Laparoscopic Adrenalectomy in India :
Minimally Invasive Surgery
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What are the adrenal glands?
The adrenal glands are triangular-shaped glands located on top of the kidneys. They produce hormones such as estrogen, progesterone, steroids, cortisol, and cortisone, and chemicals such as adrenalin, norepinephrine, and dopamine.
The adrenal glands are small yellow-bronze organs found in the retroperitoneum, (the back of the abdomen behind the abdominal lining) usually near the top of each kidney.
They provide essential hormones that control the body's fluid and salt regulation, blood pressure, muscle development, sexual drive and development and sugar metabolism, as well as serving as the source for epinephrine, also called adrenaline. Like the kidneys, only one adrenal gland is usually required to live a normal life. The removal of an adrenal gland is an operation called, naturally enough, an adrenalectomy.
What are some reasons for having an adrenalectomy?
Adrenalectomy is primarily done for tumors of the adrenal gland. It is performed for a variety of benign and malignant conditions, ranging from pheochromocytoma and hyperaldosteronism (primary and secondary) to adrenal cancer.
The traditional method of removal has been either through incisions on the front of the abdomen or through an incision in the lower back. Both of these incisions are occasionally associated with pain and prolonged recovery periods. The laparoscopic approach can reduce the pain and disability associated with these incisions.
When is a laparoscopic approach indicated?
For many benign conditions, especially Conn's tumors and sporadic pheochromocytoma -- both of which are benign tumors that can secrete hormones that make the patient's blood pressure extremely high -- and for hormonally inactive tumors found while looking for some other condition, laparoscopic adrenalectomy is an excellent alternative.
What are the Symptoms for Laparoscopic Adrenalectomy ?
Everyone has two adrenal glands located directly above their kidneys. People who have problems with their adrenal glands may be completely asymptomatic or often have symptoms of high blood pressure, excess fluid retention, and heart irregularities because the adrenal glands regulate sodium (salt) and potassium levels. These symptoms may be due to a noncancerous tumor of the adrenal gland. Another type of noncancerous tumor of the adrenal gland, called a pheochromocytoma, produces excess adrenaline. This causes headaches (severe), excess generalized sweating, racing heart, anxiety, nervousness and feelings of impending death, nervous shaking (tremors), pain in the lower chest or abdomen, nausea, weight loss, and heat intolerance. These symptoms are listed in order from the most to the least common.
What are the indications for Laparoscopic Adrenalectomy?
Adrenalectomy is primarily done for tumors of the adrenal gland.
These may include :
- Benign tumors of the adrenal gland that produce a hormone.
- Benign tumors of the adrenal gland that do not produce a hormone but grow or are large.
- Tumors of the adrenal gland suspicious for malignancy.
What is Laparoscopic Adrenalectomy?
Laparoscopic adrenalectomy refers to the surgical removal of the adrenal gland through a small incision in the abdomen. A small telescope is used to visualize the adrenal gland so it can be dissected and removed through a small abdominal incision.
What are the Contraindications to Laparoscopic Adrenalectomy?
Patients who have untreated blood clotting disorders run the increased of blood loss which would be more difficult to treat laparoscopically. Because this operation and disease processes are not common, surgeon experience with prior similar cases is an important factor in choosing this method. Patients with pheochromocytoma are usually prepared with medications for several days prior to surgery.
How is Laparoscopic Adrenalectomy Done?
Laparoscopic adrenalectomy is a surgical technique used to remove the adrenal gland without making a big incision. You will be given general anesthesia. After you are asleep, a nurse will insert a tube into your bladder to drain the urine while you are asleep. Surgery may be done with you lying on your abdomen or turned onto the side opposite the affected adrenal gland, depending on surgeon preference. Four or five small incisions will be made into the chest to give the surgeon access to the abdominal cavity. One is used for the laparoscope, which is attached to a camera that sends images to a video monitor. The other incisions are used to hold or manipulate tissue in the abdomen. Carbon dioxide gas is insufflated into the abdominal cavity to allow room to work and to allow the surgeons to see. Parts of the adrenal gland are freed from surrounding tissue. Blood vessels to the adrenal gland are visualized, tied off or clipped with a metal clip. Once the adrenal gland is dissected free of its attachments in the abdominal cavity, it is placed in a special surgical retrieval bag and removed through one of the small abdominal incisions. At the end of the procedure, carbon dioxide gas is removed. The small incisions are closed with suture, the skin is cleaned and the incisions are covered with a small dressing.
