Adrenal Gland Surgery

Adrenal neoplasms are becoming more common as the use of abdominal imaging increases. Autopsy studies have examined the prevalence of incidental adrenal masses and discovered that they occur in up to 6% of individuals. Adrenal masses are found in fewer than 1% of people younger than 30 years old, and up to 7% of patients beyond the age of 70. 

Minimally invasive adrenalectomy through a laparoscopic transabdominal technique was originally developed in the early 1990s and has revolutionised adrenal tumor therapy. Since then, it has been demonstrated that minimally invasive adrenalectomy results in reduced blood loss, earlier patient mobility, shorter duration of stay, and a quicker return to routine activities These benefits have resulted in a rise in the frequency of surgery and the evolution of reasons for adrenalectomy.

Laparoscopic adrenalectomy is the gold standard for removal of benign adrenal masses with less complication. 

Evaluation of patient with adrenal mass

An adrenal incidentaloma, defined as the discovery of an unnoticed adrenal mass during imaging for another reason, is a common first presentation of an adrenal mass. Up to 5% of patients undergoing abdominal computed tomographic (CT) scans for various reasons have been found to have an adrenal incidentaloma.

Although biochemical screening is indicated in all individuals with adrenal incidentalomas, the majority of adrenal masses are benign. A hormonally active adrenal tumor or a suspected or proven cancer are both reasons for adrenalectomy. Primary adrenocortical carcinoma (ACC) or metastases from another primary tumour are both possible causes of adrenal malignancies.

Imaging of Adrenal Masses

Adrenal masses have become more common as a result of greater frequency and technological advancements in abdominal imaging. The imaging is usually done for other purposes and isn't designed to evaluate the adrenal glands. Some traits, however, can be found to help establish the nature of the lesion in general.

Size less than 4 cm, smooth contours with intact planes across organs, and homogeneous density are common features of benign adrenal neoplasms; in contrast, malignant neoplasms are typically bigger than 6 cm in size, have irregular borders without obvious planes, and are heterogeneous.

The intracytoplasmic fat content of benign adrenal adenomas is considerable; roughly 70% of adrenal adenomas are lipid-rich. Because of the high lipid content, unenhanced CT may be used to identify benign from malignant lesions using densitometry, which is quantified in Hounsfield units (HU). Initially, a HU threshold of less than 0 was used to identify a benign lesion, with excellent specificity (100%) but low sensitivity (47 %).

A meta-analysis of 10 studies that used unenhanced CT to analyze 495 adrenal lesions (272 benign and 223 malignant) indicated that a HU threshold of less than 10 had a sensitivity of 71% and specificity of 98 % for the identification of an adrenal adenoma without additional radiologic imaging.   Without intravenous contrast, this approach has become the gold standard for evaluating incidental adrenal lesions. An indeterminate HU (between 10 and 30) is found in about 30% of adrenal masses, necessitating contrast-enhanced CT with delayed washouts.

Malignancies with enhanced neovascularization tend to accumulate more contrast; as a result, intravenous contrast ishes out more quickly from adenomas, both lipid rich and lipid poor, than from adrenal malignancies and pheochromocytomas.

MRI scan can also be utilized to diagnose adrenal lesions. Although pheochromocytomas might have a similar look, malignant adrenal lesions contain more water and less fat than benign lesions, resulting in a greater signal on T2 imaging. Adenomas look more homogeneous when gadolinium contrast is utilized, whereas malignancies appear more diverse.

However, because the features of benign and malignant tumors are so similar, MRI may not be able to identify adenomas from malignant masses. Radionuclide adrenal imaging using particular radio-labeled chemicals that target components of adrenal function and assist describe lesions may improve adrenal lesions that are not well characterized by CT or MRI. For medullary tissue lesions, radiotracers such as metaiodobenzylguanidine (MIBG) and fludeoxyglucose F18 (18F FDG) may be used. 

Biochemical Evaluation of Adrenal Tumors

The first step in evaluating an adrenal mass is to ascertain its functioning condition. A complete medical history and physical examination should be acquired, with specific questions regarding symptoms of increased aldosterone, cortisol, or catecholamine production. Other constitutional symptoms, such as weight loss, cancer history, and smoking history, should be assessed as a primary ACC or adrenal metastases must also be evaluated in the differential diagnosis.

