Approach to Adrenal Surgery: Video

Hi, I'm Dr. Masha Livhits, an endocrine surgeon at UCLA. Today, let's talk about approaches to adrenal surgery.

Adrenal nodules are quite common, affecting about one in every 20 older adults. Most of these nodules are benign and generally don't cause any health problems. However, in some cases, adrenal nodules can become functional, producing hormones that can lead to issues like hypertension, weight gain, or diabetes. When this happens, surgical removal of the affected adrenal gland may be necessary to resolve the excess hormone production and alleviate associated health complications.

There are three main approaches to adrenal surgery. The positive aspect is that adrenal surgery can frequently be conducted through very small incisions utilizing a video camera and specialized tools, known as minimally invasive or endoscopic surgery. Endoscopic adrenal surgery involves one of two approaches: the transperitoneal approach, which involves small incisions on the front of the abdomen, and the retroperitoneoscopic approach, where small cuts are made on the back. The latter approach, going through the back, can contribute to a slightly quicker recovery as it avoids contact with the intestines. These methods can be performed with or without the assistance of a robot, depending on the surgeon's preference. Both the transperitoneal approach and the retroperitoneoscopic approach work well, though fewer surgeons nationally are familiar with the retroperitoneoscopic approach. The third method, open surgery, necessitates a single large incision to extract the adrenal gland. Typically, open surgery is reserved for cases where there is a concern of a large adrenal cancer that is unsuitable for a minimally invasive approach. Regardless of the surgical technique employed, it is crucial to ensure the complete removal of the adrenal nodule without any tumor spillage. Even benign nodules have the potential to regrow in the surgical site if there is tumor spillage during the procedure. When considering adrenal surgery, it is essential to seek out a surgeon who has extensive experience in performing these procedures to maximize the chances of a successful outcome.

The choice of approach in each patient depends on several factors:

Size of the adrenal tumor. The retroperitoneoscopic approach is best suited for tumors 6 cm or less in diameter. The transperitoneal approach can be used for both small and large tumors up to 8 cm. Above 8 cm, cancer of the adrenal gland is a significant concern and may prompt open adrenalectomy.
Body type of the patient. The retroperitoneoscopic approach is most suitable for lean patients (body mass index <30) and for women, who tend to carry excess weight in the hips and thighs. Obese patients or those with excess abdominal fat are often better managed with the transperitoneal approach.
History of prior surgery. In patients who have had extensive surgery involving the stomach, intestines, liver, or pancreas, the retroperitoneoscopic approach offers the advantage of avoiding scar tissue in the abdominal (peritoneal) cavity.
Familiarity of the surgeon with different approaches. Given the large number of adrenal operations performed at our center annually, our surgeons have been able to master all operative techniques.

Key Insights:

Adrenal nodules or tumors can cause hormone-related problems such as high blood pressure, weight gain, or diabetes. Surgery is needed to remove adrenal tumors causing hormone excess.
Minimally invasive (endoscopic) adrenal surgery may be performed via either a transperitoneal or retroperitoneoscopic approach. More than 90% of adrenal tumors can be removed using one of these two endoscopic approaches, both of which work well in the hands of an experienced surgeon.
The choice to use a robot in minimally invasive surgeries depends on the surgeon's preference and experience.
Open surgery is reserved for cases with larger tumors (usually 8 cm or larger) or suspected adrenal cancer.
It is crucial to remove adrenal tumors without spilling any tissue during surgery, as even benign nodules can regrow in the area.
Consulting a surgeon who specializes in adrenal surgery is essential for a successful procedure.