Laparoscopic Adrenalectomy Surgery in India

Laparoscopic Adrenalectomy is the procedure of choice for benign (non-cancerous) adrenal tumors. Laparoscopic surgery has proved to be a major advancement for the management of adrenal tumors. In this procedure three to five small incisions are made to insert a video chip camera and long tubes called ports through which long instruments are introduced for the surgery into the abdomen. The video chip camera projects an image of the inside of the abdomen on a television monitor and the surgeon then performs the surgery while visualizing the procedure on the TV monitor.
Patients that have undergone laparoscopic surgery have much shorter hospitalization (the average hospitalization after a laparoscopic procedure is one to two days compared to five to seven days after an open procedure), more rapid recovery (approximately 2 weeks compared to 4 to 8 weeks after open surgery) and earlier return to work. The postoperative pain is markedly reduced after laparoscopic surgery and the general feeling of physical well being returns at a much faster rate.

Common indications for laparoscopic removal of the adrenal gland are the following:

• Benign adrenal tumors 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. Given the safety record of a laparoscopic adrenalectomy and the risk of cancer in an adrenal gland that is abnormally enlarged more that 4cm, removal of the gland should be considered.

• Cushing’s syndrome –

  Removal of both adrenal glands is sometimes considered in patients who have brain pituitary tumors that produce excessive amounts of a hormone called ACTH. ACTH stimulates the adrenal to release steroids. In patients with pituitary tumors producing excessive amounts of ACTH, the adrenal is stimulated to produce an excessive amount of steroids causing a Cushing syndrome. If the pituitary tumor is not treatable by standard neurosurgical and radiation treatments, then both the adrenal glands are removed to treat Cushing syndrome.

What are the adrenal glands ?

The adrenal glands are two small organs, one located above each kidney. They are triangular in shape and about the size of a thumb. The adrenal glands are known as endocrine glands because they produce hormones. These hormones 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 – epinephrine and norepinephrine – and a small fraction of the body’s sex hormones (estrogen and androgens).

What causes adrenal gland problems ?

Diseases of the adrenal gland are relatively rare. The most common reason that a patient may need to have the adrenal gland removed is excess hormone production by a tumor located within the adrenal. Most of these tumors are small and not cancers. They are known as benign growths that can usually be removed with laparoscopic techniques. Removal of the adrenal gland may also be required for certain tumors even if they aren’t producing excess hormones, such as very large tumors or if there is a suspicion that the tumor could be a cancer, or sometimes referred to as malignant. Fortunately, malignant adrenal tumors are rare. An adrenal mass or tumor is sometimes found by chance when a patient gets an X-ray study to evaluate another problem.

What are the symptoms of adrenal gland problems ?

Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. Adrenal tumors associated with excess hormone production include pheochromocytomas, aldosterone-producing tumors, and cortisol-producing tumors. Some of these tumors 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 tumors 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 tumors 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 tumors and are not treated by adrenal gland removal. Overall, adrenal tumors 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 tumors, 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 tumors is indicated only if:
• The tumor is found to make excess hormones.
• Is large in size (more than 4-5 centimeters or 2 inches in diameter)
• If there is a suspicion that the tumor could be malignant.
• Adrenal gland cancers (adrenal cortical cancer) are rare tumors that are usually very large at the time of diagnosis. Removal of these tumors is usually done by open adrenal surgery.

If an adrenal tumor is suspected based on symptoms or has been identified by X-ray, the patient should undergo blood and urine tests to determine if the tumor is over-producing hormones. Special X-ray tests, such as a CT scan, nuclear medicine scan, an MRI or selective venous sampling are commonly used to locate the suspected adrenal tumor.

What are the advantages of  laparoscopic adrenal gland removal ?

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 tumor. Today, with the technique known as Minimally Access 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.

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