Laparoscopic adrenal gland removal

Adrenal glands are hormone producing organs, which should be surgically removed in case of their benign or malignant processes.

The anatomy and function of the adrenal glands

The adrenal glands are triangle shaped organs, which are located in the upper poles of the kidneys, and they can be divided into two parts: cortical and medullary tissue. The main function of these is the production of steroid hormones (androgens, cortisol, glucocorticoids) and the so called catecholamines (adrenaline, noradrenaline). The hormones regulate – among other things – the body’s sodium and water balance, metabolic processes, the development of primary and secondary sexual characteristics, bone formation, anti inflammatory reactions, and stress situations.

The majority of the adrenal gland tumors are accidentally diagnosed as an additional finding on the abdominal ultrasound or CT scans. Since adrenal glands are hormone producing organs, the change in the hormone levels induces the symptoms in the setting of the tumors. Therefore, symptoms may vary: apple shaped obesity, dry skin, bone loss and muscle pain, male pattern hair growth in women, abdominal complaints, weight loss, abdominal pain, high blood pressure, high heart rate, headache, sweating.

Why is the surgery necessary?

Adrenal glands are removed due to benign or malignant neoplastic diseases. Adrenal cortical adenoma is a single sided, rounded, capsulated benign neoplasm. Adrenal cortical cancer (carcinoma) is a malignant neoplasm, which grows large, invades its environment (invasive), and may give distant metastases.

Adrenal cortical hyperplasias, adenomas, and carcinomas can be hormone producing, but functionally inactive too. Out of the adrenal glands’ non hormone producing neoplasms, the most common is myelolipoma, which consists of hematopoietic cells and fat tissue.

How are adrenal glands removed?

The surgery should be performed in general anesthesia, so in narcosis, with mechanical ventilation. Once anesthesia is induced, the patient is turned on their side, because side lying is necessary for the intervention. The removal of the abnormality is performed with a laparoscopic technique. This means that tubes, the so called probes are inserted into the abdomen through four small incisions, and a camera and devices are conducted into the surgical site (Figure 2) through these. A pressure of 10 mm Hg is created by blowing CO2 gas inside, providing the space for preparation.

During the surgery, an ultrasonic cutting device is used for preparation and for burning the smaller vessels; the larger vessels are clamped with plastic or non magnetic metal clips. In the end of the surgery, the abnormality is removed in accordance with its size: either through the probe or through the abdominal wall with the help of a bag, by making any of the incisions bigger.

It can happen with larger abnormalities that a hand assisted laparoscopic intervention is performed, during which the surgery is assisted by putting a hand into the abdominal cavity, and by making any of the probes’ spots bigger, then the adrenal gland is removed through this opening.

A silicone drain is left in the surgical site for 24 hours in the majority of the cases. The skin is closed with stitches.

During every surgery, unexpected circumstances, congenital disorders may occur because of which the surgery cannot be continued as a laparoscopy due to its technical limits. In a case like this, the procedure must be switched to the conventional open surgery. The adrenal glands can be reached through an oblique incision, which is made at the 11th rib. Since the adrenal glands are located behind the peritoneum, so retroperitoneally, the chance for abdominal organ injuries is lower during this surgery than in surgeries affecting the abdominal cavity.

What happens right after the adrenal glands were removed?

You may talk and move your head and neck freely after the surgery. If there are drains, you need to take care of them, and pay attention to not to tug on them! You can swallow after the surgery, but primarily, please consume fluids only on the day of the surgery. You can get up with assistance a few hours after the procedure. The drain is removed usually on the next day after the operation, depending on the drained amount. After the intervention, an anti coagulant injection is administered in the evening. This therapy must be continued at home too, your treating physician will provide a prescription for you. You may go home on the next day after the surgery. At home, the wounds should be dressed and cleaned every day with an antiseptic solution for the skin. The wounds must be protected from water usually for 3 5 days.

If the surgical stitches are not absorbable, they are usually removed on the 7th day after the procedure; it is possible to deviate from this according to the surgeon’s instructions, who performed the surgery. If symptoms develop after the surgery, you must call the treating physician immediately. A follow up examination is recommended on the 7th day unless your treating physician orders otherwise.

You must contact the treating endocrinologist after the surgery.

What happens if the justified surgical treatment is not performed?

If it is a benign process, not performing the surgical treatment will lead to the growth of the process, the increase of the symptoms, and the development of a malignant neoplasm.

In case of a malignant process, the development of metastases, and the deterioration of the general condition can be expected if the intervention is not performed.