Is Surgery on Your Adrenal Gland Being Discussed? What You Need To Know

By Barbra Miller, MD

The adrenal glands, of which you typically have two, are located behind the liver on the right, the spleen and pancreas on the left, and just above the kidneys close to your back muscles. The adrenal glands are responsible for making hormones — substances that make other cells in the body respond in various ways. These hormones enable the body to respond to stress, regulate blood pressure and the amount of fluid in the body, and are involved in the regulation of body chemical components such as sodium and potassium. The adrenal glands can develop nodules/masses or produce excess amounts of hormones. In some cases, one or both of the adrenal glands may need to be removed.

The surgical approach chosen for adrenal gland removal is dependent on the size of the tumor, prior surgical history and concern about adrenal cancer, also called adrenocortical [uh-dree-noh-kawr-ti-kuh-l] carcinoma (ACC). ACC is an extremely rare cancer that occurs in 1-2 people per million people in the worldwide population. Approximately 600 new cases per year are diagnosed in the United States.

Surgical options to remove an adrenal gland include the more traditional open approaches and the newer laparoscopic [lap-er-uh-skop-ik] and robot-assisted approaches. What is called an open adrenalectomy [ə-drē’nə-lěk’tə-mē], or surgery performed by first making an incision large enough to allow the surgeon the ability to see and touch internal tissues and organs, may be performed through the front (anterior), the side (thoracoabdominal) [thō’ră-kō-abdom’i-năl] or the back (posterior) of the body. Most open adrenalectomies are done through the front, and a fairly long incision is placed along the length of the rib cage on the side of the tumor, or the cut through the skin is down the center of your abdomen. Surgery may be performed through the side if the tumor is quite large or if you have had prior abdominal surgery. Surgery through the back is most commonly done if you have had previous abdominal surgery or both adrenal glands need to be removed.

Popularized in the past 20 years, laparoscopic surgery uses specialized tools and cameras inserted through several small incisions rather than one large incision. Laparoscopic adrenal surgery can be performed through the front, the side, or the back. Advantages of a laparoscopic approach include less pain from smaller incisions, a shorter hospital stay, and shorter overall recovery time. While laparoscopy has become the preferred approach for benign (non-cancerous) adrenal tumors, disadvantages of a laparoscopic approach in patients with adrenal cancer have been reported to include shorter survival, less complete removal of the tumor, and shorter time to – and greater chance of – tumor returning.

It is important that the covering of the tumor not be penetrated during surgery. A wide margin of normal tissue around the tumor should be included to ensure complete removal of any tumor cells that may have extended outside the adrenal gland and to minimize the chance for recurrence of the tumor. It is thought that laparoscopic instruments might rub against the tumor more so than during open surgery and spread tumorcells to other parts of the abdomen, leading to early tumor recurrence. Certain aspects of appropriate cancer surgery cannot be carried out using a laparoscopic approach, and because adrenal cancer is one of the most aggressive cancers with no particularly successful chemotherapy, it is extremely important that surgery be done correctly the first time. A poorly performed open adrenalectomy will also have poor outcomes.

If patients with adrenal cancer are able to undergo surgery, it is imperative that surgery is performed by a surgeon experienced in the treatment of adrenal cancer – not just a surgeon who can remove a benign adrenal tumor. Only a few centers in the United States treat adrenal cancer on a regular basis.

If surgery is recommended by your doctor specializing in hormonal diseases (your endocrinologist), you will be referred to the surgeon that your endocrinologist works with closely. Ask your surgeon what the best approach would be for your adrenal surgery—and make sure your questions are fully answered!

Barbra S. Miller, M.D., FACS is an Assistant Professor in the Division of Endocrine Surgery, Section of General Surgery, at University of Michigan in Ann Arbor. Her entire practice is focused on endocrine surgery. She serves on the AACE Endocrine Surgery Committee. Dr. Miller’s specific clinical and research interests include adrenal cancer and benign adrenal disorders, thyroid cancer, Graves’ disease, intraoperative parathyroid hormone monitoring and ultrasound.