Why We Rarely Recommend Laparoscopic Adrenalectomy

In our view, laparoscopic adrenalectomy through the abdomen (belly) is not the best choice for most adrenal gland removal, since the approach through the back is faster and less painful, with a quicker recovery. Despite this, many patients are only offered laparoscopic adrenalectomy. The reason for this is often that their surgeon only performs adrenal surgery rarely and does not offer the approach through the back. The typical surgeon who performs adrenal surgery does about one adrenal operation per year, and more than 80% of adrenalectomies in the United States are performed by low-volume surgeons. Yes, you read that correctly. It is hard to be an expert on something you only do once a year, and outcomes are better with surgeons who do it regularly.

The best advice is to identify an experienced, high-volume adrenal surgeon for your operation. In our experience, the best adrenal operation for most tumors is the Mini Back Scope Adrenalectomy (MBSA). 

Watch me perform this procedure in 20 minutes below.

The Top 5 Reasons Laparoscopic Adrenalectomy Should Be Avoided:

1. The operation takes longer.
2. There is more pain.
3. The patient has to stay longer in the hospital with a slower recovery.
4. The surgeon has to deal with scarring from previous operations, making the operation more difficult.
5. The operation can cause long-term problems with hernias and bowel obstructions.

Laparoscopic adrenalectomy takes longer to perform

Laparoscopic adrenalectomy takes considerably longer than the Mini-Back Scope Adrenalectomy (MBSA). The reason laparoscopic adrenalectomy takes longer is that the operation is done through the abdomen (belly). The adrenal glands are located in the very back of the abdomen on top of the kidneys. That means that the surgeon has to move a lot of organs just to get to the adrenal gland.  On the right side the surgeon has to dissect out and move the duodenum, the right colon, the liver, the vena cava, and the right kidney just to get to the adrenal gland. On the left side a similar dissection has to be performed of the spleen, the pancreas, the left kidney, and the left colon. More dissection means more surgery and more potential for blood loss. Also, longer anesthesia time for the patient can lead to side effects including nausea, vomiting and brain fogginess.

A laparoscopic adrenalectomy through the abdomen often takes one to three hours. Adding a robot does not, in our view, make the operation faster or better; it adds cost. Unless your tumor requires it, we recommend that you don’t have adrenal surgery through your belly.

A Mini-Back Scope Adrenalectomy (MBSA) typically takes about 20 minutes, with very little blood loss.

Learn more about what to expect from adrenal gland surgery.

Laparoscopic adrenalectomy is more painful

Laparoscopic adrenalectomy is more painful than the approach through the back. The reason laparoscopic adrenalectomy is more painful is that the incisions are through the abdomen and pass through the muscles of the belly. This leads to more pain afterwards. Often patients have to take strong pain medications that contain narcotics. The problem with these medications is that not only can they cause dependency, but they also slow down the bowel function leading to a higher rate of constipation. Not surprisingly, if you have constipation after an operation this will create even more pain.

The best option is to have an operation of the adrenal gland that does not require strong pain medication, only over-the-counter Tylenol and ibuprofen. These pain medications do not have the same negative effects on the bowels and do not lead to constipation.

The patient has to stay in the hospital longer and have a slower recovery after laparoscopic adrenalectomy

Patients undergoing laparoscopic adrenalectomy have a longer hospital stay and a longer time until recovery. Again, this is related to the more extensive surgery and the incision being made on the front, through the belly. The dissection associated with laparoscopic adrenalectomy leads to more inflammation, pain and a resulting longer hospital stay. On average, patients stay about a day longer in the hospital after laparoscopic adrenalectomy compared to the Mini Back Scope Adrenalectomy (MBSA). In addition, it takes longer to return to normal activities such as walking, running, playing tennis and golf, skiing, and other physical activities.

During laparoscopic adrenalectomy, the surgeon has to deal with scarring from a previous operation on the abdomen, which makes the operation more difficult

Many patients have had previous operations on their abdomen. This can have been performed because of bariatric surgery (gastric band, sleeve gastrectomy, gastric bypass), surgery of the gallbladder (cholecystectomy), liver, pancreas, stomach, bowel (colectomy, appendectomy) or any previous kind of gynecological operation (Caesarian section, hysterectomy).  What all these operations have in common is that they cause scar tissue in the abdomen. Adhesions are scar tissue that form just from touching and manipulating the bowel, meaning the small and large intestine. Any subsequent operation has to deal with all this scar tissue if you go through the belly. This makes the operation more difficult and there is a risk of causing an injury to the bowel or a perforation of the bowel. Leakage of bowel contents into the abdominal cavity can have catastrophic results if it is not immediately detected.

Laparoscopic adrenalectomy in a patient who has had previous abdominal surgery is, in our view, not the best choice. It is much better to perform the Mini Back Scope Adrenalectomy (MBSA) through incisions in the back where the surgeon does not have to deal with all the scar formation from the previous operations.

Hernias and bowel obstructions can happen after laparoscopic adrenalectomy

We also rarely recommend laparoscopic adrenalectomy because it can cause long-term problems such as hernias and bowel obstructions. After any operation going through the belly there can be a hernia, meaning a defect of the abdominal wall that does not heal up properly. A hernia can cause bowel to get trapped which leads to a bowel obstruction. It is usually the small bowel that gets trapped in these hernias and causes bowel obstruction. A bowel obstruction can make a patient very sick with vomiting and inability to pass gas or bowel movements. Sometimes extensive surgery is needed to treat a bowel obstruction.

Having an operation going through the back avoids these abdominal complications since the operation is designed in such a way that the bowels are not even touched or manipulated. The whole operation is performed behind the abdominal cavity in what is called the retroperitoneum. An operation through the abdomen does remain appropriate for some patients, such as those with very large tumors or known or suspected adrenal cancer.

Read more about the top patients worries concerning adrenal gland surgery. 

Additional Resources: 

Learn more about the Carling Adrenal Center

Learn more about Dr. Tobias Carling

Learn more about our sister surgeons at the Norman Parathyroid Center, Clayman Thyroid Center and Scarless Thyroid Surgery Center