Surgical Approaches to the Adrenal Gland
A Treatment for Adrenal Cancer
There are five well recognized techniques by which a surgeon can remove an adrenal gland. The specific technique used will be dictated in large part by the situation at hand. Most small tumors can now be removed using minimally invasive techniques such as the posterior approach, or more frequently, the newly developed laparoscopic approach. Large tumors (>10 cm) and tumors which are known to be malignant are almost never removed by minimally invasive operations, rather a more formal exploration and resection are required.
Five Surgical Techniques for Adrenalectomy:
- Standard Trans-Abdominal. The surgeon approaches the adrenal glands through an incision on the anterior abdominal wall, moving the bowel and other organs out of the way to gain access to the kidney and adrenals. Works very well for most tumors. Very good if diagnosis of cancer is not sure prior to the operation. Allows excellent exposure of the surrounding organs and the major blood vessels within the abdomen.
- Thoraco-Abdominal. This approach allows the greatest exposure to the adrenal gland and all the surrounding structures and entails making a large incision which traverses both the abdominal and thoracic cavities...including some the diaphragm which separates them. This large operation is reserved for only the largest and most malignant tumors of the adrenal gland in hopes of providing adequate exposure of the tumor and its blood supply to allow curative resection.
- Posterior. The posterior approach gains access to the adrenal gland through an incision in the back overlying the top of the kidney. This provides limited exposure to nearby organs and their blood supply so large or malignant tumors cannot be removed in this fashion. Small tumors whether producing hormone (functional) or not can be removed easily using this approach. The small scope of this operation is tolerated very well by patients; they have very little pain, and are usually discharged from the hospital within 2 or 3 days of the operation.
- Retroperitoneal. The retroperitoneal approach combines the better tolerated advantages of the posterior approach with the greater exposure gained by the anterior trans-abdominal approach. The patient is rolled partly on his/her side and the incision is made in the flank. The kidney, adrenal, and great vessels are exposed, but the greater abdominal cavity is not entered so there is less pain and a faster recovery yet good exposure of the adrenal and its neighbors.
- Laparoscopic Adrenalectomy. The laparoscopic approach for adrenal resection allows small to moderately sized tumors to be removed using scopes and very small incisions. This technique is tolerated very well and has been shown to have the least amount of postoperative pain and require the shortest hospital stay. This is now the preferred method for removal of small to moderate size adrenal tumors whether they produce hormones or not. It is not for malignant tumors of any size. We now have a large page dedicated to this new technique.
The decision to use one of these different operations to remove an adrenal mass depends on several different factors. Each of these factors is important and will be considered by the surgeon prior to beginning the operation. In fact, occasionally a surgeon will start the operation using a smaller or even laparoscopic approach, and decide half-way through the operation that to be safe and to assure the best chance of cure that the operation should be made larger. That is not only OK, it is done in the best interest of the patient. A national average would expect that about 5% of operations which are started in the laparoscopic fashion are converted to a larger conventional operation in the best interest of the patient.
Factors which determine which adrenal operation a surgeon will perform:
- The size of the tumor. Since very large adrenal masses are more likely to be cancer, they require a larger incision and a more careful dissection. Additionally, it is almost impossible to remove a large adrenal tumor laparoscopically because the surgeon cannot see around it with the camera.
- The type of adrenal tumor. All cancers require a larger more careful operation and therefore must be removed through a larger operation. Cancers are not appropriately removed using the new minimal or laparoscopic operations. Remember, sometimes a biopsy to determine if a tumor is cancer or benign has not been performed prior to an operation. There are many circumstances when this is OK. A biopsy is not needed prior to all adrenal operations if the physicians believe that it must be removed regardless of the biopsy results. If this is the case, the surgeon will use his/her best judgment to decide which operation is the most appropriate.
- The appearance of the tumor on CAT scans and MRI scans. Adrenal tumors are imaged very well with both of these two "X-ray" techniques. Cancers tend to look different on these tests than do benign tumors. An entire page now examines these tests and pictures of benign and malignant adrenal masses are demonstrated. This picture shows a large adrenal cancer outlined in yellow.
- A history of previous abdominal operations. If a patient has had previous abdominal operations then the laparoscopic adrenalectomy can be more technically difficult. This is NOT a contraindication to this advanced procedure since surgeons who perform this are typically very good at operating through a scope so they can usually deal with the scars inside the abdomen which are a normal result of previous operations. This presence of abdominal scars and their locations will be considered, however, when deciding who can have a laparoscopic adrenalectomy.
- The surgeon's experience with different operations. Surgeons tend to do what they do well. This is not a bad thing at all, since it results in the patient receiving the best care available. Patients are not experimental animals! Laparoscopic adrenalectomy was developed in the mid 1990's so it is NOT performed by all surgeons. In fact, it performed by a small minority of surgeons who perform other types of laparoscopic surgery such as gall bladder removal and acid reflux procedures. One reason is that the operation was only recently developed, but the major reason is that adrenal tumors are not very common so many surgeons do not have the opportunity to learn the technique.