Adrenalectomy is a surgical procedure which removes one or both adrenal glands located next to the kidney. This procedure is used to treat different adrenal gland diseases like benign or malignant tumors, hyperplasia, and hyperfunctional states.
The adrenal glands synthesize hormones that are vital for functions of the body, like aldosterone, cortisol, and adrenaline. Dysregulation, which is caused by tumors or hyperactivity of these glands, can change hormonal disruptions, which can result in serious health problems. A large incision is made in the abdominal area or back area during open adrenalectomy. It gives direct access to adrenal gland.
The choice of surgical treatment depends on factors like tumor size and location with the general health status of patient. The surgeon dissects the nearby tissue to reveal the adrenal gland.
Indications
Adrenal tumors: Adrenal tumors include benign and malignant forms. Surgery may be needed remove the adrenal gland to manage adrenal tumors, specifically they cause hormonal imbalances.
Pheochromocytoma: Pheochromocytoma is a rare tumors of adrenal gland. It causes excessive production of other hormones like adrenaline. It elevates the blood pressure and cause symptoms. Surgical removal of affected adrenal gland is the first line of treatment.
Hyperaldosteronism: This disease includes excessive secretions of aldosterone hormone from adrenal glands. It can cause elevated blood pressure and reduced levels of potassium. If traditional treatment is not effective, adrenalectomy is suggested.
Cushing’s syndrome: This disease is caused by an excessive production of cortisol hormone from adrenal glands. It can lead to different symptoms like hypertension, weight gain, and diabetes. Adrenal tumor may be present and need surgical removal of adrenal gland if treatment is not effective.
Adrenal gland infections: Severe infections in the adrenal glands may need surgical removal of affected gland to reduces the risk of sepsis.
Adrenal gland trauma: Surgical treatment may be needed to remove the adrenal gland if the severe injury is prolonged because of the blunt abdominal trauma or penetrating injury.
Contraindications
Poor overall health: Patients who have more comorbidities like advanced heart disease, lung disease, or other severe conditions can not go for this procedure because of the elevated risk of complications during surgery.
Severe coagulopathy or bleeding disorders: Factors which can affect the blood coagulation or increase the risk of bleeding like hemophilia or severe thrombocytopenia may contraindicate with this procedure because of increased risk of excessive bleeding during surgery.
Outcomes
Equipment
Standard surgical instruments:Â Scalpels, scissors, clamps, forceps, retractors, and sutures.
Cauterization equipment:Â This is used to control the bleeding by sealing the blood vessels with heat.
Dissection instruments:Â These are used to separate the adrenal gland from the nearby tissues.
Retractors: These are used to hold the incision open and provide the surgeon with a clear view to operate.
Laparoscopic equipment:Â An open adrenalectomy can be converted to laparoscopic procedure in some cases. This minimally invasive method involve the use of small camera and surgical instruments to introduce into multiple small opening in the abdomen.
Anesthesia machine:Â This machine gives anesthesia for pain free surgery.
Monitoring equipment:Â This equipment observes the important indicators of condition of patient during the surgical procedure like saturation level of oxygen, blood pressure, and heart rate.
Patient preparation
Pre-surgery Evaluation: Patient will go for a comprehensive evaluation to check the overall health status. This evaluation may include physical examination, blood test, imaging studies like CT and MRI scans, and other tests.
Medical Optimization: Patients may need improve the medical condition before surgery. This may include managing chronic diseases like hypertension, diabetes, or heart disease to lower the risk of complications during and after the surgery.
Medication Review: Patient must discuss their medications like prescription drugs, over-the-counter medications, and supplements to healthcare providers.
Smoking and Alcohol Cessation: Patient who smoke is advised to quit smoking before the surgery. It can affect the wound healing and elevate the risk of complications. Excessive alcohol consumption must be avoided before surgery.
Bowel Preparation: The patient can be instructed to go for bowel preparation to empty the bowel before the surgery. This can reduce the complications linked with bowel functionality during and after the surgery.
Patient position
Lateral decubitus:
The patient lies on one side of the surgical table. The side must be facing upwards. The arm on the exact same side is placed above the head or secured to the side to give access to the field. The lower arm is bent and placed in front of the patient. The lower leg can be slightly flexed at the hip and knee to prevent pressure points.
This position allows the surgical team to access the flank area where the adrenal gland is located. It gives good exposure and minimizes the risk of complications which are related to positioning, like pressure sores or nerve injury.
Lumbodorsal approach
Step 1: Patient is placed in proper position with arms are extended overhead.
Step 2: A sharp incision is made at the 11th and 12th rib. It may be extended in a hockey stick pattern for better access.
