Adrenal Surgery can be Performed 8 Different Ways Depending on Skills and Experience of the Surgeon

Adrenal surgery can be performed eight different ways. Some are MUCH better than others but which one you get will be determined by the experience of your surgeon, and NOT what is best for you. You must do your homework! Here we provide an overview of the 8 very different surgical techniques and methods a surgeon can use to remove an adrenal gland or adrenal gland tumor. As you will read, some of these techniques are still commonly used, but should not be! Surgeons without much experience perform adrenal surgery in ways that they learned to performe gallbladder or hernia surgery and these techniques should not be used for adrenal surgery.

It is unfortnuate that 90% of adrenal surgery is performed by surgeons who do less than 4 or 5 adrenal operations per year. They almost always use techniques that are out-dated or not the best choice, and the patients suffer because of it. Please chose your adrenal surgeon wisely--your local general surgeon or urologist is very likely not the best choice for you.

The 8 Good and Bad Techniques for Adrenal Surgery:

#1) Mini Posterior Retroperitoneal Scope Adrenalectomy (Mini-PRSA) (The Mini-Back Scope Adrenal Operation). This minimally invasive adrenal operation is performed with 2 small scopes placed through the lower part of the patient's BACK (on the sides of the lower back because the arenal glands are in the very back of the abdomen). Thus we also refer to this operation as the Mini-Back-Scope-Adrenalectomy. This mini-scope surgery is preferable for the vast majority of adrenal tumor patients, as it uses an endoscope and very small incisions (less than 1/2 inch). The Mini-Back-Scope-Operation is the preferred operation for more than 95% of patients with adrenal tumors. Please do not have any of the other options which most people get because their surgeon does not know this most advanced procedure. This is the mini-scope adrenal operation that Dr Carling does on about 95% of his patients and these operations usually take him less than 35-40 minutes. We have two complete pages dedicated to the Mini BACK Scope Adrenalectomy, and its benefits.

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#2) Laparoscopic Trans-Abdominal Adrenalectomy (LTA). This is a laparosocpic operation (done with scopes) that goes through the front of the abdomen. This is the adrenal operation that most surgeons with little expertise in adrenal surgery perform. It is simply a modification of the laparoscopic operation they perform for gallbladder and hernia surgery. This is NOT the best adrenal operation for 95% of people, but it is by far the most common adrenal operation performed because 90% of adrenal operations are performed by surgeons who are not experts in adrenal surgery and perform 4 or fewer (yes four or fewer) adrenal operations per year. There are no expert adrenal surgeons who perform adrenal surgery with this method. Dr Carling uses this method in less than 1% of the hundreds of adrenal surgeries he performs each year. Yet it is the most common adrenal operation because non-experts who have zero specialized training in adrenal surgery are doing most operation. You should avoid this operation and find a surgeon with more expertise.

Another unfortunate fact is that the most commonly performed adrenal operation (the laparoscopic adrenal operation that goes through the FRONT of the abdomen) is NOT the best operation for almost every patient. The best operation for almost every adrenal tumor is the laparoscopic approach through the patient's BACK.

This laparoscopic-tans-abdominal adrenal operation does allow small to moderately sized tumors to be removed using scopes and small incisions. This technique is tolerated well and because it is done with scopes, the surgeons who do this operation will call it "minimally invasive adrenal surgery". Compared to the Mini Posterior Retroperitoneal Scope Adrenalectomy (the Mini-BACK-scope operation), patients tend to have more pain after the operation, longer hospital stays, longer time of recovery and slower return to work and normal activities.

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To summarize, the best operation for almost everybody is 1) a minimally invasive SCOPE operation, and 2) the scopes go through the patient's lower BACK and not through the patients front abdomen.

#3) Laparoscopic Hand-port Assisted Trans-Abdominal Adrenalectomy. This surgical approach to adrenal tumors is a hybrid between laparoscopic transabdominal adrenalectomy (LTA) and Open Standard Trans-Abdominal Adrenalectomy. The positioning of the patient, and approach is similar as the laparoscopic transabdominal adrenalectomy (LTA). This approach is appropriate for larger tumors (>7-12 cm) and tumors which are suspected or known to be malignant or very large, aggressive pheochromocytomas. Also, this approach may be used dependent on the patient’s body habitus (especially obesity). This is the preferred operation that the adrenal surgery experts like Dr Carling use for patients with very large adrenal tumors. This operation is NOT the preferred method to remove small adrenal tumors which makes up about 95% of patients with adrenal masses. We have videos of Dr Carling performing this operation.

#4) Open Standard Trans-Abdominal Adrenalectomy. In this adrenal operation, the surgeon approaches the adrenal glands through an incision on the anterior abdominal wall. Think of this as a typical, old-fashioned operation where a large incision (usually about 10 inches) is made and the surgeon moves the bowel and other organs out of the way to gain access to the kidney and adrenals.

