LAPAROSCOPIC ADRENALECTOMY

1. What is an adrenal gland?

The adrenal glands are paired endocrine glands that produce hormones involve in regulating blood pressure, blood electrolytes and body metabolism. There is one adrenal gland located at the upper pole of each kidney.

2. What are the symptoms of adrenal gland tumor?

Adrenal gland tumors commonly overproduce one hormone. This can result in high blood pressure that is difficult to control, muscle weakness due to low blood potassium or excessive weight gain, skin striae, moon face etc consistent with Cushing's syndrome. Alternatively, they can present with symptoms related to the mass effect of the tumor or pain when the size is large and invades surrounding tissues. Occasionally, the adrenal tumor maybe detected incidentally during investigation for unrelated reason.

3. How can adrenal tumor be detected?

Detecting an adrenal tumor requires combination of biochemistry tests for hormones in the blood and radiologic imaging of the adrenal glands, usually computerized tomography (CT scan) or magnetic resonance imaging (MRI scan). Angiography (radiography with the use of contrast in the blood vessel) maybe indicated in selected cases. Majority of the adrenal tumor are benign.
In the rare incidence of adrenal gland hyperplasia due to excessive external stimulating factors from the pituitary, CT scan or MRI of the brain may be needed.

4. What are the indications for laparoscopic adrenalectomy?

*Laparoscopic adrenalectomy is generally not recommended for malignant adrenal tumor, large adrenal masses (>10 cm) and in patients with bleeding tendency.

5. How do I prepare for the operation?

Your endocrinologist will check and ensure that your hormonal balance, blood pressure and electrolytes are optimally controlled prior to the operation. These may take several days to few weeks.
Arrangement will be made for an anesthesiologist to assess your general fitness for general anesthesia and the operation. Some baseline blood tests, chest X-ray and ECG will be done.
You will be admitted to the hospital one day before the scheduled operation. Blood tests may need to be checked one more time, and blood and blood product standby for the operation. You may be given laxative to clear your bowel in preparation for the operation.

6. How is the operation conducted?

Laparoscopic adrenalectomy is performed under general anesthesia and with the patient in the semi-lateral position. We prefer the trans-abdominal approach. The abdominal cavity is distended by insufflation with carbon dioxide to create space for the operation. Visualization is achieved with a 10mm diameter rigid telescope and the operation carried out using two to three 5mm-diameter instruments. Majority of the adrenal tumor secrete active hormones, the approach is to detach the adrenal gland from its surrounding tissue, ligating its connecting blood vessels and minimal handling of the gland; to minimize sudden release of active hormones to the blood circulation causing fluctuation in blood pressure. The completely detached adrenal gland is then retrieved using a plastic pouch.

7. Are there dangers associated with the operation?

Complications following laparoscopic adrenalectomy are few. Symptoms related to anesthesia such as nausea, headache and sore throat are quite common. Collapse of lungs bases, leg vein thrombosis and embolism of clots to the lung, and wound infection may affect small number of patients. These complications are more common among patients with Cushing disease.
More specific surgical complications such as bleeding, damage to adjacent organs occurs rarely but may necessitate conversion to conventional operation via open wound.
Fluctuation of blood pressure may occur during operation especially in patients with pheochromocytoma. The anesthesiologist in attendance will be prepared to counter these with intravenous drugs.

8. What can I expect after the operation?

Post anesthetic nausea, headache and sore throat are common; you will be prescribed medications to relieve these symptoms and they usually resolve after 1-2 days.
Majority of patients have good pain relief with oral analgesics only. If needed, patient control analgesia can be added and is very effective in relieving surgical wound pain.
Most patients recover without complications and are well enough to go home on 2nd or 3rd post-operative day. The surgical stitches can be removed after one week.
The opposite normal adrenal gland may be suppressed by the abnormally high hormones level from the tumor and may take a while to regain normal function. During this period, you may need replacement hormone therapy. Your endocrinologist will be attending to you and these medications will be weaned off in the next few weeks.

9. When can I return to work and resume normal activities?

This varies from patient to patient. One of the advantages of laparoscopic adrenalectomy is the smaller wounds, therefore faster recovery and lesser wound pain. Most patients recover very quickly after laparoscopic adrenalectomy and are comfortable returning to normal daily activities such as driving, walking, climbing stairs and deskwork within the one week. However, strenuous physical exercises are usually not recommended until at least 4-6 weeks after the operation.

10. Are there long-term problems after the operation?

There is no significant long-term side effect following removal of one adrenal gland. In fact, excessive hormones production from adrenal gland tumor is one of the causes of the rare form of secondary hypertension; this can be cured after excision of the adrenal tumor. The remaining adrenal gland can normally compensate adequately for the absent counterpart although it may take a while (up to a few weeks) to regain normal function after being suppressed by the abnormally high hormonal level from the tumor. Patients who have had bilateral adrenalectomy need long-term hormonal replacement therapy.