Adrenalectomy - Procedure, Indications, and Contraindications

Introduction

The adrenal glands are triangular-shaped pairs of small glands located above or at the top of the kidneys. Though the size of these glands is relatively small, they play an essential role. These glands are responsible for producing male and female hormones, hormones that regulate blood sugar levels, blood pressure, steroids, dopamine, etc.

Any abnormality in the adrenal glands may affect the production of these essential hormones and affect the body's overall functioning. Sometimes, when medications cannot treat the disease of adrenal glands, then complete or partial removal of these glands is recommended. The surgical removal of the adrenal gland is called adrenalectomy. The surgery can be done through open or laparoscopic techniques. Laparoscopic adrenalectomy is nowadays the most commonly performed procedure.

What Is the Anatomy of Adrenal Glands?

Every gland has an outer layer called the adrenal cortex, and the center or inner layer is called the adrenal medulla. Both parts produce different hormones. The adrenal medulla contains ectodermal cells and produces three hormones - epinephrine or adrenaline, dopamine and norepinephrine. The adrenal cortex has three zones they are:

1. Zona glomerulosa produces aldosterone.

2. Zona fasciculata produces corticosteroid

3. Zona reticularis produces aldosterone and androgen.

What Are the Functions of the Adrenal Glands?

The main functions of adrenal glands are:

• Production of male and female hormones.

• Production of hormones that help in regulating blood pressure and sugar levels.

• Production of other hormones such as epinephrine or adrenaline, dopamine, and norepinephrine.

What Are the Indications of Adrenalectomy?

The removal of adrenal glands is indicated in the following conditions:

• Primary Aldosteronism- It is a rare condition caused by excessive production of aldosterone.

• Pheochromocytoma- It is a tumor of the adrenal glands.

• Adrenal Cushing Syndrome- It is a rare condition with increased production of cortisol.

• Ectopic Cushing syndrome- It is a tumor in which there is excessive production of adrenocorticotropic hormone.

• Size: The mass or tumor in the adrenal gland is more than four centimeters.

• Malignancy: Malignancy or cancer such as adrenocortical carcinoma. It is a type of cancer in which cancer cells are present in the adrenal cortex.

What Are the Contraindications of Adrenalectomy?

The adrenal glands should not be removed if there are:

• A severe form of coagulopathy. It is a bleeding disorder in which the body fails to form a blood clot resulting in excessive bleeding.

• Inadequate performance of the heart, lungs and muscles of the patient. It is done through a test called cardiopulmonary performance. The test measures how well these organs function while doing physical activity.

How Is Adrenalectomy Performed?

Adrenalectomy can be done through open or laparoscopic adrenalectomy. Laparoscopic adrenalectomy is considered the standard gold technique and is widely performed by doctors nowadays. The doctor can access the adrenal glands from two locations to remove them: through the abdomen (transabdominal) or from the back of the abdomen (peritoneal). Based on these approaches, mentioned below are the various techniques:

1. Laparoscopic Adrenalectomy:

• A minimally invasive procedure is done through a camera fitted in a long thin tube that sends an image on a monitor or screen called a laparoscope. A magnified or zoomed image is seen on the screen and guides the doctor.

• In this process, the patient is given general anesthesia.

• Multiple small incisions of three to four centimeters are made on the affected area or surgery site.

• A laparoscope is then inserted through these incisions.

• The internal structures are seen on the screen through which the doctor cuts the glands and removes them without damaging the surrounding tissues and structures.

• The incisions are then closed with sutures or stitches.

The laparoscopic adrenalectomy can be done through a transabdominal or peritoneal approach as mentioned below:

1.1 Laparoscopic Transabdominal Adrenalectomy:

• The patient is positioned in a supine position (the head and stomach face the roof).

• General anesthesia is given to the patient.

• Various laparoscopic ports are inserted from the lateral side of the abdomen.

• Generally, three ports are used to perform the surgery. These ports must be placed with a gap of 5cm.

1.1.1. Right Adrenalectomy:

• It is done to remove the adrenal gland on the right side.

• The liver is retracted, and a cut is made on the posterior peritoneal space.

• The adrenal vein is present just behind the liver, which is dissected.

• If an additional adrenal vein is present two to three centimeters above the central vein, it should be dissected.

• The adrenal gland and the fat tissues are lifted and dissected or cut.

• It is then placed in a bag and taken out from the patient’s body.

1.1.2. Left Adrenalectomy:

• On the left side of the abdomen, the spleen is present, which should be mobilized to remove the left adrenal gland.

• A cut is made on the backside of the abdomen, exposing the spleen.

• The sphenoparietal ligament is dissected or cut, allowing complete mobilization of the spleen.

• The left adrenal gland is exposed by retracting the spleen, the tail of the pancreas, and the top part of the kidney.

• Various important veins that pass through are divided and clipped, such as a renal vein, diaphragmatic vein, etc.

• The left adrenal gland is dissected and placed into a bag.

• It is then taken out of the patient’s body.

1.2. Posterior Retroperitoneal Laparoscopic Adrenalectomy:

• The patient is positioned in a supine position.

• An incision is made parallel to the last rib of the patient, and the retroperitoneal area is accessed.

• A laparoscope is inserted, and then a laparoscope ultrasound is done to identify the exact location of the gland.

• The gland is dissected and removed.

1. Robotic Adrenalectomy:

• This technique provides a three-dimensional zoomed view of the internal structures.

• The surgery is done in the same way mentioned above but is done through a robot the doctor guides.

1. Partial Adrenalectomy:

• It is done in small tumor masses or small malignancies related to the excessive production of hormones in the adrenal glands.

• This technique reduces the risk of future malignancy.

1. Open Adrenalectomy:

• It is done in patients with cancerous adrenal glands, such as a tumor size of more than six centimeters.

• The surgery is performed in the same way mentioned above but is done without a laparoscope.

• Large incisions are made to access the adrenal glands transabdominal or peritoneally.

What Are the Complications of Adrenalectomy?

• Insufficiency of hormones in the body.

• Depression.

• Loss of libido (decreased interest in sexual activities).

• Low energy levels.

• Excessive production of cortisol.

• Nelson’s syndrome (abnormal production of hormones).

• Injury to the liver.

Conclusion

Adrenalectomy is commonly done nowadays through a laparoscopic technique. The complete removal of a single or both the adrenal glands is indicated when there is excessive production of the hormones or tumor. Laparoscopic adrenalectomy is considered the standard gold technique widely performed by doctors. An adrenal surgeon is the best to perform the adrenalectomy. Although there are various complications associated with this surgery, the rate of occurrence of these complications is low.