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content contributed by Richard M. Newman M.D.
The adrenal glands are small, triangular shaped organs that lie deep in the
back, just above each kidney. Normally, the gland secretes substances that have
many hormonal functions including steroid production and control of blood pressure.
Problems arise in the adrenal glands when conditions produce abnormal secretion
levels of these substances. These hypersecretory tumors of the adrenal gland
are rare, but include benign lesions that can result in serious side effects,
such as very high blood pressure readings. Some tumors of the adrenal gland
are cancerous and require different treatment than functioning benign lesions.
In addition, some adrenal tumors are found by accident, or incidentally, by
tests done for other reasons. These tumors are called "incidentalomas"
and have unique criteria for removal.
The objective of this introduction is to inform patients and their families
about these unusual set of problems associated with the adrenal gland and to
present new treatment options utilizing minimally invasive surgery that can
result in better patient outcomes.
Laparoscopic Adrenalectomy- The Procedure
As demonstrated below, the adrenal gland is very inconveniently placed deep
in the back. It is surrounded by several other vital structures. Approach to
the adrenal used to require a very large incision to safely get to the gland.
It is also important to note that the adrenal gland on the left is surrounded
by different structures than on the right. This presents a completely different
set of challenges to surgeons attempting to approach these two organs. Neither
side is necessarily more difficult than the other, but experience with removing
both is mandatory prior to safely attempting this operation.
In the early 1990s, with the invention of small video cameras and surgical
telescopes, there was a drastic change in general surgery. Many procedures that
used to require large incisions now were being performed with only tiny incisions
because the operation was conducted utilizing long instruments and guided by
video images on a television monitor. The removal of the adrenal gland was first
removed in this fashion in 1992. Advantages of the minimally invasive method
were immediately recognized and are similar to other types of minimally invasive
operations.
The advantages are:
- Less Pain
- Smaller Scars
- Less hospitalization
- Quicker recovery
The laparoscopic approach was soon recognized as the gold standard for removal
of the adrenal glands for most indications.
Indications are listed below and expanded upon in the last section of this
review. They Include:
- Small (less than 8cm) functional tumors of the adrenal gland such as:
- Aldosteronoma
- Pheochromocytoma
- Cortical adenomas
- Incidentalomas
- Isolated metastatic deposits in some malignancies
The Laparoscopic Adrenal Gland Removal Operation
The laparoscopic
adrenalectomy is a technically difficult operation that requires different training
than more commonly performed laparoscopic procedures such as the cholecystectomy.
The surgical approach is different than in the open operation, and, as stated
above, the right- and left-sided adrenalectomiese completely different operations.
The patient is positioned on a special operating table on his or her side with
the affected side up in the air.
 Long,
thin surgical instruments and telescopes are inserted through the abdominal
wall through small (less than 1 centimeter ) incisions. They are used to manipulate
the gland and clip blood vessels in order to remove the organ without any large
incisions
This is how the left adrenal gland appears during a laparoscopic adrenalectomy:
The laparoscopic approach to the right adrenal gland requires the patient to
be on his or her left side. Similar smaller incisions are are made and long
instruments are used to dissect the gland from surrounding structures. The vein
on the right side presents a particular challenge as it is quite large and quite
short. Extreme care must be taken in this crucial step. | 