This approach through the front of the abdomen should only be used for large adrenal tumors (>12 cm, more than 5 inches) and those adrenal massses/tumors which are suspected or known to be malingnant (cancerous), especially if the tumor is invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel, or major vessels such as the inferior vena cava (IVC). Dr Carling only uses this standard trans-abdominal operation for these large, cancerous adrenal tumors. If your surgeon has planned to perform this operation and you have a small tumor (less than 3 cm) then you need to get a second opinion. This likely would only be done in this instance if your surgeon is not an expert at adrenal surgery and that is all he knows.

#5) Open Thoraco-Abdominal Adrenalectomy. This approach allows the greatest exposure to the adrenal gland and all the surrounding structures and therefore is only used for the very largest adrenal tumors and masses. This approach entails making a large incision which traverses both the abdominal and thoracic (chest) cavities, including some the diaphragm which separates them. This large operation is reserved for only the largest and most malignant tumors of the adrenal gland in hopes of providing adequate exposure of the tumor and its blood supply to allow curative resection. This approach is primarily used for large tumors (>12 cm, 5 inches) and tumors which are suspected or known to be malignant, especially if they are invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel, or major vessels such as the inferior vena cava (IVC).

#6) Open Posterior Adrenalectomy. The posterior approach gains access to the adrenal gland through an incision in the back overlying the top of the kidney. This operation is now more of historical interest since the introduction of the Mini Posterior Retroperitoneal Scope Adrenalectomy (Mini-PRSA).

#7) Open Retroperitoneal Adrenalectomy. The retroperitoneal approach combines the better tolerated advantages of the posterior approach with the greater exposure gained by the anterior trans-abdominal approach. This operation is now more of historical interest since the adoption of the Mini-Posterior Retroperitoneal Scope Adrenalectomy (Mini-PRSA). This operation is out-dated and you should not have it. There are no scopes, but you get a large incision on your back.

#8) Robotic (Robot-Assisted) Adrenalectomy. Robot adrenal surgery uses a surgical robot to expose and remove the adrenal gland. Robotic adrenal surgery started in about 2003 but it is NOT the preferred way to remove an adrenal tumor and was abandoned by all of the experts by 2010. This approach is similar to Laparoscopic Trans-Abdominal Adrenalectomy (LTA) and the Mini Posterior Retroperitoneal Scope Adrenalectomy (Mini-PRSA), except that the surgeon uses a robot to run the scopes and dissecting instruments instead of using these instruments with his/her hands. Again, the difference is that the surgeon has to rely on a robotic system (robot-assisted) approach. The reason the surgeon would use this technique it is usually due to inexperience with adrenal surgery, and not having performed enough minimally invasive adrenal operations; “scope-adrenalectomy”. Again, Robot Adrenalectomy is NOT the preferred way to perform adrenal surgery and very few people benefit from this.

It is possible that robotic surgical systems in the future will become significantly better, more minimalistic, become less expensive, and cumbersome without the current potential increased harm to the patient. Thus, the surgeons of the Carling adrenal center do not perform and do not endorse robot-assisted adrenalectomy. These operations are typically performed by general surgeons and urologists who use the robot to do other operations and they are simply adapting the robot to the adrenal operation. All of the high-volume adrenal surgery experts in the world abandoned robotic adrenal surgery over a decade ago. None of the high-volume experts perform robot adenal surgery.

What Adrenal Operation is Best for Me?

The best adrenal operation depends on the problem that needs to be fixed. Since 95% of patients with adrenal tumors have a small tumor that is not cancerous, the best adrenal operation for 95% of people is the Mini Posterior Retroperitoneal Scope Adrenalectomy (Mini-PRSA), also called the "Mini BACK Scope Adrenal Operation". There are a number ofactors which an expert adrenal surgeon will consider to determine which adrenal operation will be performed on any particular patient:

  • The size of the tumor
  • The type of adrenal tumor
  • The appearance of the tumor on CT, MRI, PET or other imaging studies
  • A history of previous abdominal operations
  • The surgeon's experience with different operations
The decision to use one of these different operations to remove an adrenal mass depends on several different factors. Each of these factors is important and will be considered by the surgeon prior to beginning the operation. In fact, occasionally a surgeon will start the operation using a smaller or even minimally invasive approach and decide at one point during the operation that to be safe and to assure the best chance of cure that the approach should be altered. For instance, in tumors suspected or known to be malignant, especially if they are invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel, or major vessels such as the inferior vena cava; IVC. Conversion to a larger incision is not only appropriate, it is done in the best interest of the patient.

Please do your homework before you have adrenal surgery. Very few surgeons perform 3 or more adrenal operation per year and therefore you are very likely to have a surgeon who is not exert at this operation and you will get an operation that the surgeon knows how to do, and verly likely NOT the operation that is best for you. If you came this far and somebody you know needs an adrenal operation, the next pages for you to read are: