The adrenal glands (also known as suprarenal glands) are triangular shaped endocrine glands located on top of each kidney. These glands are important to the body’s endocrine (hormonal) system and produce hormones some of which we cannot survive without. There are two main parts to each adrenal gland - the Adrenal Medulla and the Adrenal Cortex.
The Adrenal Medulla is the central part of the adrenal gland and is responsible for the production of adrenaline (epinephrine) and nor-adrenaline (nor-epinephrine). These are the hormones underlying the “flight or fright” response and are normally secreted at times of stress.
The Adrenal Cortex consists of the outer layers of the adrenal gland and produces the hormones cortisol, aldosterone and adrenal sex hormones.
What disorders can occur?
As with most other endocrine organs the adrenal glands may develop functioning (excessive hormone producing) tumours or non-functioning tumours. Malignant tumours of the adrenal gland are uncommon but may occur as a result from seeding to the adrenal gland from a distant tumour (adrenal gland metastasis) or can develop from the adrenal gland itself (adrenal carcinoma)
Adrenal adenomas are benign tumours of the adrenal cortex. All adrenal nodules need to be investigated for excess hormone production as approximately 20% will be functioning tumours that secrete excessive hormone. Any patient with a functioning tumour should be assessed by an Endocrinologist who will treat and stabilise any significant symptoms prior to surgery. The symptoms of excessive hormone production depends on the hormone produced by the tumour.
- Cortisol – the features that occur due to excessive cortisol production is known as Cushing Syndrome. Some of the features that occur include central obesity, round red face (moon face), acne, thin skin with easy bruising, large purple stretch marks of the skin, osteoporosis, muscle weakness and excessive hair growth in women
- Aldosterone – the condition that occurs with excessive aldosterone production is known as Conn’s syndrome. High blood pressure is often the only symptom of this condition. A low potassium level may also be present which can result in muscle weakness, headaches and generalised fatigue. Excessive loss of potassium can result in abnormal heart rhythms that can result in cardiac arrest.
- Adrenal sex hormones – the adrenal sex hormones contribute to the physical changes that occur during the development of adult sexual characteristics. These tumours are rare but seen more frequently in infants and children where the predominant feature is precocious puberty (abnormally early development of puberty).
Phaeochromocytomas are tumours that arise from the central potion of the adrenal gland (the medulla). These tumours secrete excessive amounts of adrenaline (epinephrine) and nor-adrenaline (nor-epinephrine). These hormones are normally involved in the “fight or flight” response. Excessive production of theses hormones can therefore result in similar symptoms to those experienced with a severe fright with high blood pressure, palpitations, headache, tremor, anxiety, sweating and occasionally sudden death due to cardiac arrest.
An incidentaloma is a non-functioning and benign adrenal adenoma that is found as an incidental finding with radiological imaging in approximately 5% of middle aged adults. Incidentalomas do not require surgery unless investigations excess hormone production or demonstrate features that raise the possibility of malignancy.
Adrenal carcinoma is a cancer that arises from the adrenal gland. This is a very aggressive form of cancer that is often advanced on presentation and as a result prognosis is usually poor. Surgical excision of the tumour is the only chance for a cure of this condition as this cancer responds poorly to currently available chemotherapy or radiotherapy treatments.
Adrenal gland metastases
Adrenal gland metastases are tumours that have originated elsewhere in the body which have seeded to the adrenal gland. Patients will often have a prior known history of cancer. The management and prognosis of an adrenal gland metastasis depends on the extent of disease and the tissue of origin of the primary cancer.
Why do I need adrenal Surgery?
Surgery for the adrenal gland is usually recommended for:
- An excessive hormone producing tumour
- Suspicion of cancer
- Treatment of adrenal cancer or adrenal gland metastasis
What incision will I have?
Removal of the adrenal gland (adrenalectomy) should be done by surgeons who have suitable training and experience with adrenalectomy to ensure an optimal outcome. I regularly perform adrenalectomy and have completed a medical doctorate on both clinical and molecular aspects for management of adrenal tumours. As far as I am aware I performed the first single incision adrenalectomy procedures in Australasia with removal of the adrenal gland through a single 2.5cm incision.
Most patients are able to have a laparoscopic (“key hole” or “minimally invasive”) procedure. This procedure can be done through the front of the abdomen (transperitoneal approach) or from the back (retroperitoneal approach). I regularly perform both of these approaches for adrenalectomy however for smaller lesions favour the retroperitoneal approach as this is a more direct approach to the adrenal gland with no need for bowel or organ mobilization. For most cases laparoscopic surgery will usually require three (sometimes four) key hole incisions with the largest incision dependent on the size of the adrenal tumour.
Large adrenal tumours, adrenal cancers or larger tumours with strong suspicion of cancer are usually excised by an open surgical approach to avoid the potential for tumour rupture. The only potential for a long-term cure in patients with an adrenal cancer is complete surgical excision which is best achieved through an open approach. In most cases the incision will be in upper part of the abdomen just beneath the lower left or right ribs (similar to the traditional gall-bladder incision). The size of the incision depends on the size of the tumour and patient factors. This incision requires the muscles of the upper abdomen (on the side of the affected adrenal gland) to be cut so does result in much greater post-operative discomfort than a laparoscopic approach.
What will the scar look like?
The incisions required for a laparoscopic approach are small and will often be virtually undetectable once fully healed.
The scar from an open approach is much larger and therefore often more obvious, however in most patients the scar eventually will fade to a faint white line and satisfactory cosmetic result. Patients with darker skin may initially have exaggerated pigmentation of the scar but this will also fade with time. Very rarely some patients develop a thick exaggerated scar (hypertrophy or keloid scar) but this is uncommon.
What complications can occur?
Most adrenal operations are straightforward and associated with few problems. As an expert in this area my complication rates for this procedure are low. However all operations carry risks which include the potential for postoperative infections, bleeding from the wound or surgical site and miscellaneous problems due to anaesthesia. Specific complications related to adrenal surgery are rare but include injury to the bowel and internal organs (spleen, liver, pancreas kidney) and major haemorrhage from injury to the inferior vena cava (which the right adrenal vein drains into).
Will I need to be on medications after adrenal surgery?
For non-functioning adrenal lesions and adrenal cancers no pre- or post-operative medications are usually required and the remaining adrenal gland will compensate adequately.
Patients who have adrenal tumours with excessive hormone production usually require medical treatment for control of their symptoms prior to surgery. After successful removal of the adrenal tumour any medications started for symptom control can be rapidly weaned and in most cases able to be stopped. The exception to this is for cortisol secreting tumours (Cushing Syndrome) where the remaining adrenal gland is often suppressed for months to years before regaining adequate function again. After surgery for Cushing Syndrome patients require steroid hormone supplementation which is carefully monitored and gradually weaned by the patient’s Endocrinologist.
Removal of both adrenal glands is rarely required. In this case without replacement of essential adrenal hormones the patient will not survive.
How long will I be in hospital and expected recovery time?
Most patients are able to be discharged after 1-2 nights in hospital after a laparoscopic adrenalectomy and are usually able to return to a sedentary or light duty occupation within 1-2 weeks after surgery. For work with heavy manual labour I usually recommend 4-6 weeks of recovery before return to work.
An open adrenalectomy procedure results in greater postoperative pain and higher risk of wound infection. Patients usually require 3-5 days recovery and are usually not ready to return to work for 6 weeks to allow adequate time for wound healing and the abdominal muscles to knit back together.