Bilateral adrenalectomy
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Adrenalectomy (Latin root Ad "near/at" +
renal The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; bloo ...
"related to the kidneys" + Greek '' ‑ectomy'' “out-cutting”; sometimes written as ADX for the procedure or resulting state) is the surgical removal of one (
unilateral __NOTOC__ Unilateralism is any doctrine or agenda that supports one-sided action. Such action may be in disregard for other parties, or as an expression of a commitment toward a direction which other parties may find disagreeable. As a word, ''un ...
) or both (
bilateral Bilateral may refer to any concept including two sides, in particular: *Bilateria, bilateral animals *Bilateralism, the political and cultural relations between two states *Bilateral, occurring on both sides of an organism ( Anatomical terms of l ...
)
adrenal glands The adrenal glands (also known as suprarenal glands) are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer cortex whic ...
. It is usually done to remove tumors of the adrenal glands that are producing excess hormones or is large in size (more than 2 inches or 4 to 5 centimeters). Adrenalectomy can also be done to remove a cancerous tumor of the adrenal glands, or cancer that has spread from another location, such as the kidney or lung. Adrenalectomy is not performed on those who have severe coagulopathy or whose heart and lungs are too weak to undergo surgery. The procedure can be performed using an open incision (
laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ane ...
) or minimally invasive
laparoscopic Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
or robot-assisted techniques. Minimally invasive techniques are increasingly the gold standard of care due to shorter length of stay in the hospital, lower blood loss, and similar complication rates. One
adrenal gland The adrenal glands (also known as suprarenal glands) are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer cortex whic ...
sits above each
kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...
. The two adrenal glands produce
hormone A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are require ...
s (
steroid hormone A steroid hormone is a steroid that acts as a hormone. Steroid hormones can be grouped into two classes: corticosteroids (typically made in the adrenal cortex, hence ''cortico-'') and sex steroids (typically made in the gonads or placenta). Withi ...
s and
catecholamine A catecholamine (; abbreviated CA) is a monoamine neurotransmitter, an organic compound that has a catechol (benzene with two hydroxyl side groups next to each other) and a side-chain amine. Catechol can be either a free molecule or a su ...
s) that help regulate blood pressure, blood sugar level,
metabolism Metabolism (, from el, μεταβολή ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run c ...
,
immune system The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splint ...
,
stress Stress may refer to: Science and medicine * Stress (biology), an organism's response to a stressor such as an environmental condition * Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
and other essential functions. If one adrenal gland is removed, the other adrenal gland will take over the hormone-producing role. If both adrenal glands are removed, the patient will require lifelong steroid supplementation.


Indications

Most adrenal tumors are noncancerous (
benign Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...
), often found incidentally as a mass via imaging such as CT scans,
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
, or
ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...
that were taken for other health workups (see
incidentaloma In medical or research imaging, an incidental imaging finding (also called an incidentaloma) is an unanticipated finding which is not related to the original diagnostic inquiry. As with other types of incidental medical findings, they may represe ...
). Although these adrenal masses do require evaluation, the majority of them (approximately 80%) do not require adrenalectomy. However, due to the hormone-producing function of the adrenal glands, some noncancerous adrenal tumors may produce too much hormones, such as aldosterone (called
primary aldosteronism Primary aldosteronism (PA)'','' also known as primary hyperaldosteronism or Conn's syndrome, refers to the excess production of the hormone aldosterone from the adrenal glands, resulting in low renin levels and high blood pressure. This abnormalit ...
), cortisol (called
Cushing's disease Cushing's disease is one cause of Cushing's syndrome characterised by increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary (secondary hypercortisolism). This is most often as a result of a pituitary adenoma (spe ...
or
Cushing's syndrome Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to glucocorticoids such as cortisol. Signs and symptoms may include high blood pressure, abdominal obesity but with thin arms and legs, reddish stretch marks, a ...
), or
catecholamine A catecholamine (; abbreviated CA) is a monoamine neurotransmitter, an organic compound that has a catechol (benzene with two hydroxyl side groups next to each other) and a side-chain amine. Catechol can be either a free molecule or a su ...
s (called
pheochromocytoma Pheochromocytoma (PHEO or PCC) is a rare tumor of the adrenal medulla composed of chromaffin cells, also known as pheochromocytes. When a tumor composed of the same cells as a pheochromocytoma develops outside the adrenal gland, it is referred t ...
). These hormone-producing tumors may need adrenalectomy. Additionally, adrenal tumors that are larger than 4 centimeters in size, regardless of whether they produce hormones, also require adrenalectomy due to increased risk of adrenal cancer. Rarely (5-12%), the adrenal tumor may be cancerous (
adrenocortical carcinoma Adrenocortical carcinoma (ACC) is an aggressive cancer originating in the cortex (steroid hormone-producing tissue) of the adrenal gland. Adrenocortical carcinoma is remarkable for the many hormonal syndromes that can occur in patients with ste ...
), requiring adrenalectomy. Rarer still, the mass may be a metastatic cancer that spread from another location, such as the kidney or lung. If the metastasis is isolated to the adrenal gland, it may be a candidate for adrenalectomy.


