This is an operation to remove one of the adrenal glands which sit just above the kidneys, usually because it has developed an abnormal area that has started to over produce a hormone. This can give rise to a variety of conditions eg Cushing's syndrome, Conn's syndrome etc. The gland on the left sits just below the spleen and on the right, behind the liver. The remaining adrenal gland will serve the function originally carried out by the two glands. Occassionaly it is necessary to remove both glands.
Most patients attend a pre-admission clinic where a number of routine tests will be carried out. We will ask details of your past medical history, medications, allergies etc. It is also a good opportunity to ask any questions. The anaesthetist will visit you before the surgery.
The procedure is performed under a general anaesthetic. Instead of making a large incision which allows the surgeon to access the abdominal contents with conventional instruments and hands, a series of small 1cm incisions are made just below the ribs on the side of the gland that is to be removed and specialized instruments are used. One of these instills carbon dioxide into the abdominal cavity to blow it up. A camera is then place into the abdominal cavity which allows the surgeon to see what he/she is doing. The remainder of the small holes (ports) are used to pass long instruments (forceps, scissors, etc.) through them into the abdomen for the actual dissecting of tissues. The actual operative procedure is exactly the same. It is only the access that is different.
Unfortunately it is sometimes necessary to convert to an open procedure (<5%)
This picture depicts a long instrument dissecting the left adrenal vein (blue) as it empties into the renal (kidney) vein during the laparoscopic resection of an adrenal tumor. The adrenal tumor is the large orange mass which makes up the right-upper portion of the picture. The left adrenal gland normally sits on top of the kidney (the pink organ on the right side of the picture), and under the pancreas and spleen. During the dissection of the left adrenal, the pancreas and spleen must be lifted up to allow the surgeon access to the adrenal. Here, the spleen (normally this same purple color) and the pancreas (normally this same yellow color) have been lifted (dissected) off of the adrenal and and kidney are held out of the way with a "fan" retractor in preparation for clipping the adrenal vein.
The picture on the right shows a close-up of the adrenal vein which is smaller than the renal vein and is going to have clips placed on it so it can be cut without bleeding. Once the adrenal artery and vein are identified, clipped, and then cut, the adrenal gland itself is dissected off of the kidney and then removed. Surgeons will put a small cloth bag through a port and into the abdominal cavity. The adrenal tumor is placed into this bag which makes it easier to remove through the relatively small skin incisions and ports.
A small drain will be left overnight to drain away any fluid that collects at the operation site.
What are the risks?
Like all operations there are small risks. These are largely assessed on an individual patient basis taking into account co-morbidities eg heart and lung disease. There is a very small risk of bleeding, infection and hernia formation, DVT, pulmonary embolus, heart attck (all much lower than if a conventional operation had been carried out. The risks are probably highest when we carry this operation out for Cushing's syndrome where the tissues are very fatty and thin.
You will wake up in the recovery room after surgery wearing an oxygen mask. Nurses will check you blood pressure etc and ensure that you are comfortable. You will be offered medication if you feel sick. You will be encouraged to mobolise, eat and drink within hours of the surgery. Most people will be allowed home on the 2nd postoperative day. It usually takes another 10-14 days to recover at home. You will be reviewed in a few weeks when the results of the histology are available.
Who is a Candidate For Laparoscopic Adrenalectomy?
Tumors < 10 cm in diameter .
- Tumors which secrete hormones
- Pheochromocytomas arise from the central zone of the adrenal gland (the medulla) and secrete epinephrine (adrenaline).
Tumors which do not secrete hormone...if > 4 cm Laparoscopic adrenalectomy is the perfect approach to these masses which would otherwise necessitate numerous repeated CT scans and often life-long follow-up.
Tumors which have NO characteristics of malignancy. Laparoscopic removal of the adrenal gland is not appropriate for any malignant tumors or those which have clinical / radiologic characteristics of malignancy.