Adrenalectomy refers to the surgical removal of the adrenal glands. An adrenalectomy is mainly done for adrenal cancer. A tumour in the adrenals can impair the functioning of the gland. This results in increased or decreased production of hormones creating a hormonal imbalance in the body. Thus, creating complications that necessitates an adrenalectomy. Either one or both of the adrenal glands may be removed.
Adrenals are endocrine glands situated above the kidneys. They are composed of two parts namely the adrenal cortex and medulla. The two parts of the adrenals produce different hormones.
The adrenal cortex produces hormones like
•Hydrocortisone or cortisols essential for the regulation of metabolism, blood pressure and cardiovascular function. It also produces various other hormones.
•Corticosteroid is essential for the regulation of immunity and to suppress an inflammatory reaction.
•Aldosterone is responsible for the maintenance of electrolyte balance in the body
·Adrenal medulla hormones include
•Adrenaline - a hormone that helps prepare the body to respond to stress
•Noradrenaline- along with adrenaline helps to prepare the body to respond stress
An imbalance of any of these hormones can create complication to the body and necessitate a surgery.
Adrenal gland removal surgery or Adrenalectomy is a major surgery. As with any major surgery, there are risks involved with this surgery, however it has been seen that adrenalectomy surgery has a high success rate in treating Cushing’s Syndrome and Conn’s Syndrome.
Pre-operative measures for adrenalectomy:
The preparation for adrenalectomy is similar to that of any major surgery. A major challenge for the surgery is the hormonal imbalance created by the adrenal tumour. The hormonal imbalance may increase the blood pressure and blood sugar levels. There will be complications due to the decreased levels of potassium in the blood. All these problems need to be rectified before the surgery. So, the doctor may prescribe appropriate drugs a few hours before the surgery.
Various imaging studies like CT and MRI scans will be done before the surgery to precisely locate the tumour. These studies will also help to understand whether the tumour is malignant or benign. Though usually they look different in CT or MRI scans, a precise differentiation is impossible. So, a tumour that looks benign in a scan can turn out to be malignant or vice versa. But a basic understanding of the nature of the tumour can help the surgeon to decide the type of surgery. An open surgery is best for malignant tumours while benign tumours are good candidates for laparoscopic surgery.
•The patient will have to be admitted in the hospital the day before surgery
•Any blood thinners if taken by the patient will have to be discontinued
•The blood pressure and blood sugar levels will be monitored to ascertain that they are within limits
•The patient will be counselled regarding the surgical procedure, duration and what to expect after surgery
•The patient is not supposed to eat or drink anything from the night before surgery
•Both laparoscopic and open adrenalectomy is done under general anaesthesia
•In open surgery there will be a large incision for access to the adrenals. The site of the incision will depend on the approach. In laparoscopic adrenalectomy the incisions will be small but three or four of them will be made in different sites.
•The aim of both the surgeries is to remove the adrenals along with the tumour.
•Once this aim is achieved the incisions will be closed.
•The patient will then be shifted to the recovery room.
•The vital signs as well as blood levels of various minerals and hormones will be taken at regular intervals.
•The patient will remain in the surgical ICU for a day and then shifted to the room
•Discharge from the hospital may happen in two or three days.
An open adrenalectomy is advised when the tumour is large in size or thought to be cancerous. There are various types of open adrenalectomy. The common types of surgeries are:
•Anterior open approach-the approach through the anterior wall of the abdomen
•Thoraco-abdominal approach-used only in very large tumours as the surgery involves the opening up the thoracic cavity.
•Posterior open approach- this approach is used only if the tumour is very small in size. A laparoscopic approach is more ideal in such situations.
This is minimally invasive surgery done through keyhole incision. There are two types of approaches for a laparoscopic adrenalectomy. They are
•An anterior trans peritoneal approach where the adrenals are approached from the front or side of the abdominal cavity.
•A poster retroperitoneal approach where the adrenals are approached from the back.
A laparoscopic approach can be used for the surgical removal of most tumours. A laparoscopic surgery may have to be converted into an open surgical procedure under certain circumstances. They include unfavourable anatomy of the internal structures, suspicion of malignancy and other unforeseen complications.
Depending on the kind of adrenalectomy surgery performed, a patient’s recovery time will vary.
For patients who’ve undergone laparoscopic surgery, they will be able to move around and eat /drink the same day as the surgery. For patient’s who’ve undergone open surgery, they will need to wait a day or two before they can eat or drink.
