Adrenalectomy

Adrenal Gland Removal

An adrenalectomy is a surgery to remove one or both adrenal glands when the gland’s anatomy and function have been compromised by:

  • Benign tumors and cysts
  • Malignant primary tumors
  • Metastatic tumors that have spread from other organs of the body

The adrenal glands are two small organs, one located above each kidney. They are triangular and about the size of a thumb. The adrenal glands are known as endocrine glands because they produce various hormones. These hormones are involved in the regulation of metabolism, immune system support, controlling blood pressure, chemical levels in the blood, water use in the body, glucose usage, and the “fight or flight” reaction during times of stress. These adrenal-produced hormones include cortisol, aldosterone, the adrenaline hormones – epinephrine and norepinephrine – and a small fraction of the body’s sex hormones (estrogen and androgens).

Each gland is comprised of two parts, an outer layer called the adrenal cortex, and the center of the gland called the adrenal medulla. The adrenal cortex makes important hormones, including steroids that balance the water and salt in the body and help maintain normal blood pressure. The adrenal medulla makes catecholamines, the hormones epinephrine (adrenalin), norepinephrine, and dopamine. Although individuals have two adrenal glands, only one normal gland is needed to provide an adequate hormonal function. Where both glands must be removed, patients must take steroid supplements of cortisone and hydrocortisone.

Diseases of the adrenal gland are rare. However, the most common reason that a patient may need to have the adrenal gland removed is excess hormone production caused by a tumor located within the adrenal. Most of these tumors are small and not cancers. They are known as benign growths that can usually be removed with laparoscopic surgical techniques. Removal of the adrenal gland may also be required for certain larger tumors even if they aren’t producing excess hormones if there is a suspicion that the tumor could be cancerous. Fortunately, malignant adrenal tumors are also rare. Often an adrenal mass or tumor is found by chance when a patient gets an X-ray study to evaluate another problem.

Causes of Adrenal Problems

Adrenal gland problems are most often attributed to hormone imbalances from damage to the physical structure of the organ(s). This damage to the adrenal glands can be genetic or caused as an effect of trauma, medication side-effects, or a by-product of other gland problems. Adrenal gland problems can also be caused by an imbalanced lifestyle, such as overuse of stimulants, sleep irregularity, or poor diet and exercise, however, this type of over-taxation of the adrenals rarely causes the severity that requires surgical removal. Causes of adrenal problems are wide and varied, however, the two most common adrenal conditions, with or without an existent tumor, that may require adrenalectomy are as follows:

In the case of Addison’s Disease, where the adrenals are damaged and cortisol or aldosterone is insufficiently produced by the glands, the most common cause is a sudden stoppage of corticosteroid medications, prescribed for another condition. Also, damage to the adrenal glands can be caused by an auto-immune disease or infection. Less common causes are:

  • Cancer cells or bleeding in the adrenal glands
  • Genetic disorders of the adrenals
  • Certain medicines, such as antifungal medicines or etomidate, a type of general anesthesia
  • Pituitary gland bleeding, tumors, or infection
  • Genetic diseases or surgical removal of the pituitary gland

In the case of Cushing’s Syndrome, where cortisol is overproduced or overexposed, the most common cause is the use of corticosteroid medications, such as prednisone, in high doses for a long period. Healthcare providers can prescribe these to treat inflammatory diseases, such as lupus, or to prevent rejection of a transplanted organ. High doses of injectable steroids for the treatment of back pain can also cause Cushing’s syndrome.

Symptoms of Adrenal Problems

Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. These symptoms are specifically related to the hormone(s) that is out of balance.

Common general symptoms of Adrenal problems are:

  • Upper body obesity, round face and neck, and thinning arms and legs
  • Skin problems, such as acne or reddish-blue streaks on the abdomen or underarm area
  • Dizziness, weakness, sweating, or fatigue
  • High blood pressure
  • Muscle and bone weakness
  • Moodiness, irritability, or depression.
  • High blood sugars
  • In severe cases of adrenal insufficiency: abdominal pain, nausea, diarrhea, or vomiting
  • Slow growth rates in children

Adrenal tumors associated with excess hormone production include pheochromocytomas, aldosterone-producing tumors, and cortisol-producing tumors. Some of these tumors and their typical features are:

  • Pheochromocytomas produce excess hormones that can cause 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.
  • Aldosterone-producing tumors 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 tumors 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 tumors and are not treated by adrenal gland removal. Overall, adrenal tumors account for about 20% of cases of Cushing’s syndrome.
  • Adrenal gland cancers (adrenal cortical cancer) are rare tumors that are usually very large at the time of diagnosis. Removal of these tumors is usually done by open adrenal surgery.

A found mass in the adrenal may be any of the above types of tumors or may produce no hormones at all. Most 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 tumors is indicated only if:

  • The tumor is found to make excess hormones
  • Is large (more than 4-5 centimeters or 2 inches in diameter)
  • If there is a suspicion that the tumor could be malignant
Adrenal Gland Diagram

Sign & Symptoms of Adrenal Fatigue

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Adrenal Gland Removal Treatment

Adrenal surgery is relatively uncommon. For this reason, it is critical to find a surgeon who specializes in this type of operation. In the experienced hands of Dr. David W. Ford, the risks of adrenal surgery, especially laparoscopic adrenalectomy using the da Vinci Surgical System, are low.

Treatment begins with locating glandular damage and hormone checks. Since Adrenalectomy is the preferred treatment for patients with adrenal tumors that secrete excess hormones and for primary adrenal tumors that appear malignant, Dr. David W. Ford will order X-rays or other scans to first confirm any suspected tumors. Special X-ray tests, such as a CT scan, nuclear medicine scan, an MRI or selective venous sampling are commonly used to confirm and locate the suspected adrenal tumor. Once a tumor is confirmed, Dr. David W. Ford will order blood and urine tests to determine if the tumor is over-producing hormones.

If a tumor is not found, then other therapies may first be employed before surgical intervention. In some cases of Adrenal Insufficiency or Addison’s Diseases, which is the adrenal gland’s insufficient production of certain hormones, Hormone Replacement Therapy (HRT) is first prescribed. In the case of Cushing’s Syndrome, or the adrenal gland’s over-production of cortisol, treatment is a prescription of medications that block cortisol from the adrenals or pituitary gland.

If a tumor is located, Dr. David W. Ford will employ either Open Adrenalectomy Surgery or employ the da Vinci Surgically assisted system for the Adrenalectomy. Adrenalectomies are most commonly performed using laparoscopic or robotically assisted laparoscopic surgical systems. In more complicated cases, larger posterior incisions are necessary to remove one or both adrenal glands. This is called an open adrenalectomy. Dr. David W. Ford uses both open and the da Vinci Robotic Surgical System depending on the needs of his patients. In some cases, Dr. David W. Ford will begin with the da Vinci surgical system and find it necessary to make a larger incision because of scar tissue from previous operations or other complications in the adrenals or kidneys. Dr. David W. Ford will make a decision regarding which approach to use is based on the features of the tumor including size, type, appearance on imaging studies, and whether or not the patient has had prior abdominal surgery.

Both surgical methods, open and the da Vinci robotically assisted laparoscopy will require general anesthesia, and carry complexities that will require consultation with an endocrinologist, due to immediate hormonal imbalances that will be caused. Prior to the operation, some patients may need medications to control the symptoms of the tumor, such as high blood pressure. Patients with a pheochromocytoma (see above) will need to be started on special medications several days prior to surgery to control their blood pressure and heart rate. Patients with an aldosterone-producing tumor (see above) may need to have their serum potassium checked and take extra potassium if the level is low. Patients with Cushing’s syndrome (see above) will need to receive extra doses of cortisone medication on the day of surgery and for a few months afterwards until the remaining adrenal gland has resumed normal function. Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition. Blood transfusion and/or blood products may be needed depending on your condition.

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Trans-Abdominal Approach to Adrenalectomy:

Traditional (Open) Adrenalectomy Trans-Abdominal

Traditional (Open) Adrenalectomy:

If an adrenal tumor is larger than 10-15 centimeters and/or thought to be adrenocortical cancer, Open Adrenalectomies are preferred.

During an open adrenalectomy, Dr. David W. Ford utilizes a Trans-Abdominal Approach. This method uses either a vertical incision in the middle of the abdomen or a subcostal incision, along the bottom of the ribcage. This approach has the advantage of giving the surgeon access to both adrenal glands through one incision. The main downside to this approach is that a number of different organs need to be moved out of the way in order to get to the adrenal gland. This need to move organs out of the way raises the risk of injuring surrounding organs.

Dr. Ford then removes one or both adrenals, and the incisions are sutured or stapled closed, and you're taken to a recovery area. If necessary, a drain may be placed at the incision site. Expect to spend a few days in the hospital recovering, and once at home, it may take four to six weeks to fully recover.