Contraindications

An absolute
contraindication In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...
(a reason not to do the surgery under any situation) for adrenalectomy are patients who are generally unsuited to surgery: having severe coagulopathy and poor cardiopulmonary performance due to the stress to the body that surgery will produce. In addition,
American Association Of Clinical Endocrinologists The American Association of Clinical Endocrinology (AACE), formerly known as the American Association of Clinical Endocrinologists, is a professional community of physicians specializing in endocrinology, diabetes, and metabolism. AACE's missio ...
and
American Association Of Endocrine Surgeons The American Association of Endocrine Surgeons (AAES) is a professional organization for endocrine surgeons. The organization partakes in patient care, education, and scientific investigations in the field of endocrine surgery, including training ...
guidelines state minimally-invasive techniques should be avoided when there is a large tumor size (larger than 6 cm) due to difficulties in maneuvering around a large mass, and in adrenocortical carcinoma where there is a risk of not fully removing the cancerous tissue. However, at least one meta-analysis of 898 patients has found shorter length of stay, less blood loss, and no higher rates of complications even in large (>5 cm) tumors using minimally-invasive techniques.


Techniques

Techniques for adrenalectomy is largely divided into two types: open surgical
laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ane ...
versus
minimally invasive Minimally invasive procedures (also known as minimally invasive surgeries) encompass Surgery, surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by d ...
techniques.


Open Surgery

Surgeons usually reserve open surgery for large (larger than 6 cm) or cancerous tumors where there is a risk of not fully removing the cancerous tissue. They perform open surgery using traditional instruments and cuts (incisions).


Minimally Invasive Techniques

Minimally invasive techniques may be
laparoscopic Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
, where several small cuts (incisions) are made to allow for the surgeon to directly control surgical instruments with their hands while visualizing the surgery via a tiny camera that provides a magnified, 3D view of the surgical site. Laparoscopic surgery has many benefits. For example, this surgery has smaller scars, less pain, less blood loss, similar complication rates, and a shorter recovery period than traditional open surgery. Traditionally, this has been through the laparoscopic transperitoneal approach (LTA) where the small cuts are made in the abdomen to reach the adrenal glands through the
peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of meso ...
from the front-side. However, an alternative approach is possible called retroperitoneoscopic adrenalectomy (PRA), where the adrenal glands are reached through small cuts made in the back. Studies have shown that both LTA and PRA are equally safe and effective, though some suggest advantages of PRA over LTA in terms of lower intensity of postoperative pain, shorter hospital stay, faster recovery, and lower early morbidity. However, PRA involves high pressure CO₂ within a limited
retroperitoneal space The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on thei ...
, and therefore may cause kidney injury in those at high risk. Sometimes surgeons perform robot-assisted adrenalectomies. They perform the surgery through small cuts (incisions) using robotic arms with a camera and instruments attached. The camera gives doctors a high-definition, magnified, 3D view of the surgical site. No siginficant differences were found between laparoscopic and robot-assisted adrenalectomy in two meta-analyses for complications, blood loss, or mortality, however robotic adrenalectomy had shorter hospital stays at the cost of longer operating time and higher cost of surgery.


