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Open adrenal surgery can be done through three types of approaches: anterior, posterior, or thracoabdominal. Open adrenalectomy is preferred when there is a very large adrenal tumor or the adrenal tumor is at high risk of cancer. Patients having an open adrenalectomy will stay in the hospital for 5-10 days after surgery.
Multiple small incisions are made in the abdomen, a camera and instruments are used to remove the adrenal gland. Patients will leave the hospital in a day or two following surgery.
Cortical Sparing Adrenalectomy
This surgery involves removal of just the adrenal tumor and a margin of normal adrenal gland tissue surrounding the tumor. This approach is possible if the tumor is small and the tumor is clearly not cancer.
The surgery approach is dependent on factors, such as size, features, and appearance of the tumor, if the patient has had previous abdominal surgeries, and patient body type.
Adrenal surgery is typically done with general anesthesia. You will have a breathing tube in place during the surgery, which is removed after surgery prior to you waking up. Patients having an open adrenalectomy will stay in the hospital for 5-10 days after surgery. Patients will leave the hospital in a day or two following laparoscopic surgery.
Risks of Surgery
In the hands of an experienced adrenal surgeon, adrenal surgery is a safe procedure with few complications.
In general, complications are higher in open adrenalectomies than laparoscopic adrenalectomies. In open adrenalectomies, the common complications are lung related. Pneumonia and atelectasis occurs in approximately 6% of open adrenalectomies. As with other surgeries, there is a risk of wound infection, bleeding, and blood clot formation in the veins of the legs. Blood clot formation risk is reduced by wearing stockings that periodically compress the legs, injections of mild blood thinner, and walking frequently after surgery. After any surgery in the abdomen, the intestines "fall asleep" and do not work as they should. This will get better in a few days and improve as time goes on after surgery.
Adrenal insufficiency is a life-threatening condition where the body is not making enough steroids. Patients that get only one of the adrenal glands surgically removed and their other adrenal gland is normal have a low risk of developing adrenal insufficiency. There is an increased risk of adrenal insufficiency in patients with Cushing's Syndrome because the adrenal gland that is normal and left intact is often not working properly from being suppressed for a long period of time due to the adrenal tumor excreting large quantities of hormone. Adrenal insufficiency can also occur if both adrenal glands are removed and the patient is not receiving enough steroids post-operatively. Patients are monitored closely after an adrenalectomy for adrenal insufficiency.
Injury to Surrounding Organs
Rarely, the organs or blood vessels surrounding the adrenal glands will be injured when they are moved during surgery to gain access to the adrenal glands for removal. The left adrenal gland is surrounded by the colon, kidney, pancreas, spleen, stomach, and blood vessels. During left sided surgery, although rare, the spleen is the most commonly damaged organ and may need to be removed. Also during left sided surgery, the blood vessels supplying the kidney are also at risk. Damage to the kidney blood vessels may result in hypertension. The right adrenal gland is surrounded by the colon, kidney, liver, pancreas, small intestine, and blood vessels. On the right side, the liver and duodenum (first part of the small intestine) are most at risk.
Prior to surgery, you will need to have a pre-surgical evaluation to be sure you are healthy enough to undergo surgery. This evaluation is done by our peri-operative prep center (link) or your primary care physician. You will have blood work done and depending on your age and/or medical history may need other testing, such as an EKG or chest x-ray. If you have a history of significant cardiac or pulmonary conditions, you may need to get clearance from your medical specialist to continue with surgery.
Pre-operative imaging in the case of adrenal masses is critical in planning the surgical procedure. Pre-operative CT or MRI will provide critical information to the location of the mass, involvement of surrounding structures, mass size, and possibility of metastatic disease in the case of adrenal carcinoma. This imaging may also help to differentiate between a concerning mass and a simple benign tumor.
Most patients will be eating, drinking, and walking around the night of their surgery. Patients that have had an open adrenalectomy may need to wait until the next day or two days to eat and drink.
Patients that have a laparoscopic adrenalectomy will have mild pain after surgery that can usually be controlled by non-narcotic pain medications, such as Tylenol or ibuprofen. Patients that have an open adrenalectomy may require pain control with narcotics.
A light bandage consisting of a gauze pad and a clear plastic covering will be placed over your incision after surgery. This bandage may be removed 48 hours after surgery. If you have steri-strips on your incision, leave them in place until they begin to fall off naturally. If they have not fallen off in 7-10 days, you may gently remove them.
If staples were used to close your incision, leave them in place, they will be removed on your follow up clinic visit. Your incision may be sensitive so avoid tight restrictive clothing. You may feel a firm ridge directly under the incision. This is normal and will soften and go away when healing is complete usually in 3-6 months.
All incisions are sensitive to sunlight. The ultraviolet light of the sun and tanning booths will darken the scar area in the first year. Always use sunscreen.
You may shower the day after surgery. Try not to get the bandage totally soaked. Once the bandage is off, it is still OK to shower. Still, try not to totally saturate the incision. You should not go swimming or soak in a tub or hot tub until your surgeon tells you it is okay.
You may eat whatever you choose. You may prefer softer foods and liquids initially if you have a sore throat. Advance your diet as you see fit. Make sure you stay hydrated. Your appetite may be decreased right after surgery, but will improve with time.
This is normal to experience after surgery and will often last up to 5 days after surgery. Lozenges and a softer diet may be helpful until this resolves. You may also feel like you have phlegm in your throat and need to cough. This is due to the irritation of the tube in your windpipe during surgery. It should clear up in 4-5 days.
Pain Management at Home
Take NSAIDS like ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve) or acetaminophen (Tylenol) for the first 3-5 days as needed. Take medication as directed on the medication container. To prevent acetaminophen overdose, do not take acetaminophen when you are taking the pain reliever - Percocet - that was prescribed on your discharge from the hospital. They both contain acetaminophen.
If you take the Percocet or any other narcotic - DO NOT drive a car or drink alcohol. If you are taking Percocet or any other narcotic, they can cause constipation and you may need to take a stool softener, such as Colace.
Back to Normal Activities
Patients with cortisol-producing tumors or Cushing's Syndrome will need to take steroid pills after surgery. The steroid dose will slowly be decreased over time as the remaining normal adrenal gland resumes adequate function and production of steroids.
If you had both adrenal glands removed or the remaining adrenal gland is not working properly, you may need to take steroids to replace the hormones that were previously made by your adrenal glands. These steroids may be essential for life so you should never stop them before contacting your doctor.
When to Notify Our Office
You should call our office if you experience the following symptoms:
If you have trouble breathing, call 911 immediately.
Follow Up Visit
Your post-operative appointment will be scheduled for 1 or 2 weeks after your surgery. Please call 410-328-6187 to make the appointment.
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