Adrenalectomy — open, laparoscopic, or robotic — is the surgical treatment for functioning and malignant adrenal tumours. This page covers preoperative preparation, surgical anatomy, operative approaches, tumour-specific principles for adrenocortical carcinoma and pheochromocytoma, postoperative management, partial (cortical-sparing) adrenalectomy, and ablative options.
Pre-operative Management
All patients undergoing surgery for large adrenal masses must be counselled about the possibility of concurrent en bloc nephrectomy. Consider peri-operative steroids in patients undergoing adrenalectomy.
Pheochromocytoma:
- Excessive catecholamine secretion from chromaffin tissue may cause tachycardia, diaphoresis, headache, hypertension, cardiac arrhythmias, left ventricular dysfunction, and impaired glucose tolerance. Preoperative cardiac work-up (electrocardiography, echocardiography) and assessment of hypertension-induced end-organ dysfunction are indicated.
- Preoperative sympatholytic therapy with α-adrenergic blockers for at least 2 weeks before surgery aids both haemodynamic and glucose control and should be continued until the day of surgery. Phenoxybenzamine is time-proven to be safe and effective but has drawbacks: its non-selective nature may cause tachycardia (β-adrenergic blockade may be necessary), and as an irreversible non-competitive α-blocker it may produce prolonged immediate-postoperative hypotension and CNS effects such as somnolence. Newer selective competitive α1-blockers (doxazosin, prazosin, terazosin) obviate the drug-induced need for β-blockade. β-blockade, if needed, must be given with caution in myocardial depression and started only after phenoxybenzamine.
- Intraoperatively, anticipate hypertensive episodes and control them with rapid-onset, short-half-life IV agents (nitroprusside, phentolamine, nitroglycerin, nicardipine); temporary cessation of surgical manipulation may be necessary. Short-acting β-blockers such as labetalol and esmolol are also good choices.
Hyperaldosteronism: an aldosterone antagonist (spironolactone) should be started at least 1–2 weeks before surgery, especially in patients on long-term ACE inhibitors.
Surgical Anatomy
- The right adrenal vein is short, drains into the posterior segment of the inferior vena cava, and is usually not exposed until the gland is mobilized.
- The longer left adrenal vein joins the inferior phrenic vein and enters the cranial aspect of the left renal vein.
- For bilateral adrenalectomy, the left side should be done first, as it is more difficult.
Approach
Two options: open adrenalectomy and laparoscopic/robotic adrenalectomy.
Laparoscopic Adrenalectomy
Absolute contraindications:
- Local recurrence of a previously resected adrenal mass.
- Invasive adrenal cortical carcinoma with invasion of neighbouring organs, the renal artery, or the vena cava.
- Contraindications to establishing pneumoperitoneum: cardiac failure, pulmonary failure, renal failure, haemodynamic instability/shock, increased intracranial pressure, acute intestinal obstruction with dilated bowel loops, large pelvic mass, soft-tissue infection at port sites, acute glaucoma, recurrent spontaneous pneumothorax, vascular endocranial malformation, hypertensive retinopathy, expected extensive adhesions from previous abdominal surgery, and abdominal aortic aneurysm (possible increased risk of vascular rupture).
Relative contraindications: large tumour (>6 cm), localized adrenal cortical carcinoma without adrenal vein or vena caval involvement, morbid obesity, malignant pheochromocytoma, virilizing adrenal tumour (70–80% are actually functional adrenal cortical carcinoma), significant abdominal adhesions, history of recurrent pyelonephritis, and pregnancy.
Open Adrenalectomy
Broadly classified into transperitoneal and retroperitoneal approaches.
- Transperitoneal (anterior transabdominal and thoracoabdominal) — advantages: excellent surgical exposure and better access to the hilum and great vessels; disadvantage: higher risk of intra-abdominal organ injury and ileus.
- Retroperitoneal (flank and posterior lumbodorsal) — advantages: reduced risk of visceral and bowel injury by avoiding the peritoneum, less ileus and shorter hospitalization, ideal for the morbidly obese (the abdominal panniculus falls forward in a flank or prone position), reduced haemodynamic and respiratory morbidity without pneumoperitoneum, and avoidance of dense intraperitoneal adhesions from previous surgery or inflammation; disadvantage: a smaller operative field, making dissection of large tumours difficult. The posterior lumbodorsal approach should not be used for large tumours or adrenal cortical carcinoma.
The main advantage of the flank approach over the posterior approach is the ease of conversion to transperitoneal should difficulties be encountered; conversely, the prone posterior lumbodorsal approach allows bilateral adrenalectomy without patient repositioning.
Surgery for Adrenal Cortical Carcinoma
Principles (7):
- No-touch technique.
- Preservation of the intact peritoneum on the anterior surface of the adrenal gland if there is no evidence of invasion through the overlying peritoneal layer.
- En bloc resection of the tumour with a wide margin of surrounding benign tissue outside the tumour capsule.
- Strict preservation of an intact tumour capsule.
- Exclusion of the remainder of the peritoneal cavity as much as possible, using barriers such as laparotomy pads, plastic barriers, or drapes.
- Minimizing bleeding and fluid spillage into the peritoneal cavity.
- Change of gloves, gowns, and instruments after tumour removal and before abdominal closure.
Surgery for Pheochromocytoma
Early ligation of the main adrenal vein and minimal manipulation of the affected gland are important. Catecholamine release can be caused by thermal injury to the adrenal even in the absence of pheochromocytoma. It is important to notify anaesthesia when the adrenal vein is ligated.
Post-operative Management
Pheochromocytoma — aggressive fluid management with volume repletion is necessary after removal, because hypotension can occur from sudden loss of tonic vasoconstriction. Postoperatively, fluid administration and vasopressors such as phenylephrine, guided by invasive monitoring, help manage hypotension; correct electrolyte abnormalities and hypoglycemia. Patients not uncommonly remain hypertensive postoperatively, and antihypertensive management should be continued.
Partial Adrenalectomy
Unilateral adrenalectomy is often well tolerated and is the gold standard for treating functioning or malignant adrenal tumours. Indications for partial adrenalectomy (3): bilateral adrenal tumours, a solitary adrenal gland, and familial syndromes (von Hippel–Lindau disease, familial pheochromocytoma, and multiple endocrine neoplasia type IIA).
Patients with bilateral adrenalectomy require lifelong adrenal replacement therapy. Fixed daily steroid dosing is associated with overdosing (which may cause osteoporosis, obesity, and Cushing syndrome) and with underdosing in times of stress (life-threatening Addisonian crisis can occur). Patients continue to report poorer quality of life than the general population after bilateral adrenalectomy. The amount of adrenal tissue that must be left behind after partial adrenalectomy to avoid insufficiency is not known.
Ablative Therapy for Adrenal Tumours
Current indications include patients with small tumours who are not keen on or suitable for surgery, and palliation of painful metastases not amenable to resection. The three major thermal ablative techniques:
- Radiofrequency ablation (RFA) — uses frictional energy from oscillating tissue ions to deliver destructive heat (target tissue 60–100 °C), causing protein and enzymatic degradation and cell death.
- Cryoablation — relies on rapid freezing and thawing to rupture cell membranes; its main advantage is the ability to follow iceball formation in real time on CT.
- Microwave ablation — creates an alternating electric field that oscillates surrounding water dipoles, heating the tissue; suggested advantages include larger ablation volumes, decreased procedural pain, and the potential to treat cystic lesions.
Self-Test
1. Which blood vessel should be ligated first during an adrenalectomy? The adrenal vein.