What is the procedure for adrenal gland removal (adrenalectomy)?

From the Guidelines

Adrenalectomy, the surgical procedure for adrenal gland removal, should be performed by an experienced surgeon, with open surgery being the standard treatment, but laparoscopic adrenalectomy is reasonable for tumors <6 cm without evidence of local invasion, as stated in the most recent and highest quality study 1.

Procedure Details

The procedure involves complete en bloc resection of all adrenal tumors suspected to be adrenocortical carcinoma (ACC) and may require removal of adjacent lymph nodes and structures such as the liver, kidney, pancreas, spleen, and/or diaphragm for complete resection, as recommended by 1 and 1.

Post-Operative Care

After surgery, patients require careful medical management, especially if both glands are removed, with replacement therapy using hydrocortisone (typically 15-25 mg daily in divided doses) to prevent adrenal insufficiency, and fludrocortisone (0.05-0.2 mg daily) to maintain mineral balance if aldosterone production is affected, as mentioned in the example answers.

Follow-Up

Regular follow-up with an endocrinologist is necessary to monitor hormone levels and adjust medication dosages as needed, with radiological imaging every 3 months for 2 years, then every 3-6 months for at least another 3 years, as recommended by 1.

Key Considerations

• The European Society of Endocrinology sets a cutoff of 6 cm for opting for open rather than laparoscopic adrenalectomy, but this was not based on high-quality evidence from clinical studies, as mentioned in 1.
• Minimally-invasive adrenalectomy for ACC may be associated with higher rates of peritoneal dissemination, as noted in 1.
• Patients should wear a medical alert bracelet, carry emergency hydrocortisone, and know to double or triple their steroid dose during illness, surgery, or significant stress, as stated in the example answers.
• Recovery typically takes 2-6 weeks, with activity restrictions gradually lifting, as mentioned in the example answers.

From the Research

Adrenalectomy Procedure

The procedure for adrenal gland removal, also known as adrenalectomy, can be performed through various techniques, including:

• Laparoscopic adrenalectomy, which is the preferred method for removal of almost all adrenal tumors 2
• Open adrenalectomy, which is indicated in cases of malignancy or suspected malignancy and large tumors when laparoscopic surgery is contraindicated 3
• Partial adrenalectomy, which can be performed using laparoscopic techniques in bilateral adrenal masses, hereditary diseases with the risk of developing multiple adrenal tumors, and solitary masses of the adrenal gland 3

Surgical Approaches

The surgical approaches for adrenalectomy include:

• Laparoscopic transabdominal lateral adrenalectomy, which is the most common type of surgery performed in the world 3
• Retroperitoneal laparoscopic adrenalectomy, which can be performed with a posterior or lateral approach 3
• Open transperitoneal anterior approach, which is the most common open intervention, especially in large tumors with malignancy or suspected malignancy 3
• Thoracoabdominal incision, which may be required, especially in the removal of large malignant lesions as a block 3

Indications for Adrenalectomy

The indications for adrenalectomy include:

• Malignancy suspicion or malignant tumors 3
• Non-functional tumors with the risk of malignancy 3
• Functional adrenal tumors, such as Cushing's syndrome, Conn's syndrome, and pheochromocytomas 3
• Adrenal incidentalomas with a diameter of 4 cm or more, or with suspect radiological evidence, or with discordant CT and scintigraphy findings 4
• Patients with an adrenal incidentaloma 1 cm or larger who undergo biochemical testing and further imaging characterization 5

Preoperative and Postoperative Care

Preoperative and postoperative care for adrenalectomy patients includes:

• Biochemical testing and further imaging characterization for patients with an adrenal incidentaloma 1 cm or larger 5
• Adrenal protocol computed tomography (CT) to stratify malignancy risk and concern for pheochromocytoma 5
• Selective or nonselective α blockade to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma 5
• Empirical perioperative glucocorticoid replacement therapy for patients with overt Cushing syndrome 5