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- Adrenal Surgery
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- Adrenal Incidentaloma
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- Adrenal Program at Jersey Shore University Medical Center
- Endocrinology Center of New Jersey
- Alexander L. Shifrin, MD
Removal of the adrenal gland can be performed by open approach or by minimally invasive - laparoscopic technique. If tumor is very large (usually bigger then 8 - 10 cm), then open surgery is performed. If adrenocortical carcinoma is suspected, then open approach is undertaken to perform radical cancer surgery.
A) Open adrenal surgery
Open adrenalectomy is performed for radical removal of adrenal gland cancer - adrenocortical carcinoma (Figure 1).
Figure 1. Incision immediately after performing open radical adrenalectomy for large adrenocortical carcinoma that invaded into surrounding organs
Minimally invasive adrenal surgery is laparoscopic removal of the adrenal tumor (partial adrenalectomy) or entire gland through the abdominal or back approaches. Laparoscopic adrenalectomy is preferable approach for all functional adrenal tumors and incidentalomas that are less then 8-10 cm. The biggest advantage is not only cosmetic result, but short recovery time, and significantly less pain.
There are two approaches.
B) Laparoscoipc transabdominal lateral adrenalectomy (through the abdomen). More traditional, involves mobilization (separation and braking of the abdominal wall attachment) of the spleen on the left side and liver on the right. This may result in longer postoperative pain and recovery (but much less then with open technique). If patient had prior abdominal surgeries and developed significant amount of adhesions, then this approach may be difficult and sometimes impossible.
There will be 3 - 4 small incisions instead of one large as it used to be in a past with open approach (Figures 2, 3, 4, and 5). Minimally invasive laparoscopic technique makes the healing process faster and with minimum scar formation. Most of the time, patient is staying in the hospital over night and will be discharged to home the next day. See my video "Laparoscopic Left Adrenalectomy for Large 14 cm Pheochromocytoma" at http://cine-med.com/index.php?nav=surgery&subnav=acs&subsubnav=acs&cat=E....
Figure 2. Scars immediately after the left laparoscopic trans-abdominal lateral adrenalectomy (laparoscopic surgery to remove adrenal gland through the abdomen). Incisions are covered with skin glue.
Figure 3. Scars in 2 weeks after the left laparoscopic trans-abdominal lateral adrenalectomy (different patient).
Figure 4. Scars in 2 weeks after the left laparoscopic trans-abdominal lateral adrenalectomy (different patient).
Figure 5. Scars in 2 weeks after the right laparoscopic trans-abdominal lateral adrenalectomy (different patient).
C) Posterior retroperitoneoscopic adrenalectomy (Laparoscopic posterior retroperitoneal adrenalectomy through the back). It is more modern and advanced technique that was developed by Professor Walz form Germany. Trully minimally invasive and direct approach! It has significant advantage of avoiding entrance into the abdominal cavity that results in significantly less postopretaive pain, quicker recovery, can be performed on any patients even those who have had multiple abdominal surgeries and developed sever adhesions. The cosmetic result is much better then abdominal approach. Almost each surgeon in United States and all over the world, who is able to perform this technique, had to visit Dr Walz's Hospital in Germany and learn technique of posterior adrenalectomy from him (Figure 6a and 6b).
Figure 6b Dr Walz (left) and myself (right) in Kliniken Essen-Mitte in Essen, Germany.
After administrating of general anesthesia when patient is asleep he/she is positioned prone and surgery is performed through 3 small incisions through the back (Figure 7-12)
Figure 7. Prone positioning for the posterior retroperitoneoscopic adrenalectomy
Figure 8. Three small incision are used to insert three ports for the right posterior retroperitoneoscopic adrenalectomy
Figure 9. Right after the surgery. Skin is closed and skin glue is applied
Figure 10. Right after the surgery. Drapes are removed, you only have skin glue, no drains or stiches to remove.
Figure 11. Two weeks after the surgery (skin glue is off).
Figure 12. Four weeks after the surgery (the same patient as Figure 11).
Figure 13. Left adrenal pheochromocytoma 5.0 cm x 4.0 cm x 2.5 cm
Figure 14. Scar in 2 weeks after the left posterior retroperitoneoscopic adrenalectomy for 5 cm (2 inches) pheochromocytoma (tumor is on prior picture) in 51 year-old male
Figure 15. Scar in 2 weeks after the left posterior retroperitoneoscopic adrenalectomy for 5 cm (2 inches) pheochromocytoma (tumor is on prior picture) in 51 year-old male
POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY
The National Comprehensive Cancer Network Guideline (see link below)
The National Comprehensive Cancer Network® (NCCN®) defined Clinical Practice Guideline in Oncology (NCCN Guidelines®) for treatment of Adrenal and other Neuroendocrine Tumors
Adrenal surgery in children.
Benign adrenal pathology is rare in children. Adrenal surgery in children is performed most commonly for neuroblastoma. Because of the infiltrative nature of neuroblastomas, they are often not suitable for laparoscopic adrenalectomy. Nevertheless, more articles, especially from Asia, describe a laparoscopic approach. This may only be recommended when performed by experienced teams and as part of a multidisciplinary program.
International Pediatric Endosurgery Group (IPEG) published Guidelines for the Surgical Treatment of Adrenal Masses in Children
How to find the surgeon?
Adrenal glands produce hormones that crucial for normal body functions. Those hormones can be replaced but this replacement is very complex and not always favorable for the patient daily life activities. Removal of one adrenal gland is almost never cause any deficit in adrenal function since the other gland is completely taken over the all function. When both glands are involved then all attempts should be make to preserve at least part of one gland if it is not involved by tumor. Even surgery on one gland requires very experienced surgeon who can safely perform this complex procedure. It either surgeon who is trained as and Endocrine Surgeon or trained as laparoscopic surgeon. Surgeon should perform more than 20 adrenal operations a year to be considered an expert.
You can find an expert in your area by looking at the following link of the American Association of Endocrine Surgeons.