| Surgical removal of the adrenal gland (adrenalectomy) | | | | For the left adrenal: |
| may be recommended in situations of hormone | | | | The left colon is first freed from its peritoneum and |
| overproduction or if there is a concern that a mass of | | | | reflected down inferiorly. Then the spleen is delivered |
| the adrenal gland may be a cancer. Three main | | | | medially from the left upper quadrant to allow the |
| situations exist where hormone overproduction is an | | | | division of the splenocolic ligament and it's mobilisation. |
| indication to have an adrenalectomy. The first is | | | | This allows retraction of the stomach, the pancreatic |
| Cushing's Syndrome in which excess steroid | | | | tail and the spleen medially, exposing the left kidney |
| production (cortisol) is caused by a tumor of the | | | | and the left adrenal gland. The left adrenal vein, which |
| adrenal cortex. The second is Conn's Syndrome in | | | | drains into the left renal vein, is ligated and divided close |
| which a tumor of the same area produces excess | | | | to the renal vein. Arteries are then clipped and divided |
| aldosterone, which may cause problems with high | | | | starting superiolaterally and proceeding medially until the |
| blood pressure and blood potassium levels. The third is | | | | gland is entirely freed for removal. A standard |
| a tumor of the medulla which is called a | | | | abdominal closure concludes the operation. |
| pheochromocytoma. This tumor may manufacture | | | | Thoracoabdominal approach: |
| excess adrenaline and cause problems such as high | | | | This is essentially the same as the anterior approach |
| blood pressure, excess sweating, tremor, and anxiety. | | | | but involves more extensive thoracic exploration for |
| Preoperative measures for Adrenal Surgery: | | | | removal of large and malignant tumours to minimise |
| | | | the chance of leaving malignant cells behind. |
| 1. A History and Physical Examination: It is important to | | | | Posterior approach: |
| know patient's full health history and any and the entire | | | | This is a less extensive operation, with incisions being |
| medicines patient takes. Depending on patient's other | | | | made in the back. The patient is obviously prone (on |
| medical problems, patient may need to be seen by | | | | their front) but flexed at the waist to encourage |
| another specialist before operation. | | | | descent of the abdominal organs away from the |
| 2. Bloodwork and Tests: According to patient's age, | | | | retroperitoneum, minimising interference in the surgical |
| medical condition, and the type of surgery planned, | | | | field. The operation is the same for the right or left |
| patient may be asked to have an EKG (heart tracing), | | | | adrenal gland. An initial incision is made in a curvilinear |
| chest x-ray, or blood work before the surgery. 3. | | | | fashion from the midline at the level of the 10th rib |
| Anesthesia Evaluation: The anesthesiologist will see | | | | inferiolaterally to the superior border of the posterior |
| patient on the morning of surgery if patient is generally | | | | iliac crest. Then the surgeon dissects down through the |
| in good health. Type of Adrenal Surgery: Either one | | | | fat and latissimus dorsi muscle to the thoracolumbar |
| (unilateral) or both (bilateral) adrenals can be removed, | | | | fascia. Here, a longitudinal incision is made, exposing |
| the decision depending on which glands are affected | | | | sacrospinalis muscle that is retracted medially. The 12th |
| and what the underlying problem is. The operation of | | | | rib and its associated vascular bundle are retracted as |
| choice for adrenalectomy is now laparoscopic surgery. | | | | medially as possible. The 12th intercostal nerve is then |
| The open approaches for the right and left | | | | retracted (gently) superiorly exposing the |
| adrenalectomy differ in detail but in essence there are | | | | retroperitoneum. This is entered and the diaphragm |
| four main types of operation. | | | | elevated from Gerota's fascia (the fascia lining the |
| Laparoscopic approach: | | | | kidney). The pleuron is then separated from the |
| This is "key-hole surgery". Rather than large incisions | | | | diaphragm and the diaphragm is divided to allow |
| being made, a few (3-5) small holes are made in the | | | | access to Gerota's fascia. This is then incised, the |
| abdomen of the patient through which a camera and | | | | kidney retracted inferiorly to expose the adrenal gland, |
| surgical instruments are introduced. This is expected to | | | | allowing the adrenal to be isolated. Clipping and division |
| further reduce patients' pain and recovery time | | | | of arteries proceeds from the superior aspect |
| post-operatively. However, this can only be used for | | | | inferiorly. The adrenal vein is then ligated (either at the |
| small tumours, and where surgeons are adequately | | | | left renal vein on the left or the IVC on the right) and |
| trained in this relatively new technique. The advantage | | | | the gland freed proceeding from superior to inferior, |
