This document outlines the history, surgical anatomy, approaches, techniques, and complications of adrenal gland surgery. It discusses: - The history of open adrenalectomy dating back to the late 1800s and early adoption of laparoscopic approaches in the 1990s. - Surgical anatomy of the right and left adrenal veins which can vary and need to be carefully managed. - Indications for adrenalectomy including functional tumors and malignancy risk based on size. - Various surgical approaches including open, laparoscopic, robotic, and newer minimally invasive techniques. - Important technical aspects like patient positioning, gaining access, and intraoperative maneuvers for each approach. - Post-operative care including

1. Surgery of the Adrenal Glands
Dr. Oladele Situ
Snr. Registrar in Surgery
National Hospital Abuja
November 10, 2020

2. Outlines
• History
• Surgical anatomy
• Indications for Adrenalectomy
• Contraindications
• Pre-operative work up
• Approches to adrenalectomy
• Open
• Laparoscopic
• Laparo-endoscopic single site
(LESS)
• Natural Orifice Transluminal
Endoscopic Surgery (NOTES)
• Hand assisted
• Robotic
• Ablative techniques
• Partial adrenalectomy
• Complications
• Local experience

3. History
• Knowsly Thornton removed a 20-pound left adrenal mass with the
left kidney in 1889
• Charles Mayo performed the first flank adrenalectomy for
pheochromocytoma in 1927
• Young described the “hocky stick” posterior approach in 1936 while
Chute et al. described the thoracoabdominal approach in 1949
• Gagner et al were the fist to perform laparoscopic adrenalectomy in
1992
• Robot-assisted laparoscopic adrenalectomy was described Piazza et al
and Hubens et al in 1999.

4. Surgical anatomy
The right adrenal vein is a potentially perilous structure to manage, because it is short, wide, variable,
and confluent with thin-walled, large capacitance vessels. A significant second adrenal vein may be
found in up to 10%of patients. In the right AVOID BLEEDING, in the Left GET THE PLANE RIGHT!

5. Variations in the right adrenal veins

6. Indications and contraindications for
Adrenalectomy
• Absolute Contra-indications to
adrenalectomy:
• Extensive metastatic disease
• Uncontrolled coagulopathy
• Severe cardiopulmonary disease
that precludes anaesthesia
Size of adrenal mass and risk
of malignancy:
<4cm = <2%
4-6cm = about 6%
>6cm = up to 25%

7. Making the decision
to operate
• Incidentalomas make up 1-4% of all
abdominal images
• Plasma aldosterone concentration
(PAC)/ Plasma renin activity (PRA)
can help rule out conn’s
• Suspicious CT features:
heterogenicity, high attenuation rate,
irregular margins

8. DDx of adrenal incidentaloma

9. Pre-operative work up
• History & exam:
• Age and obesity
• Is it a functional adrenal mass?
• What is the likelihood of
malignancy?
• Past surgical/medical history
preventing laparoscopy
• Primary or recurrence?
• Comorbidities like HTN, DM, etc
• Consent for Nephrectomy!
• Diagnosis and work up:
• Contrasted CT/ MRI (where is the
site and what size is it?)
• CXR
• Serum cortisol and DST
• Urinary metanephrines
• FBC
• EUCr*
• Clotting and LFT
• GXM-HTN + vascularity
*malignant Pheochromocytomas are poorly responsive to chemotherapy or radiotherapy
hence surgery is mainstay of treatment.

10. Specific Peri-Op
concerns
• Close sugar monitoring in Cushing's disease
and watch out for adrenal insufficiency
• Close BP, EUCr monitoring in patients with
Conn's and pheochromocytoma
• Phenoxybenzamine 10mg b.d (max 40mg
t.i.d) reverse chronic α-receptor
downregulation
• aldosterone antagonist (spironolactone)
should be started at least 1 to 2 weeks
before surgery in Conn’s dx
• Norepinephrine, Na+ Nitroprusside, lidocain
• CVL monitoring, PPIs, prokinetics
• NG tube, urethral catheter & DVT care

11. Open Adrenalectomy
Indications Approaches
• Transperitoneal
• Anterior trans abdominal
• Thoraco-abdominal (lateral)
• Retroperitoneal
• Flank approach (lateral)
• Posterior lumbodorsal
• Anaesthesia:
• General anaesthesia

12. Open Adrenalectomy: Positioning
for left lateral transabdominal
laparoscopic adrenalectomy For posterior lumbodorsal approach

13. Open Adrenalectomy: Access to both
adrenals
Anterior transperitoneal approach Posterior lumbodorsal approach
11th or 12th
rib may have
to be excised.
Ablasion
procedures
5cm from
midline

14. Open Adrenalectomy: Access to a single
adrenal
Thoraco-abdominal approach (Thoraco-abdominal)
Between the 8th and 9th ribs into the rectus abdominis.
Facilitate mobilization of the liver in large tumours

15. Open adrenalectomy: flank incision
Gaining access over the 11th rib
Excise rib, protect neurovascular
bundle

16. Intra-operative manipulations: Left Adrenals
Anterior transperitoneal approach Anterior transperitoneal approach
Mixter
forceps

17. Intra-operative manipulations: right adrenals
Anterior –transperitoneal approach Adrenal tumour invading the IVC

18. Intra-operative manipulations: right adrenals
Specimen with IVC IVC repaired with PTFE

19. Open adrenalectomy: Wound closure
• Ensure dry bed, drain not necessary
• Wound closed in layers:
• Absorbable for muscles,
• rib re-approximation in the flanks with absorbable
• non-absorbable prolene for costal cartilage
• Subcute closure
• Skin closure
• Need for CTTD?

