Frequently Asked Questions - Adrenal surgery

How is an adrenal tumour removed?

A general anaesthetic is required, so you will be fully asleep. There are 3 main approaches to adrenal surgery:

OPEN: a large open incision is the procedure of choice for a very large tumour or a known adrenal cancer

LAPAROSCOPIC ANTERIOR: Keyhole surgery through the abdominal cavity has smaller incisions and a quicker recovery than open surgery. It is a safe approach for benign (non-cancerous) tumours <8-10cm.

PRA - POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY: This technique is an improvement over the laparoscopic technique, as it causes less pain than even laparoscopic surgery, is safer in obese patients, and is not affected by scar tissue from previous abdominal surgery. PRA is safe for benign tumours <7cm. In fact, two thirds of patients require nothing more than panadol to relieve discomfort after PRA!

The patient is placed face down and the adrenal tumour removed via 3 small incisions in the back, just below the ribcage. The technique was developed in Europe by Prof. Martin Walz, and more than 2000 adrenal operations have been safely completed this way. Dr. Miller learned the procedure directly form Dr. Walz and was the first surgeon in Victoria (and the second in Australia) to perform it. As of early 2020, she has performed more PRA operations than any other surgeon in Australia, and has mentored more than ten surgeons in four states successfully perform PRA.

What are the potential complications of Adrenal surgery?

As with anything in life, there are risks to surgery. These risks are weighed against the risks of not having surgery. Listed below are some of the possible complications of surgery.

The rate of major complications after PRA is less than 2%.

Risks include, but are not limited to:

  • Numbness or weakness of the flank muscles around the incision (usually temporary.)
  • High blood pressure.
  • Bleeding.
  • Injury to surrounding organs such as the bowel, or the liver on the right or the spleen or pancreas on the left.
  • Infection of the incisions.
  • Bruising/swelling.
  • Incisional hernia (less common with PRA or laparoscopic surgery).
  • Collapsed lung (pneumothorax).
  • Other unforeseen risks.

You will require general anaesthetic, given by a specialist anaesthetist. Risk of a serious complication in a healthy person is very rare. Potential risks include, but are not limited to:

  • Heart problems (death, heart attack, arrhythmias).
  • Lung problems (pneumonia, wheezing).
  • Blood clots (stroke, clots in leg veins or lungs).
  • Drug reactions (also possible with local anaesthetic).
  • Chipped teeth.
  • Other unforeseen risks.

You will meet the anaesthetist just before your operation and have the chance to ask any additional questions.

What are the symptoms of adrenal gland tumours?

Patients with adrenal gland tumours may have no symptoms at all. A variety of symptoms can result from excess hormone production by the abnormal gland. Adrenal tumours associated with excess hormone production include pheochromocytomas, aldosterone-producing tumours, and cortisol-producing tumours. Typical features are described below.

  • Pheochromocytomas produce excess hormones that can cause episodes of very high blood pressure and periodic spells characterized by severe headaches, excessive sweating, anxiety, palpitations, and rapid heart rate that may last from a few seconds to several minutes. These episodes can result in life-threatening strokes or heart attacks.
  • Aldosterone producing tumours cause high blood pressure and low serum (blood) potassium levels. In some patients this may result in symptoms of weakness, fatigue, and frequent urination.
  • Cortisol producing tumours cause a syndrome termed Cushing’s syndrome that can be characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Most cases of Cushing’s syndrome, however, are caused by small pituitary tumours and are not treated by adrenal gland removal. Overall, adrenal tumours account for about 20% of cases of Cushing’s syndrome.
  • An incidentally found mass in the adrenal may be any of the above types of tumours, or may produce no hormones at all. Most incidentally found adrenal masses do not make excess hormones, cause no symptoms, are benign, and do not need to be removed. Surgical removal of incidentally discovered adrenal tumours is indicated if:
    • The tumour is found to make excess hormones.
    • Is large in size (more than 4 cm in diameter).
    • If there is a suspicion that the tumour could be malignant.
    • Adrenal gland cancers (adrenal cortical cancer) are rare tumours that are usually very large at the time of diagnosis. Removal of these tumours is usually done by open adrenal surgery.

If an adrenal tumour is suspected based on symptoms or has been identified by CT or other scan, the patient should undergo blood and urine tests to determine if the tumour is over-producing hormones. Special tests, such as a CT scan, nuclear medicine scan, MRI, or selective venous sampling may be used to obtain more information about the adrenal tumour.

How exactly is PRA performed?

  • The surgery is performed under a general anesthesia, so you are asleep during the procedure.
  • 3 small incisions are made in the back and small ports (metal tubes) are placed through them. The space above the kidney is filled with carbon dioxide gas so the surgeon can see.
  • A laparoscope (a small telescope) connected to a special camera is inserted through the port. This gives the surgeon a magnified view of your internal organs on a television screen.
  • Your surgeon delicately separates the adrenal gland from its attachments and seals the blood vessels. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. This incision may need to be enlarged slightly to remove the tumour. The small incisions are then closed.

What happens if the procedure cannot be performed by PRA?

In a small number of patients the PRA method cannot be performed. The operation is then converted to a laparoscopic or open procedure. Factors that may increase the possibility of choosing or converting to the "open" procedure may include:

  • Large tumour size or very large patient size
  • A history of prior abdominal surgery causing dense scar tissue (this affects laparoscopy but not PRA)
  • Inability to visualize the adrenal gland clearly
  • Bleeding during the operation

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert to an open procedure, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is based strictly on patient safety.

What should I expect after Adrenal surgery?

After the operation, it is important to follow your doctor's instructions. Although many people feel better in just a few days, remember that your body needs time to heal. You should expect a one night stay in hospital, unless your medical condition requires that you stay longer.

  • After adrenal gland removal, most patients can be cared for on a surgical ward. Occasionally, a patient with a pheochromocytoma may go to an intensive care unit after surgery to monitor blood pressure.
  • Patients with an aldosterone-producing tumour will need a serum potassium level checked after surgery and may need to continue to take medications to control their blood pressure.
  • Patients with cortisol-producing tumours and Cushing’s syndrome will need to take prednisone or cortisol pills after surgery. The dose is then tapered over time as the remaining normal adrenal gland resumes adequate production of cortisol hormone.

Will I have pain after the PRA operation?

Most patients are surprised at how comfortable they are after PRA surgery. You should be able to eat and drink normally, walk up and down stairs, and do light activity. Most patients take Panadol and/or Nurofen to keep them comfortable at home. You will have a prescription for something stronger for the first few days in case you need it, but beware prescription pain medicine can make you drowsy and constipated, so do not drive or operate heavy machinery, and drink lots of water and eat plenty of fruits and vegetables.

How long will I be hospitalised?

Most patients are admitted to the hospital on the morning of surgery and go home the next day unless your medical condition requires you to stay longer. Some patients feel well enough to go home on the day of surgery.

When will I know the findings of the surgery?

A final pathology report requires careful study of the surgical specimen. Therefore, the final report is usually not available until about one week after the operation.

Will I have stitches?

You will have stitches on the inside that dissolve on their own. You will have a waterproof Comfeel dressing so that you can shower as usual, but avoid baths for the first week. Leave the dressing in place until your first post-operative visit, where it will be removed.

Will I have any physical restrictions after my surgery?

In general, your activity level depends on the amount of discomfort you experience. Many patients have resumed golf or tennis within a week or two after the operation. Most patients return to work in a week, and you are able to drive as soon as you are comfortable. Let your body be your guide and use your common sense.