Overview of Adrenalectomy
Advancements in medical diagnostics have resulted in an increased detection of adrenal tumors, which are growths in the adrenal glands. Some of these tumors are found unexpectedly during tests done for other reasons, and these are known as incidental adrenal tumors. Similarly, there are non-incidental adrenal tumors which are found because they cause certain symptoms.
When an adrenal tumor is found, it’s important to understand its nature. It needs to be checked to see if it is producing hormones, if it is cancerous (malignant), or if it has spread from another part of the body (metastatic).
If patients have hormonally functional adrenal tumors – that is, tumors that affect the levels of hormones in the body – the treatment needs to be specifically tailored to address this. Additionally, regular health checks suited to the patient’s age should also be maintained.
Anatomy and Physiology of Adrenalectomy
The adrenal glands are small organs located near the kidneys and are surrounded by a tissue layer called Gerota’s fascia. These adrenal glands receive blood from small arteries coming from the lower phrenic artery (near the diaphragm), the aorta (main blood vessel from the heart), and the renal arteries (that supply the kidney). The adrenal glands on the left side of your body drain their blood into the left renal vein, which directly connects to a large vein called the inferior vena cava.
The adrenal gland is made up of two different layers: the outer layer called the adrenal cortex, and the inner layer called the adrenal medulla. Each of these layers produces different types of hormones-
1. The adrenal medulla, which is composed of special nerve-like cells, creates hormones called catecholamines. These include dopamine, norepinephrine, and epinephrine, which help your body respond to stress.
2. The adrenal cortex is further divided into three areas. Each area produces different types of hormones:
– The outermost area, called the zona glomerulosa, produces a hormone called aldosterone. This hormone helps your body manage salt and water balance.
– The middle part, called the zona fasciculata, produces a hormone called cortisol. This hormone helps your body deal with stress and regulates how your body uses proteins, fats, and carbohydrates.
– The innermost layer, called the zona reticularis, creates androgen hormones. These hormones influence the development of male sexual characteristics.
Why do People Need Adrenalectomy
Adrenalectomy, or the surgical removal of one or both of your adrenal glands, might be required for a few reasons. The adrenal glands are small organs located above each kidney and are responsible for producing hormones that your body needs to function properly. Here are a few of reasons a patient might need to undergo an adrenalectomy:
- Functional adrenal mass: This means there’s a mass inside the adrenal gland that’s affecting the gland’s ability to produce hormones correctly. This mass could be causing primary aldosteronism, pheochromocytoma, adrenal Cushing syndrome, or Cushing disease that hasn’t responded to treatments targeting the pituitary gland. Sometimes, the mass could be causing what’s known as ectopic Cushing syndrome when the cause is either unknown or located in a place that can’t be operated on.
- Large adrenal mass: An adrenal mass larger than 4cm might necessitate an adrenalectomy. This is determined through imaging tests taken before your operation.
- Cancerous growth: If a patient has adrenocortical carcinoma, the medical term for adrenal gland cancer, or a metastatic tumor, meaning the cancer has spread to the adrenal gland from another part of the body, removing the adrenal gland may be necessary.
Remember, these are general guidelines and the ultimate decision will be determined by your doctor based on your specific case and overall health.
When a Person Should Avoid Adrenalectomy
There are situations when removing the adrenal gland, which is a procedure known as adrenalectomy, is not advised. Two major reasons why this cannot be done are serious blood clotting issues, known as severe coagulopathy, and weak heart and lung health.
This surgery also has specific factors that can make it too risky if it’s performed in a minimally invasive way (a procedure using smaller incisions instead of one large cut). These include if the tumor in question is too large (more than 6cm in size) or if the patient has a specific type of adrenal gland cancer called adrenocortical carcinoma.
Equipment used for Adrenalectomy
The tools used for a laparoscopic procedure, a type of minimally invasive surgery, include the following:
For specific operations like removal of the right adrenal gland (right-sided adrenalectomy), dealing with a particular kind of tumor called pheochromocytoma, or helping patients who have a higher risk of heart disease, an arterial line and a central line are used. These devices help monitor blood pressure and provide fluid or medication during the surgery.
For surgeries using the ‘retroperitoneal approach’, where doctors access your kidney from the back side, tools like a ‘Cloward prone positioner’ or ‘gel rolls’ are used. These assist in placing you properly on the operating table.
If the doctor is going for a ‘transabdominal approach’, which means accessing the kidney from the front of your body, they will use a ‘surgical bean bag positioner’. This medical tool helps to position and stabilize you during the operation.
Who is needed to perform Adrenalectomy?