No matter the kind of surgery performed, post-surgery patient will experience some amount of pain. Again, for those who’ve had laparoscopic surgery, the pain will be mild. However, those who’ve had open surgery, the pain will be more, and they may require stronger doses of pain medications.
On a whole it takes about 2-6 weeks to completely recover from this surgery.
Laparoscopic Surgery Patients – they will be discharged from the hospital the day after the surgery, if there are no complications. They need about 2-4 weeks to recover and return to their normal routine. Those who have Cushing’s syndrome will be discharged after 2-5 days, since they will need to begin their steroid taper.
Open Surgery Patients – they will be discharged after 3-5 days post-surgery. They will need some time before they can get back to their daily routine with ease. Recovery usually take 4-6 weeks.
Complications of Adrenalectomy:
The risks and complications of adrenalectomy include
•Allergy to anaesthesia
•Delayed healing of the wound
•Injury of liver or spleen, a splenectomy may be necessary in certain cases
•Injury to the intestines, pancreas or kidneys
•Injury to subcostal nerve
•Addisonian crisis or adrenal insufficiency. This occurs due to a reduction of steroids in the blood. This can be a medical emergency if left untreated. Administration of steroids can control the situation.
Adrenalectomy side effects
The most important side effect of adrenalectomy is a change in levels of hormones produced by the adrenals. Hormonal supplements may be needed to correct this problem.
Do's and Don’ts during and after surgery
•Do not lift heavy weights
•Avoid strenuous exercises
•Take short walks to keep the circulation going
•Take precautions to prevent blood clot in the lungs
•Keep the body well hydrated by drinking adequate amounts of water
•Monitor blood pressure and sugar levels regularly
When to notify your doctor:
Patients should call their doctors or the hospitals asap, if they experience any of these symptoms/issues:
The first choice for adrenal cancer treatment is adrenalectomy. A primary malignant tumour originating in the adrenals are a rare occurrence. If at all they occur, they spread very fast to various parts of the body. Non-malignant adrenal tumour like adenomas of the adrenal cortex and pheochromocytoma of the medulla are more common. These tumour increases the level of adrenal hormones creating various disturbances in the body. Hence the removal of these tumours is essential for restoring the hormonal balance. Most of the time, the adrenals will have to be removed along with the tumours.
Symptoms of Adrenal Cancer:
In most patients, symptoms of adrenal cancer do not show up until the tumour is large and has started pressing against the other organs.
•High blood pressure
•Low potassium level
•Nervousness, anxiety or panic attacks
•Change in libido
Treatment by Stages:
Stage I and II: Surgery is the first choice of treatment of adrenal cancer during the first and second stage.During this surgery the entire diseased adrenal gland is removed. This should not cause any issue, because we all have two adrenal glands and living with one gland is possible. Nearby lymph nodes may be enlarged and if so, then the surgeon may remove them as well to check for cancerous cells. If the lymph nodes are not enlarged, then they are left as is.
Patients can also be treated with radiation therapy or mitotane therapy if the entire diseased adrenal gland wasn’t removed. Sometimes, these treatments can also be given if the cancer was spreading quickly. These treatments help in killing any residual cancer cells that could have been left behind.
Stage III: Surgery is still the first choice for Stage III as well. Along with the adrenal glands nearby tissues and lymph nodes will also be removed. If the cancer has affected the nearby organs such as the liver or kidney then part of all of the organ is removed. During this stage, the main focus is to remove the cancerous cells completely. Radiation therapy, Chemotherapy and Mitotane therapy may follow surgery.
Stage IV: During this stage, the cancer would have had spread to other parts of the body. Hence, surgery may not be the solution here. Usually surgery is performed if possible, however the cancer cannot be cured at this stage through it. Radiation therapy and Chemotherapy drugs may be administered. Radiation therapy can help treat the cancer that has spread to other parts of the body, e.g.: to the bones.
Adrenalectomy is done in all top hospitals in India. The average duration of surgery is about three hours. The average period of hospital stay for adrenalectomy in India is about five to seven days. The average preoperative preparation time is about two to three days. So, a person coming to India for adrenalectomy will need to spend about two weeks in the country.
The cost of adrenalectomy in India is about 5,000 to 8,000 USD. This may vary slightly according to the hospital and the surgical team.