| of the laparoscopic approach is that there is less | | | | followed by removal. The diaphragm, muscle and |
| scarring and quicker recovery after surgery. Anterior | | | | fascia, and skin are then repaired. |
| approachThe adrenal glands are accessed from the | | | | Laparoscopic adrenalectomy: |
| front of the patient via an incision just underneath the | | | | This is a relatively new procedure, a so-called minimally |
| ribs. This approach is used when the tumour is | | | | invasive technique, facilitated by the advent of |
| suspected to be malignant as it exposes a greater | | | | microcameras and the development of specialist |
| area and provides good access to the gland and | | | | surgical instruments that can be introduced into the |
| surrounding structures. | | | | abdomen via small holes. Due to the fact there is a |
| Thoracoabdominal approach: | | | | smaller area for removal of any affected structures |
| A more radical version of the anterior approach, | | | | this operation is used for smaller, generally |
| where parts of the thoracic (chest) cavity are | | | | non-malignant tumours. The precise operation depends |
| exposed. This provides the greatest access when | | | | on the surgeon, but a standard one is described below. |
| removal of surrounding tissues as a single block may | | | | The patient is positioned on their side (the affected |
| be needed (e.g. where malignant cancers are very | | | | side uppermost). First three equally spaced ports are |
| large, 10-15 cm, and may have spread). | | | | introduced in a transverse line, from the lateral edge of |
| Posterior approach: | | | | the rectus sheath of the affected side to the |
| Incision is made on the back of the patient. It involves | | | | mid-axillary line between the costal margin and the iliac |
| injury to fewer tissues, improving the patient's recovery | | | | crest. An initial exploration of the abdomen is made |
| time with less pain and better post-operative bowel | | | | using a camera introduced into the medial-most port |
| function than the anterior approach. However it can | | | | (nearest the middle). This is then transferred to the |
| only be used for small tumours where diagnosis by | | | | middle port and a fan retractor introduced into the |
| radiology has confidently excluded malignancy. | | | | medial-most port to retract the viscera from the field, |
| Procedure of Adrenal Surgery: | | | | aided by hyper-extending the patient at the waist. |
| All are performed under general anaesthesia. | | | | Instruments are then introduced through the |
| Anterior approach: | | | | lateral-most port. |
| A midline incision or bilateral subcostal incisions are | | | | Adrenal Surgery in India: |
| made to access the abdomen. Initial exploration of the | | | | With half a million doctors, over 700,000 nursing |
| abdomen should be made for evidence of metastatic | | | | professionals and established hospitals, India's |
| spread and provides an opportunity for biopsy or | | | | importance as a center for high-tech healing is growing. |
| excision of suspicious lesions to be made. | | | | Patients from neighbouring countries also came down |
| For the right adrenal: | | | | for routine and complex surgeries. Non Resident |
| First the right lobe of the liver must be mobilised and | | | | Indians, frustrated by long waits for treatment in the |
| retracted anteriomedially. Then the hepatic flexure and | | | | West, chose to get their procedures done in India |
| transverse colon are freed and retracted medially. The | | | | when on vacation. Most recently, westerners have |
| duodenum and head of pancreas are then elevated to | | | | started coming for a range of treatments. India has |
| expose the inferior vena cava (IVC), aorta, the right | | | | many world-class hospitals and medical facilities at its |
| kidney and the right adrenal gland. The retroperitoneal | | | | disposal. They definitely have an advantage over |
| space is then entered and the adrenal fully exposed. | | | | others, as apart from the cost factor, most foreign |
| Starting from the superiomedial aspect, the adrenal | | | | nationals are used to getting treated by Indian nationals |
| gland is then dissected out and the smaller feeding | | | | abroad. Indian medical professionals settled abroad are |
| arteries clipped and divided from the gland. A careful | | | | associated with high quality care. Compared to |
| dissection of the IVC posteriolaterally then allows the | | | | countries like the UK or the US, minor treatments like |
| right adrenal vein (which unlike the left adrenal vein | | | | those for dental problems or major procedures like |
| drains directly into the IVC) to be identified. This is then | | | | bypass surgery or angioplasty come at a fraction of |
| ligated with a suture and divided close to the IVC. The | | | | the cost in India, even though the quality of doctors and |
| major feeding arteries are then identified, clipped and | | | | medical equipment is comparable to the best in the |
| divided, this time proceeding from the superiolateral | | | | world. |
| aspect medially. The gland can then be removed. | | | | |