Adrenal glands are a part of our endocrine system. They are two small organs, located one above each kidney. They are triangular in shape and about the size of a thumb. These glands produce hormones which are involved in control of blood pressure, chemical levels in the blood, water use in the body, glucose usage, and the "fight or flight" reaction during times of stress. These adrenal-produced hormones include cortisol, aldosterone, the adrenaline hormones and a small fraction of the body's sex hormones (oestrogen and androgens).

The adrenal glands are fed by numerous blood vessels, so surgeons need to be alert to extensive bleeding during surgery. In addition, the adrenal glands lie close to one of the body's major blood vessels (the vena cava), and to the spleen and the pancreas. The surgeon needs to remove the gland(s) without damaging any of these important and delicate organs.

What are the indications of Adrenalectomy?

Diseases of the adrenal gland are relatively rare. The most common reason that a patient may need to have the adrenal gland removed is because of tumour within adrenal gland. Most of these tumours are small and not cancers. They are known as benign growths that can usually be removed with surgery. Removal of the adrenal gland may also be required for certain tumours even if they aren't producing excess hormones, such as very large tumours or if there is a suspicion that the tumour could be a cancer, or sometimes referred to as malignant. Fortunately, malignant adrenal tumours are rare. An adrenal mass or tumour is sometimes found by chance when a patient gets an X-ray study to evaluate another problem. Occasionally, Adrenalectomy may be recommended when hormones produced by the adrenal glands aggravate another condition such as breast cancer. Let us see the common indications for removal of the adrenal gland are the following:

   * Benign adrenal tumours such as Cushing disease and Cohn syndrome
   * Pheochromocytoma
   * Metastatic disease (spread) from lung, breast and other cancers. This is an uncommon reason for removal of the adrenal gland. The adrenal gland would only be considered for removal in metastatic disease if this were the only site of metastatic disease
   * Adrenal mass (enlargement) of uncertain origin. If the adrenal gland is more than 4cm large then there is a higher risk of cancer than a smaller mass.

What are the symptoms?

Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. Adrenal tumours associated with excess hormone production include pheochromocytomas, aldosterone-producing tumours, and cortisol-producing tumours. Some of these tumours and their typical features are given below.

   * Pheochromocytomas produce excess hormones that can cause very high blood pressure and periodic spells characterized by severe headaches, excessive sweating, anxiety, palpitations, and rapid heart rate that may last from a few seconds to several minutes.
   * Aldosterone producing tumours cause high blood pressure and low serum (blood) potassium levels. In some patients this may result in symptoms of weakness, fatigue, and frequent urination.
   * Cortisol producing tumours cause a syndrome termed Cushing's syndrome that can be characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Most cases of Cushing's syndrome, however, are caused by small pituitary tumours and are not treated by adrenal gland removal. Overall, adrenal tumours account for about 20% of cases of Cushing's syndrome.
   * An incidentally found mass in the adrenal may be any of the above types of tumours, or may produce no hormones at all. Most incidentally found adrenal masses do not make excess hormones, cause no symptoms, are benign, and do not need to be removed. Surgical removal of incidentally discovered adrenal tumours is indicated only if:

         o The tumour is found to make excess hormones
         o Is large in size (more than 4-5 centimetres or 2 inches in diameter)
         o If there is a suspicion that the tumour could be malignant.

   * Adrenal gland cancers (adrenal cortical cancer) are rare tumours that are usually very large at the time of diagnosis. Removal of these tumours is usually done by open adrenal surgery.

How is it diagnosed?

If an adrenal tumour is suspected based on symptoms or has been identified by X-ray, the patients are advised to undergo blood and urine tests to determine if the tumour is over-producing hormones. CT scan, nuclear medicine scan, an MRI or selective venous sampling are commonly used to locate the suspected adrenal tumour. Surgical removal of the adrenal gland is the preferred treatment for patients with adrenal tumours that secrete excess hormones and for primary adrenal tutors that appear malignant.  

Benefits and drawbacks

In the past, making a large 6 to 12 inch incision in the abdomen, flank, or back was necessary for removal of an adrenal gland tumour. 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 1/4-1/2 inch incisions. Patients may leave the hospital in one or two days and return to work more quickly than patients recovering from open surgery.

Laparoscopic Adrenalectomy can de performed safely in a cost-effective manner. Given the benefits of this minimally invasive technique, the laparoscopic approach is quickly gaining popularity as the treatment of choice for Adrenalectomy. 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

Complications and risks

As with any operation, there is a risk of a complication. Complications during the operation may include:

   * Adverse reaction to general anaesthesia
   * High blood pressure
   * Bleeding
   * Injury to other organs
   * Wound problems, blood clots, heart attacks, and other serious complications are uncommon after laparoscopic Adrenalectomy

For those carefully selected patients who are well-suited for the procedure, people who undergo laparoscopic Adrenalectomy have done much better than those receiving the standard, "open" operations, with a much quicker return to normal activity, a shorter hospital stay, less need for pain medication, and a markedly lower incidence of complications.