Adrenalectomy

Physical examBlood testsUrine testsAbdominal ultrasounda test that uses sound waves to find specific areas in the abdomen CT scan of the abdomena type of x-ray that uses a computer to make pictures of the kidneys and/or adrenal glands MRI scana test that uses magnetic waves to make pictures of the kidneys and/or adrenal glands CT scan of the headto examine the pituitary gland (this gland controls the adrenal glands) Nuclear scan (MIBG or NP-59)a test in which a small amount of radioactive material is injected, and then pictures are taken of the inside of the body to determine if the tumor is benign or malignantGive certain drugs to determine why the adrenal gland is not working correctly If your doctor diagnoses a hormone imbalance, high blood pressure, or low blood potassium, you may be given medications in the weeks prior to your operation In the days leading up to your procedure: Arrange for a ride to and from the procedureArrange for help at home after returningThe night before, eat a light meal, do not eat or drink anything after midnightYou may be given laxatives and/or an enema to clean out your intestinesYour doctors may need to admit you to the hospital before your planned procedure if your blood pressure has not been well controlled with medications. This will allow more aggressive treatment to stabilize your blood pressure. It will also ensure that you have enough fluid in your body to prevent blood pressure problems once the tumor is removed.

AnesthesiaGeneral anesthesia Description of the ProcedureYou will be given IV fluids, antibiotics, and steroids. There are two main types of adrenalectomy: Classic Open Abdominal Adrenalectomy:The adrenal glands can be removed through an incision just under the rib cage or in the abdomen. The adrenal gland is carefully separated from the kidney and removed. Small tumors, usually benign, are typically removed from the back or with a laparoscopic approach (see below). Large masses that may be malignant are usually removed from the front. This is done so that the mass can easily be removed and the rest of the abdomen can be examined.The surgeon may choose to place a tiny, flexible tube into the area where the gland was removed. This tube will drain any fluids that may build up after surgery. It will be removed within one week after your operation. The incision is closed with either stitches or staples, and covered with a sterile dressing. Laparoscopic Adrenalectomy:The surgeon makes 3-4 small incisions in the abdomen. A tiny camera is passed through one of these openings to provide a view of the inside. To allow a better view, the abdomen is filled with gas. Other tube-like instruments are used to separate the adrenal gland from the kidney and to pull the removed gland back out. The incisions are often small enough to be closed with just a couple of stitches or staples, and covered with small bandages.

After ProcedureThe adrenal gland(s) are examined by a pathologist. How Long Will It Take?1 hours-3 hours Will It Hurt?Anesthesia prevents pain during surgery. Pain or soreness during recovery will be managed with pain medication. Possible Complications During laparoscopic surgery, the surgeon may need to switch to a classic open abdominal adrenalectomy. This may happen in these cases: Excess scarring from previous surgeriesThe adrenal tumor or the adrenal size is larger than anticipatedThe surgeon is unable to appropriately visualize the structures in the abdomen Other possible complications include: Nelson's syndromea pre-existing pituitary tumor begins to grow at an extremely fast rate, resulting in abnormal blood hormone levels and extreme discoloration of the skinImproper hormone balanceChanges in blood pressureSlow wound healingRetained fluidBleedingInfectionBlood clots in the legsPneumonia and other risks of general anesthesia Injury to nearby organs or structuresAdverse reaction to anesthesia Average Hospital StayClassic open abdominal adrenalectomy: 4-5 daysLaparoscopic adrenalectomy: 2-3 days Postoperative CareYou might require pain medications. Patients who have had open surgery require stronger pain medications for a longer period of time than those who undergo the laparoscopic procedure.You may be nauseated for a few hours after surgery. Your surgeon may have placed a nasogastric tube through your nose and into your stomach to drain fluids and stomach acid. You won't be able to eat or drink until this is removed and you're no longer nauseated. In this case, you will continue to receive fluids and sugar through an IV. Once you begin eating, you may need to eat a lighter, blander diet than usual.You may be given special compression stockings to decrease the possibility of blood clots forming in your legs.Your body may be making substantially less natural steroid hormones. Your doctor may start you on steroid medications immediately after surgery. OutcomeRecovery time after a classic open abdominal adrenalectomy may be as long as 4-6 weeks. Recovery time after laparoscopic adrenalectomy may be as short as 7-10 days.

You'll need to be carefully monitored to see that your body is producing the right quantity of steroid hormones, or to verify that you're taking the correct dose of steroid medication.You may be asked to weigh yourself daily and to report any weight gain of two or more pounds over 24 hours. Such weight gain may indicate that you are retaining fluid. You may be asked to monitor your blood pressure regularly at home as well.Try to increase your physical activity according to your doctor's instructions. This will help you avoid respiratory complications from the general anesthesia and improve recovery of your digestive system. Call Your Doctor If Any of the Following OccursSigns of infection, including fever and chillsRedness, swelling, increasing pain, excessive bleeding, or discharge from the incision siteNausea and/or vomiting that you can't control with the medications you were given, or which persist for more than two days after discharge from the hospitalCough, shortness of breath, chest pain, or severe nausea or vomitingPain, burning, urgency, or frequency of urination, or persistent bleeding in the urineWorsening pain and/or swelling in your feet, calves, or legs RESOURCES: American Urological Associationhttp://www.urologyhealth.org/

National Institute of Diabetes and Digestive and Kidney Diseaseshttp://www.niddk.nih.gov/ CANADIAN RESOURCES: Canadian Urological Associationhttp://www.cua.org/ The Kidney Foundation of Canada: British Columbia Branchhttp://www.kidney.bc.ca/ References: Agha A, von Breitenbuch P, Gahli N, et al. Retroperitonenscopic adrenalectomy: lateral versus dorsal approach. J Surg Oncol. 2008;97:90-3. Gallagher SF, Wahi M, Haines KL, et al. Trends in adrenalectomy rates, indications, and physician volume: A statewide analysis of 1816 adreanlectomies. Surgery. 2007;142:1011-21. Hanssen WE, Kuhry E, Casseres YA. Safety and efficacy of endoscopic retroperitoneal adrenalectomy. Br J Surg. 2006;93:715-9. Jossart GH, Burpee SE, Gagner M. Surgery of the adrenal glands. Endocrinol Metab Clin North Am. 2000;29:57-68. Munver R, Del Pizzo JJ, Sosa RE. Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland. Curr Urol Rep. 2003;4:87-92. Pamaby CN. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc. 2008;22:617-21.

Rakel RE, Conn HF. Conn's Current Therapy 2000. Houston, TX: WB Saunders Co.; 1999. Thompson SK, Hayman AV, Ludlam WH, et al. Improved quality of life after bilateral laparoscopic adrenalectomy for Cushings disease: a 10-year experience. Ann Surg. 2007;245:790-94. Townsend C, Beauchamp DR, et al. Sabiston Textbook of Surgery. 16th ed. WB Saunders; 2001. Last reviewed March 2008 by David Juan, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.