Step 3: the surgeon dissects by the lumbodorsal muscles to go to retroperitoneal space.
Step 4: The latissimus dorsi muscle may be divided for proper exposure. This dissection is carried out medically.
Step 5: The peritoneum is reflected anteriorly to avoid entering into the abdominal cavity.
Step 6: The kidney may be mobilized inferiorly to give exposure of the adrenal gland.
Step 7: The adrenal artery and vein are carefully identified and ligated once the adrenal gland is seen.
Step 8: The adrenal gland is dissected from the nearby tissues like periadrenal fat and any attachments to diaphragm or kidney.
Step 9: The gland is removed, and bleeding is controlled.
Step 10: A drainage tube is placed in retroperitoneal space to drain any post-operative fluids.
Step 11: Incision is closed in the layers.
Flank approach
Step 1: Patient Positioning
The patient is lies on lateral decubitus. The targeted adrenal gland must be faced on upwards. The bed is bent at the hips and knees to provide more space between the ribs and iliac crest.
Padding is placed to prevent nerve pressure injury and bony prominences.
Step 2: Incision
A flank incision is made at 11th and 12th rib below the tip of the rib towards the umbilicus.
Step 3: Dissection
The surgeon dissects through the skin, subcutaneous tissue, and muscles to reach the retroperitoneal space. The latissimus dorsi muscle may be divided to give better access, The gerota fascia near by kidney is meticulously dissected to mobilize the kidney and expose the adrenal gland.
Step 4: Adrenal Gland Mobilization
The adrenal gland is identified and dissected from the nearby tissue. The adrenal vein is 1st main vessel to identify and control. It drained directly into the inferior vena cava (IVC) on the right side and left renal vein on the left side.
The adrenal artery is identified and controlled. It may come from the aorta, renal artery, and nearby vessels. Once the vessels are secured, adrenal gland is dissected free and removed.
Step 5: Closure
The adrenalectomy bed is meticulously checked for bleeding. The tissues are properly examined with sutures in layers. A drain may be inserted to remove any remaining fluid from surgical site.
Thoracoabdominal approach
Step 1: Position
The patient is positioned supine, upper body is rotated at 45 degree by using a body roll technique.
Step 2: Incision
The incision is carried out by costal cartilage and formed into the 8th and 9th intercostal gap through the muscle layers. The procedure includes to make an incision through both the posterior and anterior rectus sheaths which is followed by entry into the pleural cavity to displace the lung from the operating area.
Step 3: Entering the pleural cavity
The pleura is dissected and opened to get the access to the chest cavity. The lung on the affected side is collapsed and packed way to create space to see.
Step 4: Diaphragm division
The diaphragm is divided to access the retroperitoneal space where adrenal gland is located. This steps needs meticulous technique to avoid any injury to phrenic nerve.
Step 5: Adrenalectomy
Once the adrenal gland is seen, the blood vessels and nearby tissues are dissected and ligated. It is removed and placed in a retrieval bag.
Step 6: Closure
The diaphragm is repaired with sutures. The lung is replaced to proper position and pleura is closed. The skin and abdominal wall muscles are sutured and closed in layers.
Laboratory tests
Complete Blood Count: CBC gives complete information about the no. and types of blood cells. It helps to assess the anemia, infection, or other blood diseases.
BMP & CMP: These panels include tests like glucose, electrolytes, kidney function test like creatinine, BUN, and liver function test like AST, ALT and bilirubin. They help to assess the overall organ function and electrolyte balance.
Coagulation Studies: Tests like Pt, INR, and APTT are performed to check for the ability of blood to clot. It is used to check the risk of bleeding during surgery.
Imaging Studies: Imaging studies like MRI or CT scans are performed to see the adrenal glands and nearby structures. This can help to plan the surgery and to determine the extent of the procedure.
Complications
Bleeding: Adrenalectomy includes cutting through blood vessels by supplying the blood to adrenal gland. Excessive bleeding can occur during surgery or after the surgery needs blood transfusions or surgical measures to manage.
Infection: Every surgical procedure has a potential risk of infection, which can affect the surgical site and can lead to severe complications like sepsis.
Damage to surrounding organs: The adrenal glands are located near other vital organs like the kidneys and major blood vessels. Accidental damage to these structures may lead to complications.
Hormonal imbalances: Removing the adrenal gland can affect the hormonal balance which can lead to condition like Cushing syndrome or Addison disease. Patient may need hormone replacement therapy to manage imbalances.
Pneumothorax: Accidently puncture o the lung may lead to pneumothorax. This can lead to respiratory difficulties needs an urgent medical treatment.
Adrenal crisis: Where both the adrenal glands are removed, there is a risk of adrenal crisis. It is a life-threatening disease caused by low blood pressure, electrolyte imbalances, and shock because of improper adrenal hormones.