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Robotic-Assisted Surgery

"The da Vinci Surgical System allows me to make smaller incisions, resulting in reduced risk of infection, minimize scarring, reduce pain, and accelerate recovery time, allowing my patients to return to normal activities more quickly."
David W. Ford, MD, FACS
da Vinci Surgical System

Robotically-Assisted Adrenalectomy with
The Da Vinci® Robotic Surgical System

Surgical robotics for minimally invasive surgery

In general, tumors that are smaller than 10 cm in size with a low risk of being adrenocortical cancer can be removed with the da Vinci Surgical System laparoscopically. Approximately 2% of these operations need to be converted to the traditional open incision. The most common reasons to convert to an open operation include: signs of cancer, unexpected findings, difficult anatomy, a tumor that is larger than expected, and a tumor that is invading into surrounding organs.

Dr. David W. Ford will perform a robotically assisted laparoscopic adrenalectomy with the Laparoscopic transabdominal approach. This approach uses five very small incisions (ports) in the abdomen placed just below the ribcage in the front to approach the adrenal gland through the abdominal cavity. This is an excellent approach for tumors of all types and sizes.

During the robotically assisted adrenalectomy, Dr. David W. Ford makes five small ports or incisions, each less than 1 inch long, in your abdomen. A laparoscope (a tube with a tiny video camera) is usually inserted into your abdomen, just under the ribs, through one of the incisions. Dr. David W. Ford who is seated in the operating room, operates via the Surgeon Console that controls the Patient Cart’s robotic devices, including various surgical instruments and the camera. The images gathered from the laparoscope’s camera are high-definition 3D, which are sent to a monitor that Dr. David W. Ford uses to guide the surgical system during the adrenal gland removal. If needed, the abdomen can be inflated with a harmless gas (carbon dioxide), which creates space to allow Dr. Ford to view the inside of the body. Dr. David W. Ford then delicately separates one or each of the adrenal glands from its attachments. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. It is almost always necessary to remove the entire adrenal gland in order to safely remove the tumor. After one or both adrenals are removed, you may require a drain at the incision site before your incisions are sutured, glued or surgically clipped, and you're taken to a recovery area. Usually after 1 day of observation in the hospital, a patient can be discharged.

The da Vinci Robotic Surgical System is the premier system specialized in adrenalectomies. Dr. David W. Ford is not only an expert board-certified surgeon, but also certified in the use of this leading-edge technology.

This robotic platform offers Dr. David W. Ford fully wristed instruments and a 3D high-definition camera with 10x magnification.

  • The robot doesn’t get tired and Dr. Ford sits during surgery, so there is less surgeon fatigue.
  • For the patient, this translates into quicker recovery, less pain and less complications.
  • Access to clear three-dimensional images (unlike laparoscopic surgery’s two-dimensional images) of the inside of the abdomen for more precise surgery and complex situations can be fixed with small incisions.
  • Dr. Ford can easily use stitches to sew tissue on the inside of the abdomen.
  • The patient is left with tiny scars rather than one large incision scar.

How The Da Vinci® Robotic Surgical System works

Da Vinci surgical systems are comprised of three components: surgeon console, patient-side cart, and vision cart.

Surgeon Console

Surgeon Console

The surgeon console is where I sit during the procedure, have a crystal-clear 3DHD view of your anatomy, and controls the robotic instruments. Through a few small incisions, the tiny instruments are "wristed" and move like a human hand, but with a far greater range of motion.
Patient Cart

Patient Cart

The patient-side cart is positioned near the patient on the operating table. It is where the instruments used during the operation move in real time in response to your surgeon’s hand movements at the surgeon console.

A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real time to bend and rotate the instruments with precision.

Vision Cart

Vision Cart

The vision cart makes communication possible between the components of the system possible, and supports the 3D High Definition vision system.

Should the robotically assisted surgical laparoscopic surgery be recommended as part of treatment for your adrenals and/or adrenalectomy, Dr. David W. Ford and his team will have the best state-of-the-art technology at their disposal to usher in your recovery.

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Post-operative Treatment of Adrenalectomies

After adrenal gland removal, most patients can be cared for on a regular surgical nursing unit. Post-operative pain is generally mild, and patients are encouraged to engage in light activity while at home after surgery. Patients can remove any dressings and shower the day after the operation. Most patients can resume normal activities within two to four weeks, including driving, walking up stairs, light lifting, and work.

Occasionally, a patient with a pheochromocytoma may require admission to an intensive care unit after surgery to monitor their blood pressure. Most patients can be discharged from the hospital within one or two days after surgery. Patients with an aldosterone-producing tumor will need to have their serum potassium level checked after surgery and may need to continue to take medications to control their blood pressure. Patients with cortisol-producing tumors 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.

Patients whose other adrenal gland is normal should not develop adrenal insufficiency. In fact, a person needs only about 33% of their total adrenal volume to be normal from a hormone standpoint. Therefore, removing only one adrenal gland should leave patients with more than enough adrenal tissue. Adrenal insufficiency usually only happens in patients with Cushing's Syndrome where the other adrenal gland is temporarily "asleep" because the tumor has suppressed it or in patients who have both adrenal glands removed who are not getting enough steroid replacement in pill form. Patients who have had both adrenals removed, will require lifelong steroids.

