications that relax muscles and eliminate pain are injected, the patient is taken to the operation room.

A doctor fixed a soft plastic catheter in the median cubital vein to inject medications, solutions, anesthesia and pain killers. A rubber or silicone mask is put on patient’s face – it helps to sustain air flow and breathing. In a few seconds, a patient falls asleep, and the anesthesiologist pus the mask off and performs intubation of trachea (inputs a plastic tube with a ferrule into the air passages that inflates and sustains hermetic state of breathing system). During the operation, a patient has artificial lung ventilation sustained.

Besides, depending on the type of disease, a patient may need to have some medications administered and prescribed before the operation. Certain examinations and analyses are performed, as well.

Post-surgery period

Open operation is a serious stress for human body. During the first hours after operation, anesthesia gradually ceases its action, and strong pain killers are injected. Surgeons also take care of drainage. Eating during the first hours after operation is prohibited – nutrients will get into blood with infusion therapy. Doctors will control work of gastrointestinal tract to exclude the risk of peritoneal commissures.

After surgery, stitches should be processed daily. Bed rest after laparoscopic operation should last up to 1 day. If the incisions were stitched with absorbable ligatures and sutures, they don’t have to be removed, otherwise – they’re removed in 5-7 days (can be done in local hospital.

Some restrictions in diet are mostly connected with anesthesia. In case of unilateral adrenal ectomy, the adrenal body that’s left takes all load (steroid hormones are used to prevent adrenal failure). If two adrenal bodies have been removed, hormonal therapy is required.

Possible complications

  • bleeding
  • thromboembolic complications (phlebothrombosis, thromboembolia of the pulmonary artery)
  • post-surgery intestinal distention
  • lung complications (reactive pleuritis, hypventilation pneumonitis, pneumothorax)
  • adrenal failure (revealed as hypotension, hypoglemia, temperature, blurring of mind, weakness)
  • infectious-purulent wound disease

Results of operation and possible outcomes

The result of operation depends on severity of disease and its development. For example, in case of hyperaldosteronism, removal of glands gives positive results and patients recover in most cases. However, if there’s a malignant chromaffinoma, treatment is rarely efficient – five-year survival rate is less than 36%.

General Surgery Department
Chief Physician

Adrenal Surgery

Professor MD MD hc Guido Schumacher

Chief Physician

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