Evaluation of patient with metastases to Adrenal Glands  

The most prevalent cause of isolated adrenal metastases is primary lung cancer, although other primary malignancies include breast, melanoma, kidney, colon, stomach, and lymphoma. Although the benefits of surgery for metastatic malignancy are debatable, studies have shown that treatment improves survival in appropriately chosen individuals. Adrenal metastases should be considered in individuals with a known history of cancer who have an adrenal mass identified during an initial workup or routine surveillance of the underlying tumor. For a functioning adrenal tumor, examination should involve a comparison to past imaging as well as a biochemical test.

A comprehensive examination for loco-regional recurrence and other complications is recommended by the American Association of Clinical Endocrinologists (AACE) and the American Association of Endocrine Surgeons (AAES) recommendations for the management of adrenal incidentaloma. If an adrenal metastasis is suspected, it is necessary to look for metastatic locations. Because of the safety of minimally invasive surgery, it should be regarded as a first-line treatment option for a solitary adrenal metastasis.

For adrenal metastases, laparoscopic adrenalectomy has been demonstrated to be safe and oncologically suitable. A study of 92 individuals who had adrenalectomy (94 adrenalectomies: 63 open and 31 laparoscopic) for isolated adrenal metastases discovered a median overall survival of 30 months and a 5-year projected survival of 31%. 

There was no difference in local recurrence, margin status, disease-free interval, or overall survival when laparoscopic surgery was compared to open surgery. Blood loss was reduced after laparoscopic adrenalectomy. Patients with primary soft-tissue, kidney, lung, and pancreatic tumors were found to have better overall survival at 3 years: sarcoma (86% vs 30%), kidney (72% vs 27%), lung (52% vs 25%), and pancreas (45% vs 12%). 

The most prevalent risk factors for mortality were a shorter time between original diagnosis and adrenalectomy, other distant sites of disease, palliative surgery, and persistent disease. A retrospective European multicenter study found 317 individuals who had adrenalectomy for adrenal metastases; the most prevalent original tumor was non–small cell lung cancer (47%) followed by colorectal (14%) and renal (12%) malignancies followed by colorectal (14%) and renal (12%) cancers. 

Preoperative preparations

The functional condition of the mass determines the preoperative preparation. Preoperative a-adrenergic blockade is required for patients with pheochromocytoma to reduce the risk of perioperative cardiovascular problems. Medication should be begun 7 to 14 days before to surgery to provide enough time for blood pressure and heart rate to be corrected. Only after proper a-blockade may b-adrenergic blockade be used to treat reflexive tachycardia. 

To offset catecholamine-induced volume constriction, patients should be urged to increase salt and fluid consumption. Preoperative consultation and conversation with the anesthesia team is essential to ensure that they are prepared to manage hemodynamic changes throughout the surgery. Patients with high cortisol levels may require perioperative drugs, as well as outpatient follow-up for monitoring and tapering.

Types of adrenalectomy procedures

Laparoscopic Transabdominal Adrenalectomy approach:

Right Laparoscopic Transabdominal Adrenalectomy

The patient is positioned with the right side up for a right adrenalectomy, and once the ports are placed, dissection begins by incising the right triangular ligament.

The majority of the dissection should be done with an ultrasonic or bipolar instrument. This incision should be made all the way up to the diaphragm. A fourth port (placed through the falciform ligament in the midline of the abdomen) is frequently utilized to facilitate the use of a gentle liver retractor. Once the liver has been fully mobilized, it should be retracted medially to provide visibility of the adrenal gland and inferior vena cava (IVC). The right adrenal vein drains straight into the IVC and can be found by gently dissecting the gland on its medial edge.

Using blunt dissection and electrocautery, the plane between the adrenal gland and the IVC should be established softly. The adrenal vein should be precisely identified and clipped. A vascular stapler may be applied if the adrenal vein cannot be securely ligated with clips alone. The rest of the medial and inferomedial attachments are split once the vein has been secured.The gland is then raised, and the remaining avascular posterior and lateral attachments are ligated. The gland is placed in a retrieval bag and removed through the 12-mm port site, which may need to be extended to properly remove larger adrenal glands. The fascia for the 12-mm trocar site should be closed at the end of the operation.

