Definition and Overview
Adrenalectomy is the removal of one or two of the adrenal glands when tumors develop. It can be performed through the traditional open method or by using minimally invasive techniques.
The adrenal glands are a pair of thumb-sized and triangle-shaped organs that are found above the kidneys. They are part of the endocrine system and secrete hormones that are necessary to help maintain life.
The outer layer called the adrenal cortex creates cortisol, which plays a huge role in many metabolic functions and inflammation control. It also produces androgens, which can be converted into sex hormones, although the amounts are not as large as when the ovaries and the testicles create estrogen and testosterone respectively. The adrenal glands also work alongside the kidneys by regulating the level of sodium and blood pressure.
Inside the adrenal glands is the adrenal medulla that produces stress hormones including adrenaline. When a person is under stress or in a fight-or-flight situation, the hormones increase the heart rate to keep the body alert.
The adrenal glands have to produce these hormones in sufficient quantities. Anything more or less than what the body needs may result in serious problems like chronic inflammation, diabetes, and hypertension.
Who should undergo and expected results
Adrenalectomy is recommended when tumors, which could be either malignant or benign, grow in the adrenal glands. Benign ones are called adenomas, and they are more common than malignant ones or carcinomas. In fact, adrenal cancers are rare in general. Although they can occur in both adults and children, they tend to be diagnosed much earlier among children.
Adrenal tumors are also often difficult to find. They are usually detected when they have grown large and symptoms such as fluid retention or weight gain have become more pronounced. According to medical recommendations, any adrenal tumor that measures over 5 centimeters is assumed to be cancer while anything smaller than that is benign. If it's small, the endocrinologist may adopt a wait-and-see approach and monitor its growth. In both cases surgery is an option.
If the tumor is malignant, it can be classified as either primary or secondary. Primary cancers mean the disease originated from the organs. Surgery may control not only the growth but also the spread to nearby organs like the kidneys.
Secondary adrenal cancer means the condition originated from other body parts and has spread to the adrenal glands. In general, adrenal cancer has a poor prognosis if it's already distant or has metastasized.
How the procedure works
As mentioned above, adrenalectomy can be performed using either traditional open surgery or by using newer minimally invasive techniques.
An open adrenalectomy involves making one huge incision to access and remove the glands. The incision could be posterior (horizontal or vertical incision in the abdomen), anterior (incision at the back below the rib cage), and flank (incisions on each side of the body). Each of these approaches has its own advantages and disadvantages. For example, the posterior technique is the quickest way to remove the adrenal glands but may prevent the surgeon from monitoring the condition of the surrounding organs and tissues.
Open adrenalectomy is performed when tumors have become very large (and are more likely cancerous), or the surgeon has to remove other organs or tissues, which may be indicative of the cancer's spread.
The laparoscopic technique, on the other hand, involves creating four incisions underneath the rib cage. A probe is then inserted in one of the incisions to obtain a real-time image of the adrenal glands and the surrounding organs. The surgeon also operates using fine instruments while looking at the screen for guidance.
Laparoscopic technique is most recommended if the tumor is localized and small. It is not ideal for people with more than one tumor or obese.
Whether the patient undergoes laparoscopic or open surgery, general anesthesia is administered. Preparation includes balancing hormones particularly those that affect blood pressure and heart rate. This means the patient will have to be medicated first before undergoing surgery.
Possible risks and complications
Risks and complications include external and internal bleeding. In certain cases, the patient may develop a hernia in the incision site, which is characterized by the bulging of the tissue. This may cause the incision to break open and the wound may take a longer time to heal. The risk of infection is also very high. Further, damage to the other organs can be possible especially if the tumor is large, sits close to other tissues, or the approach limits the surgeon's visuals.
If only one of the adrenal glands is removed, the remaining gland immediately assumes the role. If both are affected by the adrenalectomy, the patient must take steroids for the remainder of his life. Steroids help control inflammation, but they also have side effects like muscle weakness and an increased risk of hypertension and diabetes.
- Yeh MW, Duh QY. The adrenal glands. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 41.