Related: Adrenal Conditions | Adrenocortical Carcinoma | Adrenal Crisis | CT Scan | Cushing's | Endoscopic | Hyperaldosteronism | Insufficiency | Laparoscopic | Pheochromocytoma | Scar Gallery | What are Adrenal Glands?
Endoscopic (also known as laparoscopic) adrenal surgery can be performed through the front of the abdomen (transperitoneal adrenalectomy) or through the back (retroperitoneal adrenalectomy). Endoscopic surgery refers to the technique of using fiberoptic cameras and specialized instruments to perform minimally invasive operations.
Dr. Livhits and Dr. Yeh performing single-incision retroperitoneoscopic adrenalectomy.
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Port used for single-incision retroperitoneoscopic adrenalectomy. Patient is positioned lying on their abdomen.
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Appearance of scar immediately following single-incision retroperitoneoscopic adrenalectomy.
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Appearance of scars 2 weeks after single-incision retroperitoneoscopic adrenalectomy.
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18F-DOPA scan showing a 3cm right pheochromocytoma. This whole-body scan performed at UCLA has superior resolution of the adrenal anatomy and confirms the absence of metastatic disease. This patient underwent single-incision retroperitoneoscopic adrenalectomy.
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Evolution of Adrenal Surgery
Prior to the 1990s, adrenal surgery was performed through a large (8-12 inch) incision and required a hospital stay of approximately one week. Open adrenalectomy is still required for patients with adrenal cancer.
During the 1990s and 2000s, laparoscopic transperitoneal adrenalectomy became adopted by expert centers across the nation. This was a major advance that greatly reduced pain, complications, blood loss, and recovery time for patients.
Laparoscopic transperitoneal adrenalectomy is generally done using 4 small “band-aid” incisions through which ports are placed to accommodate the endoscope and instruments. This technique remains widely used today and continues to be a part of our practice for patients with extremely large adrenal tumors. Endoscopic adrenalectomy using a posterior (retroperiteonal) approach was developed by Walz and associates from Essen, Germany. This technique is done using 3 small "band-aid" incisions on the back. In the late 2000s and particuarly since 2010, this technique has been gradually disseminated across the globe and is currently available at a small number of expert centers. Retroperitoneoscopic adrenalectomy was adopted by UCLA in 2013.
In our continued pursuit of improved surgical techniques, endocrine surgeons at UCLA (most notably Dr. Masha Livhits) began performing retroperitoneoscopic adrenalectomy through a single 2.5 cm (1 inch) "band-aid" incision in early 2015. At present, we are the only center in the United States offering this new operation.
Eligibility for Single-Incision Retroperitoneoscopic Adrenalectomy:
Am I eligible for this new technique?
Almost everyone is eligible for single-incision retroperitoneoscopic adrenalectomy (SIRA). At most other centers, retroperitoneoscopic adrenalectomy is reserved for lean patients with small adrenal tumors. At UCLA, we have had success performing SIRA on a wide variety of patients (lean, overweight, and obese) with a wide variety of tumors (small and large) and believe that 90% of patients are eligible for the new technique.
Indications for Adrenal Surgery:
When is adrenal surgery necessary?
Adrenal tumors are relatively rare. Hence, it is uncommon for even expert centers to perform more than 10 or 20 adrenal operations per year. At UCLA Endocrine Surgery, we perform 1-2 adrenal operations during the average week. Adrenal surgery is necessary for two reasons: overproduction of adrenal hormones or large size. Overproduction of adrenal hormones often causes high blood pressure (hypertension), which may be seen in pheochromocytoma (adrenal tumor releasing catecholamines - hormones such as adrenaline) and primary hyperaldosteronism.
Cushing's syndrome is a rare but extremely dangerous condition arising from overproduction of cortisol (a stress hormone) that causes high blood pressure, diabetes, weight gain, and weakening of the immune system. Cushing's syndrome may be caused by tumors of the adrenal gland or pituitary gland (the "master gland" at the base of the brain).
If you have difficult-to-control hypertension, you may have an adrenal tumor, especially if your blood potassium level has been found to be low. In other words, adrenal tumors may be discovered when doctors are trying to find an explanation for difficult-to-control hypertension.
More and more adrenal tumors are now discovered incidentally - meaning, an adrenal tumor is found by chance in a patient who undergoes a CT scan or MRI of the abdomen for an unrelated reason. Though most of these "adrenal incidentalomas" ultimately require no treatment, some of them can pose a health threat and therefore all must be carefully evaluated.
What are the Advantages of Retroperitoneoscopic Adrenalectomy?
We have been performing retroperitoneal adrenalectomy at UCLA through a single incision since early 2015. We are the only center in the United States that has significant experience with this minimally invasive technique.
The operation is performed under a general anesthetic, with the patient positioned lying on their belly on a specially padded operating table. A single 2.5cm incision is made just beneath the bottom rib on the back, on the same side as the adrenal mass. A fiberoptic camera and two laparoscopic instruments are placed through this incision. The operation usually lasts 1.5 hours.
Most patients spend the night in the hospital and go home the next morning. There is little pain after this operation, and patients can usually go back to work within a few days. Full recovery occurs quickly.
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