Adrenalectomy is a surgical procedure which removes one or both adrenal glands located next to the kidney. This procedure is used to treat different adrenal gland diseases like benign or malignant tumors, hyperplasia, and hyperfunctional states.
The adrenal glands synthesize hormones that are vital for functions of the body, like aldosterone, cortisol, and adrenaline. Dysregulation, which is caused by tumors or hyperactivity of these glands, can change hormonal disruptions, which can result in serious health problems. A large incision is made in the abdominal area or back area during open adrenalectomy. It gives direct access to adrenal gland.
The choice of surgical treatment depends on factors like tumor size and location with the general health status of patient. The surgeon dissects the nearby tissue to reveal the adrenal gland.
Adrenal tumors: Adrenal tumors include benign and malignant forms. Surgery may be needed remove the adrenal gland to manage adrenal tumors, specifically they cause hormonal imbalances.
Pheochromocytoma: Pheochromocytoma is a rare tumors of adrenal gland. It causes excessive production of other hormones like adrenaline. It elevates the blood pressure and cause symptoms. Surgical removal of affected adrenal gland is the first line of treatment.
Hyperaldosteronism: This disease includes excessive secretions of aldosterone hormone from adrenal glands. It can cause elevated blood pressure and reduced levels of potassium. If traditional treatment is not effective, adrenalectomy is suggested.
Cushing’s syndrome: This disease is caused by an excessive production of cortisol hormone from adrenal glands. It can lead to different symptoms like hypertension, weight gain, and diabetes. Adrenal tumor may be present and need surgical removal of adrenal gland if treatment is not effective.
Adrenal gland infections: Severe infections in the adrenal glands may need surgical removal of affected gland to reduces the risk of sepsis.
Adrenal gland trauma: Surgical treatment may be needed to remove the adrenal gland if the severe injury is prolonged because of the blunt abdominal trauma or penetrating injury.
Poor overall health: Patients who have more comorbidities like advanced heart disease, lung disease, or other severe conditions can not go for this procedure because of the elevated risk of complications during surgery.
Severe coagulopathy or bleeding disorders: Factors which can affect the blood coagulation or increase the risk of bleeding like hemophilia or severe thrombocytopenia may contraindicate with this procedure because of increased risk of excessive bleeding during surgery.
Standard surgical instruments:Â Scalpels, scissors, clamps, forceps, retractors, and sutures.
Cauterization equipment:Â This is used to control the bleeding by sealing the blood vessels with heat.
Dissection instruments:Â These are used to separate the adrenal gland from the nearby tissues.
Retractors: These are used to hold the incision open and provide the surgeon with a clear view to operate.
Laparoscopic equipment:Â An open adrenalectomy can be converted to laparoscopic procedure in some cases. This minimally invasive method involve the use of small camera and surgical instruments to introduce into multiple small opening in the abdomen.
Anesthesia machine:Â This machine gives anesthesia for pain free surgery.
Monitoring equipment:Â This equipment observes the important indicators of condition of patient during the surgical procedure like saturation level of oxygen, blood pressure, and heart rate.
Pre-surgery Evaluation: Patient will go for a comprehensive evaluation to check the overall health status. This evaluation may include physical examination, blood test, imaging studies like CT and MRI scans, and other tests.
Medical Optimization: Patients may need improve the medical condition before surgery. This may include managing chronic diseases like hypertension, diabetes, or heart disease to lower the risk of complications during and after the surgery.
Medication Review: Patient must discuss their medications like prescription drugs, over-the-counter medications, and supplements to healthcare providers.
Smoking and Alcohol Cessation: Patient who smoke is advised to quit smoking before the surgery. It can affect the wound healing and elevate the risk of complications. Excessive alcohol consumption must be avoided before surgery.
Bowel Preparation: The patient can be instructed to go for bowel preparation to empty the bowel before the surgery. This can reduce the complications linked with bowel functionality during and after the surgery.
Lateral decubitus:
The patient lies on one side of the surgical table. The side must be facing upwards. The arm on the exact same side is placed above the head or secured to the side to give access to the field. The lower arm is bent and placed in front of the patient. The lower leg can be slightly flexed at the hip and knee to prevent pressure points.
This position allows the surgical team to access the flank area where the adrenal gland is located. It gives good exposure and minimizes the risk of complications which are related to positioning, like pressure sores or nerve injury.
Step 1: Patient is placed in proper position with arms are extended overhead.
Step 2: A sharp incision is made at the 11th and 12th rib. It may be extended in a hockey stick pattern for better access.
Step 3: the surgeon dissects by the lumbodorsal muscles to go to retroperitoneal space.