The suggested treatments for healthy adrenal function are a diet low in sugar, caffeine, and junk food, and targeted nutritional supplementation that includes vitamins and minerals: Vitamins B5, B6, and B12. Vitamin C. Magnesium.

Doctors recommend balancing protein, healthy fats, and high-quality, nutrient-dense carbohydrates, while increasing vegetable intake to get the necessary amount of vitamins and minerals naturally. Finally, exercise and sleep management is pivotal in balancing cortisol and adrenaline.

You may call with any problems, questions, or concerns at 970-479-5036

(970) 479-5036
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Download Post OP Care

Prescription Refill Hours:
Monday – Thursday 8:30 AM – 4:30 PM
Friday before 2:00 PM

Please call if you experience any of the following:
  • Temperature greater than 101 degrees
  • Incisions with increasing areas of redness, thick or colored discharge, worsening tenderness
  • Nausea and vomiting or an inability to tolerate anything by mouth
  • Progressively worsening pain

Pain

Pain management efforts are more successful if you take the medication as soon as you start to feel uncomfortable, rather than waiting until the pain is severe. Should you require a refill, please plan ahead, as we do not call in prescriptions after hours. Scheduled medication, such as narcotics, cannot be called in and must be written in-person.
Acetaminophen (Tylenol)
  • 650mg to 1000mg every 6 – 8 hours for first 3 days, scheduled
  • After 3 days, may continue as needed for pain
  • Do not exceed 4000mg in 24 hours
  • Avoid if history of hepatic (liver) impairment, alcohol abuse
Non-Steroidal Anti-Inflammatories (NSAIDs), choose one:
  • Ibuprofen (Advil, Motrin) 400mg by mouth every 6 – 8 hours, as needed
  • Naproxen (Aleve) 440mg by mouth every 12 hours, as needed. Avoid if history of renal (kidney) impairment, or a history of coronary artery disease (CAD), hypertension. Avoid multiple NSAIDs at once (e.g. Ibuprofen + Naproxen)
Narcotics and Opioids
  • Oxycodone, Hydrocodone & combo pills are for severe breakthrough pain ONLY
  • If a combo pill (e.g. Percocet, Lortab, Vicodin, Norco), do NOT take with Tylenol.
  • Do not drive or operate machinery while taking narcotic pain medication.
  • Narcotics can be habit-forming, have addiction potential, and cause constipation, so be careful – and use sparingly.
Tramadol
  • Tramadol (Ultram) is for severe breakthrough pain & often used in place of opioids
  • It is not a true narcotic but can be habit-forming with long-term use.
  • Avoid if history of seizures
Simethicone
  • Simethicone (GasX) 40 to 125 mg every 8 hours as needed for gas pain & bloating
  • Do not exceed 500mg in 24 hours; this is sold over-the-counter

Hygiene

  • You may shower and use soap and water on surgical site incisions, the day after surgery
  • Keep dressing clean and dry for 24 hours, you may replace as needed for drainage
  • Do not swim or soak; no hot tub, pool, beach, lake, etc. for at least 7 days

Constipation

  • Post-operatively & within 2 days, should be having regular, soft bowel movements (BMs)
  • Hydrate & drink plenty of water (8 –10 glasses per day)
  • PEG 3350 (Miralax) 17g by mouth each day for BMs each day

Other alternative recommendations, as needed – Use at least one if have not had a BM for 2 days:

  • Magnesium Hydroxide (Milk of Magnesia) 15 – 30 mL by mouth once a day, as needed
  • Magnesium Citrate 200 – 300 mL by mouth once a day, as needed
  • Docusate (Colace) 100mg by mouth twice a day, as needed

Activity

  • Ambulate and increase activity as tolerated post-operatively
  • Simply walking often improves mentation, decreases pain & bloating, and improves BMs
  • Avoid heavy lifting (greater than 20 pounds) until follow-up after laparoscopic and open surgeries
  • Avoid prolonged straining and strenuous activity until follow-up
  • Wear your abdominal binder after hernia repair
  • Resume all home medication as directed

Wound Care

  • The raised, firm area called a healing ridge is normal, and should resolve over time
  • Remove your dressings/bandages 2 days after surgery, unless told otherwise by Dr. Ford himself
  • You may shower and use soap & water on surgical site incisions, the day after surgery

David W. Ford, MD, FACS

Vail Health Clinics
108 S Frontage Road W
Suite 5900
Vail, CO 81658
(970) 479-5036
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