What are the Risks of Having Laparoscopic Adrenalectomy?
Laparoscopic adrenalectomy done by an experienced surgeon is a very safe procedure. As with any surgical procedure however, complications may occur. You should discuss the risks and benefits of the procedure with your surgeon.
What Happens if Surgery Cannot be Performed by Laparoscopic Technique?
Sometimes it is not possible for the surgeon to use the laparoscopic technique because it may be difficult to see or handle the organs safely. The surgeon decides to perform an open procedure either before or during the surgery. The surgeon may decide to convert the laparoscopic surgery to an open procedure in certain situations and for patient safety. Though very infrequent, when conversion to an open technique occurs, it should not be considered a failure of the procedure. If adrenalectomy cannot be performed laparoscopically, it will need to be done in an open surgical procedure. This may require hospitalization for 5-8 days and 4-6 weeks for a full recovery.
What can I Expect to Happen Before Having Laparoscopic Surgery?
- Your physician will make a thorough medical evaluation. Several diagnostic tests may be needed. You may have blood tests, and electrocardiogram (EKG) or chest x-ray to check your heart and lungs.
- Depending on your disease process, you may need to take medications for several days to prepare you for the surgery. In certain situations you may be admitted the day prior to surgery.
- Taking no food or fluids after midnight the night before the surgery. This decreases the risk of vomiting after you receive anesthesia.
- If taking medications daily, discuss the need to take them with your doctor prior to the morning of surgery (with a sip of water). If taking blood thinners, aspirin, or arthritis medications, discuss the proper time to stop these medications before the surgery date (day).
- Speak with the anesthesiologist before surgery to discuss anesthesia and pain management postoperatively.
- Arrange for someone to drive you to the hospital the day of surgery and take you home when you are discharged from the hospital.
What can I Expect the Day of Surgery?
- Arrive at the hospital on the day and time you are instructed.
- Sign a written consent authorizing your physician to perform the surgery.
- Receive a small needle/catheter in your vein to provide medication before, during and after your surgery.
- Receive preoperative medication as necessary.
- Undergo general anesthesia (asleep) prior to your surgery.
- Understand the procedure may take several hours.
- Going back to the recovery room after surgery and having your blood pressure, pulse, and respirations closely monitored until you are fully awake.
- Going back to your room.
- Staying in the hospital the night of surgery and additional days as needed.
What can I Expect After Surgery?
- Engage in light activity at home
- Experience mild postoperative pain and having pain medication available as needed.
- Having a modified diet starting with liquids and followed by gradually taking solid foods as you tolerate them.
- Resume normal activities such as showering, stair climbing, working, lifting, driving and having sexual intercourse after discussing these with your physician.
- Call and schedule a follow-up appointment within one to two weeks after surgery. Schedule any additional follow-up appointments.
- Having any stitches removed depending on the type your physician uses.
Common indications for laparoscopic removal of the adrenal gland are the following :
- Benign adrenal tumors such as Cushing disease and Cohn syndrome.
- Metastatic disease (spread) from lung, breast and other cancers. This is an uncommon reason for removal of the adrenal gland. The adrenal gland would only be considered for removal in metastatic disease if this were the only site of metastatic disease.
- Adrenal mass (enlargement) of uncertain origin. If the adrenal gland is more than 4cm large then there is a higher risk of cancer than a smaller mass. Given the safety record of a laparoscopic adrenalectomy and the risk of cancer in an adrenal gland that is abnormally enlarged more that 4cm, removal of the gland should be considered.
- Cushing's syndrome. Removal of both adrenal glands is sometimes considered in patients who have brain pituitary tumors that produce excessive amounts of a hormone called ACTH. ACTH stimulates the adrenal to release steroids. In patients with pituitary tumors producing excessive amounts of ACTH, the adrenal is stimulated to produce an excessive amount of steroids causing a Cushing syndrome. If the pituitary tumor is not treatable by standard neurosurgical and radiation treatments, then both the adrenal glands are removed to treat Cushing syndrome.
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