Step 4: The latissimus dorsi muscle may be divided for proper exposure. This dissection is carried out medically.
Step 5: The peritoneum is reflected anteriorly to avoid entering into the abdominal cavity.
Step 6: The kidney may be mobilized inferiorly to give exposure of the adrenal gland.
Step 7: The adrenal artery and vein are carefully identified and ligated once the adrenal gland is seen.
Step 8: The adrenal gland is dissected from the nearby tissues like periadrenal fat and any attachments to diaphragm or kidney.
Step 9: The gland is removed, and bleeding is controlled.
Step 10: A drainage tube is placed in retroperitoneal space to drain any post-operative fluids.
Step 11: Incision is closed in the layers.
Step 1: Patient Positioning
The patient is lies on lateral decubitus. The targeted adrenal gland must be faced on upwards. The bed is bent at the hips and knees to provide more space between the ribs and iliac crest.
Padding is placed to prevent nerve pressure injury and bony prominences.
Step 2: Incision
A flank incision is made at 11th and 12th rib below the tip of the rib towards the umbilicus.
Step 3: Dissection
The surgeon dissects through the skin, subcutaneous tissue, and muscles to reach the retroperitoneal space. The latissimus dorsi muscle may be divided to give better access, The gerota fascia near by kidney is meticulously dissected to mobilize the kidney and expose the adrenal gland.
Step 4: Adrenal Gland Mobilization
The adrenal gland is identified and dissected from the nearby tissue. The adrenal vein is 1st main vessel to identify and control. It drained directly into the inferior vena cava (IVC) on the right side and left renal vein on the left side.
The adrenal artery is identified and controlled. It may come from the aorta, renal artery, and nearby vessels. Once the vessels are secured, adrenal gland is dissected free and removed.
Step 5: Closure
The adrenalectomy bed is meticulously checked for bleeding. The tissues are properly examined with sutures in layers. A drain may be inserted to remove any remaining fluid from surgical site.
Step 1: Position
The patient is positioned supine, upper body is rotated at 45 degree by using a body roll technique.
Step 2: Incision
The incision is carried out by costal cartilage and formed into the 8th and 9th intercostal gap through the muscle layers. The procedure includes to make an incision through both the posterior and anterior rectus sheaths which is followed by entry into the pleural cavity to displace the lung from the operating area.
Step 3: Entering the pleural cavity
The pleura is dissected and opened to get the access to the chest cavity. The lung on the affected side is collapsed and packed way to create space to see.
Step 4: Diaphragm division
The diaphragm is divided to access the retroperitoneal space where adrenal gland is located. This steps needs meticulous technique to avoid any injury to phrenic nerve.
Step 5: Adrenalectomy
Once the adrenal gland is seen, the blood vessels and nearby tissues are dissected and ligated. It is removed and placed in a retrieval bag.
Step 6: Closure
The diaphragm is repaired with sutures. The lung is replaced to proper position and pleura is closed. The skin and abdominal wall muscles are sutured and closed in layers.
Complete Blood Count: CBC gives complete information about the no. and types of blood cells. It helps to assess the anemia, infection, or other blood diseases.
BMP & CMP: These panels include tests like glucose, electrolytes, kidney function test like creatinine, BUN, and liver function test like AST, ALT and bilirubin. They help to assess the overall organ function and electrolyte balance.
Coagulation Studies: Tests like Pt, INR, and APTT are performed to check for the ability of blood to clot. It is used to check the risk of bleeding during surgery.
Imaging Studies: Imaging studies like MRI or CT scans are performed to see the adrenal glands and nearby structures. This can help to plan the surgery and to determine the extent of the procedure.
Bleeding: Adrenalectomy includes cutting through blood vessels by supplying the blood to adrenal gland. Excessive bleeding can occur during surgery or after the surgery needs blood transfusions or surgical measures to manage.
Infection: Every surgical procedure has a potential risk of infection, which can affect the surgical site and can lead to severe complications like sepsis.
Damage to surrounding organs: The adrenal glands are located near other vital organs like the kidneys and major blood vessels. Accidental damage to these structures may lead to complications.
Hormonal imbalances: Removing the adrenal gland can affect the hormonal balance which can lead to condition like Cushing syndrome or Addison disease. Patient may need hormone replacement therapy to manage imbalances.
Pneumothorax: Accidently puncture o the lung may lead to pneumothorax. This can lead to respiratory difficulties needs an urgent medical treatment.
Adrenal crisis: Where both the adrenal glands are removed, there is a risk of adrenal crisis. It is a life-threatening disease caused by low blood pressure, electrolyte imbalances, and shock because of improper adrenal hormones.
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