Throughout the operation and dissection, it is critical to avoid applying excessive pressure, retraction, or clutching to the adrenal gland, since this might result in rupture of the gland. If surgery is being conducted for a pheochromocytoma, it is critical to maintain regular contact with the anesthesia team, including telling the team when the adrenal vein is being ligated. The anesthetic and surgical teams must be prepared for major changes in blood pressure, and dissection may need to be paused to accommodate these demands.

Left Laparoscopic Transabdominal Adrenalectomy

Left adrenalectomy may be performed with 3 ports, although an additional medial port may be used to aid in retraction. The initial step is to mobilize the colon's splenic flexure. This step may be required before the most lateral port may be implanted. The splenorenal ligaments are then separated all the way up to the diaphragm, allowing the spleen to be retracted medially.

At this point, extreme caution is required to produce a correct plane between the pancreas and the left kidney; Gerota's fascia should not be accessible. With the spleen and pancreas tail medially mobilized, an extra medial port may be inserted to help with retraction. The adrenal gland should now be seen next to the kidney's superior pole. The medial border of the adrenal gland should be dissected free utilizing an ultrasonic instrument and a mix of blunt dissection and electrocautery. 

Once it is properly dissected free, it should be ligated with a clip applier. The inferior phrenic vein may also enter into the adrenal vein and may require ligation. After the adrenal vein is ligated, the remaining attachments of the gland can be divided. The inferior portion of the gland is elevated to aid in division of the posterior attachments and small arterial branches. Once the gland is completely free, it may be placed into a retrieval bag for removal.

Advantages of Laparoscopic Transabdominal Adrenalectomy:

• Can be combined with other transabdominal procedure.
• Easier access for conversion to open procedure.
• More suitable in obese patients.

Disadvantages of Laparoscopic Transabdominal Adrenalectomy:

• Need to change position for bilateral adrenalectomy.
• Need to mobilize abdominal structures.
• Not suitable for known or highly suspected malignant tumor (ACC or pheochromocytoma).
• Evidence of invasion into adjacent structures.

Posterior Retro-peritoneoscopic Adrenalectomy (PRA)

Following the placement of sequential compression devices and a Foley catheter, patients are intubated in the supine position. The patient is then shifted to the prone, jack-knife position on a Cloward table with an open area for the abdomen between the hip supports to allow contents to fall forward, with care taken to arrange suitable padding for the patient's face. 

The arms are supported by arm boards, with the elbows bent at a 90-degree angle. The hips and knees are also bent at a 90-degree angle, ensuring that the knee rest is low enough to reduce strain on the knees and prevent the hips from being lifted, which can decrease the working area.

The 12th rib and iliac crest are important markers to consider in this position.

The first incision is performed immediately below the 12th rib point. The underlying soft tissue is dissected and the retroperitoneum is reached using sharp dissection with Metzenbaum scissors. 

The index finger is used to create space, and a 5-mm port is inserted medially, just lateral to the paraspinous musculature, under direct palpation. The lateral 5-mm port is likewise palpated and implanted 5 cm lateral to the original incision. After that, a blunt 12-mm trocar with an inflating balloon and an adjustable sleeve is inserted into the original (middle) incision.

The retroperitoneal cavity is then insufflated at a pressure of 20 to 24 mm Hg with strong flow. This high insufflation pressure effectively opens the retroperitoneal space and prevents bleeding from smaller veins to aid in dissection. A 10-mm laparoscope is inserted via the central trocar, and the surgeon works through the medial and lateral trocars to ligate the retroperitoneum tissues. Once the retroperitoneal space has been created, the operating surgeon uses a 5-mm 30laparoscope via the most medial port and the lateral two ports.

The superior pole of the kidney is the first landmark to be recognized after careful blunt dissection. The IVC is visible medially with a right adrenalectomy, although it may be considerably decompressed due to the elevated insufflation pressure. The adrenal gland should always be mobilized inferiorly, by gently pressing down on the kidney with a laparoscopic peanut and raising the adrenal superiorly. An ultrasonic coagulator or bipolar device is used to gently split the tissue along the superior border of the kidney. The adrenal vein, which runs medial to the adrenal gland, should next be located.