During adrenal surgery, it’s crucial for a skilled surgeon, who specializes in operating on adrenal glands, to work closely with a medical expert called an anesthesiologist. This is because there might be sudden changes in how your body’s heart and blood vessels function throughout the procedure. The anesthesiologist is the one who makes sure you’re comfortably asleep and pain-free during the surgery. These two doctors working together is key to ensuring that the surgery goes as planned.
Preparing for Adrenalectomy
Before a person goes into surgery to remove an adrenal gland – a process called adrenalectomy – it’s very important for doctors to prepare them properly. Part of the preparation includes examining the patient to see if a growth or lump in their adrenal gland is creating certain substances like aldosterone, cortisol, or catecholamines.
If the tests show that the growth is producing too many catecholamines (a condition known as pheochromocytoma), the patients will need medicine that blocks the effects of these substances (these are called alpha-blockers) until their blood pressure levels become stable. They might also need beta-blockers if necessary. Before the operation, these patients should also increase their water intake and have a diet rich in sodium during the week leading up to the surgery to keep their hydration and electrolyte levels well balanced.
If tests show that patients have too much aldosterone (known as hyperaldosteronism) in their blood, they should have an adrenal venous sampling test. This test checks if one adrenal gland is producing more aldosterone than the other, since imaging tests can sometimes give confusing results.
How is Adrenalectomy performed
Doctors can perform a laparoscopic transabdominal adrenalectomy to remove an adrenal gland, which sits on top of each of your kidneys. This procedure uses small incisions, a camera, and special tools to remove the gland while the patient is under general anesthesia. Before the surgery, no special preparations like a catheter or antibiotics are necessary.
The positions and rooms are arranged to make the patient the most comfortable and to ensure the surgeon can access the adrenal gland easily. The surgeon makes the incisions and inserts a special needle to inflate your belly with gas, making it easier to view your organs and perform the surgery. Special ports are then placed for the surgical instruments to be inserted. The exact process differs slightly depending on which adrenal gland – the right or the left – is being operated on. However, in both cases, the surgeon isolates the adrenal gland, carefully separates it from surrounding structures, and removes it.
Another method to perform an adrenalectomy is through the back, called a posterior retroperitoneoscopic adrenalectomy. This procedure is similar to the transabdominal approach but is done with the patient lying on their stomach instead of their side. Instead of inflating the belly, the surgeon gently moves aside the fat and tissue to access the adrenal gland and remove it. After the adrenal gland removal, the wound is checked for any bleeding, and then sutures are used to close the incisions.
Both methods of adrenal gland removal have their own advantages, and your doctor will discuss which option is best based on your condition and overall health.
Possible Complications of Adrenalectomy
Primary adrenal insufficiency, a condition where your adrenal glands don’t work as they need to, can happen after a surgery to remove both adrenal glands (bilateral adrenalectomy). Some of the signs and symptoms can include lack of body fluids (volume depletion), low blood pressure (hypotension), low sodium in the blood (hyponatremia), high potassium in the blood (hyperkalemia), fever, and stomach pain.
People with this condition are usually treated with replacement therapy using different types of medications, such as glucocorticoids (like hydrocortisone or cortisone) and mineralocorticoids (like fludrocortisone), depending on the type of hormones their adrenal glands can’t produce anymore.
Some women may have a condition known as androgen deficiency, where their body doesn’t produce enough of sex hormones called androgens. Symptoms often include a low sex drive, feeling depressed or low energy levels. If other treatments don’t help, these women might be given a hormone called dehydroepiandrosterone (DHEA).
After surgery, some people might experience other problems like too much cortisol (a hormone) in the body (hypercortisolism), adrenal crisis (a severe emergency complication where your body doesn’t produce enough cortisol), or a rare condition called Nelson’s syndrome. Nelson’s syndrome typically results in dark patches on the skin due to an overproduction of certain types of hormones.
To diagnose these conditions, doctors often look at results from imaging tests or monitor levels of a hormone called ACTH in the blood. Adrenal crisis is a very serious medical emergency, where patients might feel very unwell, have a very low blood pressure, and experience nausea, vomiting, and fever. This condition can often be managed effectively with intravenous (into the vein) hydrocortisone. Most of the time, infections are what cause adrenal crises to happen.
What Else Should I Know About Adrenalectomy?
Problems with your adrenal gland could lead to conditions like high blood pressure, diabetes, high cholesterol, and obesity. Unfortunately, these conditions are often undiagnosed and, as a result, untreated.
With advancements in technology, doctors have become better at spotting growths on adrenal glands, known as adrenal masses. These growths can either affect how your gland works (functional), or not have any impact on its function (non-functional).
It’s essential for doctors to be able to evaluate and manage patients with adrenal masses to minimize health risks to the patient. If surgery is needed to remove the adrenal gland (known as adrenalectomy), doctors must pay close attention to potential hormonal changes and prepare for these changes before the surgery. This preparation is just as important as the actual surgical procedure.
