The preferred operation for benign adrenal tumors.
A benign adrenal cortical tumor is shown in this picture which also shows the entire triangular adrenal gland. This tumor produced very large amounts of the hormone "aldosterone" which helps maintain salt balance in the blood when produced in normal amounts. Production of excess aldosterone by these tumors causes high blood pressure, high serum sodium, and low serum potassium. This tumor was removed laparoscopically through a series of 5 incisions each about 1/2 inch in length. The operation took 1.8 hours and the patient went home the next day cured of their disease.
This case is a perfect example of how very small tumors of the endocrine system can make a person sick. This picture is enlarged two-fold to make the small round tumor easier to see. In reality, this aldosteronoma was less than one-half inch in diameter. Even when endocrine tumors are benign (most are) they can produce excess hormones which will act on distant organs of the body to make a person sick. Benign adrenal tumors (just like parathyroid tumors) lend themselves very nicely to minimally invasive surgical techniques since the goal of the operation is simply to remove the source of the excess hormone. Laparoscopic surgery for the removal of adrenal tumors was developed in the mid 1990's and it has quickly been shown to be less stressful on the patient, cause less post-operative pain, require a shorter hospital stay (average 2-3 days instead of 5-7 days), require less pain medicine, and allow a much faster return to regular activities than does the standard open abdominal operation.
Laparoscopic surgery refers to the technique in which a surgeon operates within the abdominal cavity with small telescopes and long instruments. Instead of making a large incision which allows the surgeon access to the abdominal contents where he/she operates with conventional instruments and their hands, a series of small (~ 1/4 to 3/4 inch) incisions are made and specialized instruments are used. One of these instruments instills air into the abdominal cavity to blow it up (like a balloon but only under modest pressure). This instillation of air makes it easier to work since the intestines and other organs will fall away from the tissues which are being examined. 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) have long instruments (forceps, scissors, etc.) placed through them into the abdomen for the actual dissecting of tissues. The patient on the right is positioned on his side for a laparoscopic adrenalectomy.
This picture depicts a long instrument dissecting the left adrenal vein 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 lives on top of the kidney (the flesh-colored 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 relationship of the adrenal glands to other organs in the abdomen can be seen nicely on CAT scans and MRI scans which are demonstrated on our page on adrenal X-ray tests.
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.
Who is a Candidate For Laparoscopic Adrenalectomy?
- Tumors less than 10 cm in diameter (~ 4 inches). Tumors larger than this are more likely to be cancerous and therefore require better exposure and a more aggressive operation. Tumors larger than this also pose a technical problem because the surgeon has difficulty seeing around it with the camera.
- Tumors which secrete hormone. These masses are ideally suited for this approach.
- Pheochromocytomas. Pheochromocytomas are tumors which arise from the central zone of the adrenal gland (the medulla) and secrete epinephrine (adrenaline). Since they are usually small and benign, they can be removed with great success using this minimally invasive approach.
- Tumors which do not secrete hormone...if they are greater than 4 cm (~ 1 3/4 inches). Laparoscopic adrenalectomy is the perfect approach to these masses which would otherwise necessitate numerous repeated CAT scans and often life-long follow-up by a physician.
- Tumors which have NO characteristics of malignancy. Laparoscopic removal of the adrenal gland is not appropriate for any cancerous tumors or those which have clinical / radiologic characteristics of malignancy.