Laparoscopic Surgery For Disorders Of The Adrenal Gland

Laparoscopic adrenalectomy is a surgery being offered by very few centres in India. Dr Deepraj Bhandarkar from Hinduja Hospital, Mumbai, Maharashtra is an expert in laparoscopic surgery who has a large experience of laparoscopic treatment of diseases affecting the adrenal gland.

What are adrenal glands?

The adrenal glands are small organs located above each kidney. The term “ad-renal” literally means adjacent to renal (kidney). A normal adrenal gland is triangular in shape and roughly the size of one’s thumb. The function of the adrenal glands is to produce hormones responsible for various functions in the body. The hormones produced by the adrenal glands include cortisol, aldosterone, epinephrine and norepinephrine and a small amount of sex hormones estrogen and androgen.

What diseases affect the adrenal glands?

Diseases of the adrenal gland are relatively uncommon. The commonest reason for removal of an adrenal gland is a tumour located within the gland producing excess hormone. Majority of these tumours are not cancers. These non-cancerous tumours, which are usually small, can be usually removed with laparoscopic surgery. Removal of the adrenal gland may also be required for certain tumours even if they aren’t producing excess hormones.

What symptoms do diseases of the adrenal gland produce?

Patients with diseases of the adrenal gland may experience a variety of symptoms related to the excess hormone/s produced. Some tumours produce no symptoms till they grow to a large size.

Cortisol producing tumours: Tumours that produce an excess of hormone cortisol cause Cushing’s syndrome. Patients suffering from this syndrome become obese (especially on the face and the mid-body), have high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Some patients with Cushing’s syndrome actually have tumours in the pituitary gland. Only when the tests suggest that the tumour is situated in the adrenal gland does removal of the adrenal gland become necessary.

Aldosteronomas: These are tumours of the adrenal gland produce an excess of hormone called aldosterone. Patients may suffer from a raised blood pressure and often have low levels of potassium in the blood. The low potassium levels can result in symptoms of weakness, fatigue and frequent urination.

Pheochromocytomas: These are tumours that produce excess of hormones called “catecholamines”. The patient may experience very episodes of high blood pressure characterized by severe headaches, anxiety, palpitations, excessive sweating and rapid heart rate. These spells may last from a few seconds to several minutes. Some of the pheochromocytomas can occur outside the adrenal glands. These are called paragangliomas or extra-adrenal pheochromocytomas. Their presentation and treatment is similar to that of pheochromocytomas occurring in the adrenal gland.

Incidentalomas: An adrenal mass or tumour may sometimes be found when a patient gets an abdominal ultrasound or CT scan for evaluation of another problem. Such tumours are called “incidentalomas”. An incidentaloma may be any of the above types of hormone-producing tumour or may not produce any hormones at all. A patient found to have an incidentaloma needs to be evaluated to check whether or not the tumour is producing excess hormones. When an incidentaloma causing no symptoms and the tests indicate that it is not producing excess hormones and is non-cancerous, it does not need to be removed.

Surgical removal of an incidentaloma is required only if:

• The tumour is found to produce excess hormone

• Is more than 4-5 centimeters in diameter

• If, based on the scans, there is a suspicion that the tumor could be cancerous.

Adrenal gland cancers: These are called adrenocortical cancers and are rare. They are usually very large at the time of diagnosis and require an open operation for their removal.

What tests are required prior to surgery?
Patients with suspected adrenal gland disorders are usually evaluated by Endocrinologists (physicians who specialize in treatment of hormonal disorders). Generally blood and urine tests are recommended to check if there is excessive production of hormones. The next step involves tests like a CT scan, MRI scan or MIBG scan to determine the precise location and the nature of the tumour.

What surgical options are available for removal of the adrenal gland?
When a patient is found to have an adrenal tumour producing excess hormone/s or is suspected to be cancerous, surgical removal of the tumour is advised. This is the point where a surgeon specialized in adrenal surgery comes in. Suspected cancerous tumours are removed by open surgery through an 8-10 inch incision in the flank or in the upper part of the abdomen. Most other tumours are ideally removed by laparoscopic surgery.

How is laparoscopic adrenalectomy performed?
The surgery is performed under a general anesthesia, so that the patient is asleep during the procedure. A cannula (a narrow tube-like instrument) is placed into the abdominal cavity in the upper abdomen or flank just below the ribs. A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula. This gives the surgeon a magnified view of the internal organs on a television screen. Other cannulas are inserted which allow the surgeon to separate the adrenal gland from its attachments. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. It is almost always necessary to remove the entire adrenal gland in order to safely remove the tumor. After the surgeon removes the adrenal gland, the small incisions are closed.

What happens if the operation cannot be performed by the laparoscopic method?
In a small number of patients the laparoscopic method cannot be performed. In that situation, the operation is converted to an open procedure. Factors that may increase the possibility of choosing or converting to the "open" procedure may include:

• Obesity

• A history of prior abdominal surgery causing dense scar tissue

• Inability to visualize the adrenal gland clearly

• Bleeding problems during the operation

• Large tumor size (over 10 cm in diameter)

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather reflects a sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

What are the advantages of laparoscopic adrenalectomy?
In the past, making a large 15 to 25 cm incision in the abdomen, flank, or back was necessary for removal of an adrenal gland tumor. Today, with the technique known as minimally invasive surgery, removal of the adrenal gland (also known as “laparoscopic adrenalectomy”) can be performed through three or four 1/2-1 cm incisions. Patients may leave the hospital in one or two days and return to work more quickly than patients recovering from open surgery.

Results of surgery may vary depending on the type of procedure and the patients overall condition.

Common advantages are:

• Less postoperative pain

• Shorter hospital stay

• Quicker return to normal activity

• Improved cosmetic result

• Reduced risk of herniation or wound separation

What happens after the operation?
After the operation, it is important to follow the doctor's instructions. Although many people feel better in just a few days, remember that your body needs time to heal. After laparoscopic adrenal gland surgery, most patients are shifted to a regular ward. Occasionally, a patient with a pheochromocytoma may require admission to an intensive care unit after surgery to monitor their blood pressure. Most patients can de discharged from the hospital within two or three days after surgery. Patients with an aldosterone-producing tumour will need to have their serum potassium level checked after surgery and may need to continue to take medications to control their blood pressure. Patients with cortisol-producing tumours and Cushing’s syndrome will need to take prednisone or cortisol tablets after surgery. The dose is then tapered over time as the remaining normal adrenal gland resumes adequate production of cortisol hormone.

Who should perform laparoscopic adrenalectomy?
Patients with adrenal diseases undergoing surgery require meticulous preoperative workup, careful monitoring during surgery as well as proper postoperative care – sometime in the intensive care unit. Laparoscopic adrenalectomy is a major operation that should be performed by surgeons experienced in complex laparoscopic surgery. For these reasons this surgery should be ideally undertaken in institutes that have all the necessary expertise available under one roof.