Postoperative

Postoperative care is highly dependent on what the adrenalectomy was performed for. After adrenalectomy for a cortisol-producing adenoma, patients should be treated with exogenous
glucocorticoid Glucocorticoids (or, less commonly, glucocorticosteroids) are a class of corticosteroids, which are a class of steroid hormones. Glucocorticoids are corticosteroids that bind to the glucocorticoid receptor that is present in almost every verteb ...
s such as
cortisone Cortisone is a pregnene (21-carbon) steroid hormone. It is a naturally-occurring corticosteroid metabolite that is also used as a pharmaceutical prodrug; it is not synthesized in the adrenal glands. Cortisol is converted by the action of the enz ...
or
hydrocortisone Hydrocortisone is the name for the hormone cortisol when supplied as a medication. Uses include conditions such as adrenocortical insufficiency, adrenogenital syndrome, high blood calcium, thyroiditis, rheumatoid arthritis, dermatitis, asthm ...
until the hypothalamic-pituitary-adrenal (HPA) axis has recovered. This process may take 6 to 18 months after unilateral adrenalectomy. Similarly, for patients who have undergone adrenalectomy for (subclinical) Cushing syndrome, perioperative glucocorticoid therapy and postoperative assessment of HPA axis recovery are necessary. For patients who have undergone adrenalectomy for a pheochromocytoma, long-term followup is necessary because 10-15% of patients may have recurrence. For those with high blood pressure (
secondary hypertension Secondary hypertension (or, less commonly, inessential hypertension) is a type of hypertension which by definition is caused by an identifiable underlying primary cause. It is much less common than the other type, called essential hypertension, ...
) from primary aldosteronism, adrenalectomy provides a clinical cure rate of approximately 27.1%. If both adrenal glands are removed, the patient can no longer create the adrenal hormones necessary for life ( primary adrenal insufficiency). Signs and symptoms include volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. This requires lifetime treatment with the hormones produced by the removed adrenal glands, including glucocorticoids and
mineralocorticoid Mineralocorticoids are a class of corticosteroids, which in turn are a class of steroid hormones. Mineralocorticoids are produced in the adrenal cortex and influence salt and water balances ( electrolyte balance and fluid balance). The primary ...
s (
fludrocortisone Fludrocortisone, sold under the brand name Florinef, among others, is a corticosteroid used to treat adrenogenital syndrome, postural hypotension, and adrenal insufficiency. In adrenal insufficiency, it is generally taken together with hydroc ...
). The glucocorticoid dose needs to be increased when in
stress Stress may refer to: Science and medicine * Stress (biology), an organism's response to a stressor such as an environmental condition * Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
or during
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...
s or else adrenal crisis may occur.surgerydoor.co.uk: Adrenalectomy
/ref> For women with deficiency in androgens as a result of the loss of androgen production from the adrenal glands following adrenalectomy, dehydroepiandrosterone (DHEA) replacement can be considered. The signs and symptoms include low libido, depressive symptoms, and/or low energy levels despite optimized glucocorticoid and mineralocorticoid replacement.


Complications

Complications from an adrenalectomy can include insufficient cortisol production,
acute kidney injury Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in kidney function that develops within 7 days, as shown by an increase in serum creatinine or a decrease in urine output, or both. Causes of AKI are c ...
, post-operative bleeding, damage to nearby organs, and post-operative infection.


See also

*
List of surgeries by type Many surgical procedure names can be broken into parts to indicate the meaning. For example, in gastrectomy, "ectomy" is a suffix meaning the removal of a part of the body. "Gastro-" means stomach. Thus, ''gastrectomy'' refers to the surgical remo ...


References


External links

{{Endocrine system intervention Endocrine system Surgical oncology Surgical removal procedures