After being carefully dissected free, the vein is gripped with a grasper on its distal side (closest to the adrenal), clips are put twice on the proximal side, and the vein is separated using electrocautery.

After making a working area in the retroperitoneum, the dissection process begins by separating the lower portion of the adrenal gland from the superior pole of the kidney. The gland is then extracted using a retrieval bag entered through the middle port. After that, the trocar is replaced, and the retroperitoneal region is checked for hemostasis. The pressure is reduced to 8 to 12 mm Hg to allow visualization of any venous bleeding that may have been obscured by the high insufflation pressure. The ports are removed once hemostasis has been established.

Indications for open surgery:

The use of minimally invasive adrenalectomy for patients of suspected adrenocortical cancer has been controversial since its introduction. ACC is a rare cancer with a yearly incidence of 1 to 2 per million per year, a high risk of recurrence, and poor long-term survival.  Open surgery supporters argue that ACC tends to penetrate through the tumor capsule with microscopic disease present at the gland surface, which laparoscopy can disturb and disseminate. 

The AACE/AAES advises open adrenalectomy with lymphadenectomy for suspected ACC, with the objective of leaving the capsule intact to limit the chance of local recurrence.  However, according to the European Society of Endocrine Surgeons policy statement on malignant adrenal tumors, laparoscopic excision of ACC or possibly malignant tumors with preoperative and intraoperative stage I–II ACC and diameter less than 10 cm may be undertaken.

Advantages of Posterior Retro-peritoneoscopic Adrenalectomy (PRA):

• Do not have to mobilize other organs.
• Not affected by prior abdominal surgery.
• No intraperitoneal insufflation (for patients with potential cardiovascular or respiratory compromise).
• Same position for bilateral adrenalectomy.

Disadvantages of Posterior Retro-peritoneoscopic Adrenalectomy (PRA):

• Not suitable for obese patients.
• Short distance between 12th rib and iliac crest (<4 cm).
• Not suitable for known or highly suspected malignant tumor (ACC or pheochromocytoma).

How much does Adrenal Gland surgery cost?

The cost of an adrenal gland removal (Adrenalectomy) ranges from $13,647 to $14,754 in the united states. 

Adrenal gland surgery recovery time 

Everyone gets better at a different pace, the symptoms of the tumor and its hormone overproduction will go away almost immediately. Most patients recover without complications in two to three weeks with less recovery time in those undergoing laparoscopic surgery. If the tumor was cancerous, your healthcare provider will monitor you for cancer recurrence and additional treatments may be necessary.

Conclusion

Adrenal tumors or adrenal masses are benign or malignant neoplasms of the adrenal gland, some of which are remarkable for their predisposition to overproduce endocrine hormones. Adrenal cancer is characterized by the presence of malignant adrenal tumors, which includes neuroblastoma, adrenocortical carcinoma, and certain adrenal pheochromocytomas.

Again, as the use of abdominal imaging rises, adrenal neoplasms are becoming more prevalent. Autopsy investigations on the occurrence of accidental adrenal masses found that they occur in up to 6% of persons. Adrenal masses are discovered in less than 1% of adults under the age of 30, and up to 7% of patients over the age of 70.

Laparoscopic adrenalectomy enables physicians to remove a damaged or malignant adrenal gland in a safe and effective manner. Adrenal tumors can be benign or malignant in nature. Many benign adrenal tumors emit hormones such as cortisol, aldosterone, epinephrine, and norepinephrine, which can cause elevated blood pressure, face flushing, weight gain, headaches, palpitations, and other symptoms. Although rare, adrenal cancer can develop to be quite massive. The majority of benign and malignant adrenal tumors are treatable laparoscopically.

Laparoscopic adrenalectomy is a less invasive approach that provides patients with less discomfort and comparable results as compared to traditional open surgery, which requires a wider incision. When compared to open surgery, laparoscopic adrenalectomy has resulted in much less post-operative discomfort, a shorter hospital stay, earlier return to work and everyday activities, a more attractive aesthetic result, and results that are identical to open surgery.