Adrenalectomy
Indications for Adrenalectomy
Adrenalectomy is indicated for adrenal tumors larger than 5 cm or for adrenal tumors with hormonal activity. Adrenal tumors <3 cm in size without hormonal activity require watchful waiting (with imaging controls). Adrenal tumors of 3–5 cm in size without hormonal activity may be surgically removed, or alternatively depending on age and comorbidities, are managed by watchful waiting (with imaging controls).
Contraindications to Adrenalectomy
- Adrenalectomy should not be done without determination of hormonal activity. The exclusion of a pheochromocytoma is crucial, since this tumor must be treated with alpha blockers before surgery to prevent a hypertensive crisis.
- Coagulation disorders
- Other contraindications depend on comorbidities (surgical risk) and the importance of adrenalectomy on the quality of life or life expectancy of the patient.
Surgical Technique of Adrenalectomy
Preoperative Patient Preparation:
- Perioperative antibiotic prophylaxis, if risk factors for wound infection are present.
- Insertion of a transurethral catheter
- Epidural anesthesia, if an open-surgical approach is chosen
Surgical Approach:
Small adrenal tumors (up to 6 cm) may be treated with a flank incision, via a laparoscopic or via a retroperitoneoscopic approach. A transperitoneal approach is preferable for larger adrenal tumors or adrenal pheochromocytoma (Brunt, 2006).
Flank incision:
Lateral decubitus position. Padding of all relevant pressure points (Knees, ankles, elbows...). The table is flexed and the kidney rest is elevated. An oblique intercostal flank incision is done between the 11th and 12th rib (or 10th and 11th rib). Careful dissection of the subcostal nerve is necessary to avoid nerval injury and consecutive flank bulge. Blunt dissection of the layer between Gerota's fascia and psoas muscle (dorsal of the kidney). Blunt dissection between peritoneum and Gerota's fascia (ventral of the kidney) until exposure of the renal vein.
Retroperitoneoscopic access to the adrenal gland:
The retroperitoneoscopic access to the kidney and adrenal glands is described in section retroperitoneoscopic nephrectomy. See also fig. retroperitoneoscopic access.
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Laparoscopic access to the adrenal gland:
The laparoscopic access to the kidney and adrenal glands is described in section laparoscopic nephrectomy.
Open transperitoneal approach:
A subcostal incision and transsection of the ligamentum teres hepatis is done. A laterocolic incision (line of Toldt) is done to dissect the colon to the middle. On the left side, peritoneal ligaments have to be dissected between spleen and abdominal wall. On the right side, the duodenum has to be mobilized from the inferior caval vein.
Mobilization of the upper renal pole:
The upper pole of the kidney is dissected from the perinephric fat until the hilar vessels of the kidney are identified.
Left adrenalectomy:
First dissect the left suprarenal vein near the renal vein. Now it is possible to dissect the adrenal gland circulary, while small vessels are clipped or coagulated.
Right adrenalectomy:
First dissect the adrenal gland from the diaphragm and the upper pole of the kidney. Now the plane between adrenal gland and vena cava is dissected, the suprarenal vein is clipped or divided between sutures.
Drains after adrenalectomy:
Draining of retroperitoneal cavity is often performed, but is probably not necessary after uncomplicated adrenalectomy.
Care after Adrenalectomy
General measures:
Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls. Wound inspections.
Analgesia after Adrenalectomy:
A flank approach or open transperitoneal approach is painful and an epidural catheter is an option. Without epidural analgesia, pain medication according to the WHO pain ladder is given, starting with e.g. metamizol and tramadol.
Drains and catheters:
- Wound drainage 0–2 days
- Bladder catheter 0–1 day
Hormone replacement therapy:
There is a risk of an Addisonian crisis (adrenal insufficiency) after unilateral adrenalectomy for Morbus Cushing, since the contralateral adrenal gland is suppressed. After bilateral adrenalectomy, adrenal insufficiency must be prevented by hormonal substitution, please see section adrenal insufficiency.Complications of Adrenalectomy
- Bleeding
- Infection
- Injury of liver or splen (splenectomy)
- Paralytic ileus, bowel injury, peritonitis
- Pancreatic injury with formation of a pancreatic fistula
- Pneumothorax
- Subcostal nerve injury and consecutive flank bulge
- Addisonian crisis (adrenal insufficiency)
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References
- Brunt, L. M.
- Minimal access adrenal surgery.
Surg Endosc, 2006, 20, 351-361.
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Deutsche Version: Adrenalektomie
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Dr. med. Dirk Manski
man...@urologielehrbuch.de