20. Oncologic principles of resection of
adrenocortical carcinoma
1. No touch technique
2. Preservation of the intact peritoneum on the anterior surface of the adrenal gland
if no evidence of invasion through the overlying peritoneal layer
3. En-bloc resection of tumor with a wide margin of surrounding benign tissue
outside the tumor capsule
4. Strict preservation of an intact tumor capsule
5. Exclusion of the remainder of the peritoneal cavity as much as possible using
barriers such as laparotomy pads, plastic barriers, or drapes
6. Minimizing of bleeding and fluid spillage into the peritoneal cavity
7. Change of gloves, gowns, and instruments after removal of the tumor and prior
to closure of the abdomen.

21. Laparoscopic Adrenalectomy (90%):
Trans-peritoneal Approach-Full lateral or modified
lateral (45-60O)
Right left
Palmer’s
point

22. Laparoscopic Adrenalectomy:
Trans-peritoneal

23. Laparoscopic Adrenalectomy: dorsal
retroperitoneal approach
Dorsal (laparoscopic) retroperitoneal

24. Laparoscopic Adrenalectomy:
lateral retro-peritoneal Approach
Lateral (laparoscopic) retroperitoneal

25. Intra-Op technicalities
• Pneumoperitoneum
• Gasless laparoscopy
• LaparoTenser®
• Balloon dissection
• 1.5cm stab incision
• 0o Camera then 30o camera
• Harmonic, ligasure,
electrocautery
• Surgeon and assistant faces
camera
• Usually no need for drain
• Open conversion:
• Bleeding, tumour size, tumour
thrombus, pancreatic injury

26. Laparoscopic Adrenalectomy:
Left adrenal
1
2
3
4

27. Laparoscopic adrenalectomy: Right adrenal

28. Gasless Laparoscopic adrenalectomy

29. Robotic
Adrenalectomy
• Advantages:
• Better ergonomics &
EndoWrist®
• Better magnification
• Tremor filtering
• Disadvantages:
• Cost
• Learning curve
• Slower
• Allow 8cm between robot
hands

30. Other Approaches to adrenalectomy
Hand-Assisted laparoscopic
• Getting out of favour due to
robotic
• May still be indicated in difficult
laparoscopic procedure
Laparo-endoscopic single site (LESS)
• Similar to laparoscopic
• Small (< 4cm) can be removed
• ? Better cosmesis
• However poor tool triangulation
and tissue retraction
• ↑operation time and ?↑risk of
injury

31. Other Approaches to adrenalectomy
NOTES-assisted Adrenalectomy
• Largely experimental
• First described in 2008 by
Fritscher-Ravens et al.
• Trans esophago-gastric
• Trans vaginal
• Robotic assisted

33. Post Op care
• Clos vitals and sugar monitoring
• Close EUCR monitoring
• Bowel function returns in about 2-3 days in open surgery
• Analgesia and antibiotics
• Hydrocortisone tapered down 50mg/day
• Can be discharge in day 1 in laparoscopic procedure or up to day day
7 in open procedure.

34. Partial adrenalectomy
• To avoid adrenal insufficiency and permanent fixed steroid dosing
• Patient requiring bilateral adrenalectomy, solitary adrenal gland,
familial syndromes e.g. MEN IIA, Familial pheochromocytoma, VHL dx
• Resect tumour without mobilizing gland
• Intra-op USS may be required for tumours <1cm, or to confirm
completeness of resection
• ? ≥ 20% of the gland must be left to prevent adrenal insufficiency

35. Ablative surgery for Adrenal gland
• RFA
• HIFU
• Cryo-ablation
• Both RFA and HIFU has a risk of dangerous catecholamine release

36. Complications of adrenalectomy
Intraoperative Post operative

37. Any controversy
• Laparoscopy > open
• Retroperitoneal approach > transperitoneal approach
• Lap > Robot (cost)
• Any advantage of LESS?
• Any use for NOTES?
• Is α-blockade always necessary?

38. Local experience and conclusion
• NHA
• Indications for adrenalectomy are clear.
• Surgery is mandated for functional adrenal tumours
• Size and nature of the tumour is a critical determinant of the access
• Perioperative mortality from pheochromocytoma in specialised
centres is now< 1%, 90% done laparoscopically
• Adrenocortical carcinoma is rare, open approach favoured.

39. Thank you