Who is the Best Adrenal Surgeon for Me?
The best adrenal surgeon is going to be the surgeon with the most experience. Adrenal surgeries are difficult and are complicated by the adrenal hormones they produce. Since surgery is the only possible cure for adrenal tumors, you should find the surgeon with the most experience with all types of adrenal surgery so your specific needs are met. It is well worth your time to find a very-high-volume adrenal surgeon. Lower volume surgeons (performing less than 6 adrenal surgeries per year) may have a complication rate that is 10-20 times higher than a high-volume adrenal surgeon.
Editorial Note: Although some surgeons will tell you that 6 adrenal operations per year makes a surgeon an "expert", Dr Carling’s experience training dozens of endocrine surgeons as the Chief of Endocrine Surgery at Yale University is that a surgeon should perform AT LEAST 50 adrenal operations per year to be a true high-volume surgeon who can offer the best operation with the lowest complication rate and highest cure rate. In the US, there are only a few high-volume adrenal surgeon experts.
The Importance of Surgeon Volume and Experience at Adrenal SurgeryIf you have an adrenal tumor, the most important factor for you to have a good outcome is your choice of adrenal surgeon. Typically, the best adrenal surgeon is the one with the most experience. That does NOT mean the surgeon with the most experience in your city! For almost all people, this means you will need to tavel to another city to be operated on by an expert.
Unfortunately, the median (average) number of adrenal operations performed by adrenal surgeons in the United States per year is… 1 (one). You read that correctly. Most people have their adrenal tumor removed by a surgeon that performs ONE adrenal operation per year. Yes, we are not kidding. Indeed, it would be a joke if it were not for the fact that you, or your loved one depends on having an experienced surgeon for optimal outcomes. When your surgeon tells you he/she is an expert at adrenal surgery because they perform 6 or more adrenal operations (adrenalectomies) per year it is self-serving. This is akin to stating that you are an expert airline pilot if you fly an aircraft only 6 times a year. In a single day, the surgeons of the Carling Adrenal Center may perform more adrenal operations than your average surgeon in a career. It may seem that this paragraph is self-serving with respect to ourselves, but unfortunately, as a referral center for patients world wide, we see complications from low-volume adrenal surgeons EVERY DAY--and it breaks our hearts.
Don't endocrine surgeons perform adrenal surgery? Yes, but unfortunately, a recent publication by several endocrine surgeons showed that endocrine surgeons in the US perform less than 3 adrenal operations per year on average--this clearly does not make them the "best". They concluded that 5 adrenal operations per year would make somebody "high volume". It is our opinion, that nobody would let a surgeon operate on themselves if they knew their surgeon performed 5 of these operations per year. You must ask your surgeon the obvious question: "How many adrenal operations did you perform in each of the last 3 years?". If they can't look you in the eye and give you a satisfactory answer, then please, seek a second opinion. For most of you, this means you will need to travel, but let's face it, few people know anybody that had an adrenal operation.
We realize we cannot operate on every patient in the world needing an adrenal operation, but you should identify the highest-volume adrenal surgeon in your area. Ideally, the best surgeon for adrenal tumors is an endocrine surgeon with a special emphasis on adrenal tumors.
Why are There so Few Adrenal Surgery Experts?The reason there are so few experts who do lots of adrenal surgery is because 1) there aren't many adrenal operations to be done, and 2) there are 4 different types of surgeons who perform an occasional adrenal operation. In any big city, there are 25 surgeons who perform 1 or 2 adrenal operations per year instead of 1 surgeon who performs 100 per year. This is most unfortunate, and frankly, the reason our Center has patients referred to us by doctors all over the world. The following doctors are known to occasionally perform adrenal surgery and who you will get if you don't seek an expert:
- Endocrine surgeons.
- "Minimally Invasive Surgeons" who also perform hernia, intestinal, bariatric, weight loss, gallbladder, gastric, and reflux operations.
- Surgical Oncologists who also operate on breast, melanoma, intestine, liver, sarcomas, pancreas, colon, rectum, and other organs.
- Urologists, who treat urinary tract infections, erectile dysfunction, kidney stones, prostate and bladder problems, as well as kidney disease and tumors.
Which Adrenal Operation is Best for Me? How Does the Surgeon Decide?The best adrenal surgeons will consider a number of factors to determine which adrenal operationis best for each patient as an individual. Although 95% of patients are best served by a the minimally invasive "Scope Back Operation", the surgeon must look at multiple things to make sure the operation chosen is the best in that circumstance. Things to consider include:
- The size of the tumor. Since very large adrenal masses and tumors are more likely to be cancer, they may require a larger incision and a more careful dissection. Unfortunately, it is not uncommon that inexperienced surgeons when operating on adrenocortical cancer or pheochromocytoma violate the capsule of the tumor and cause tumor spillage. This is a big problem since the tumor cells can implant into the surrounding tissue and make the tumor grow back (local recurrence). Additionally, it may be difficult to remove a large adrenal tumor using scopes because the surgeon cannot see around the tumor with the camera. Sometimes, performing a Laparoscopic Hand-port Assisted Trans-Abdominal Adrenalectomy may be beneficial in this scenario. This is discussed on our Eight Types of Adrenal Surgery page.
- The type of adrenal tumor. Many adrenal cancers (whether adrenocortical cancer, malignant pheochromocytoma or paraganglioma) may require a larger incision and therefore must be removed through a larger operation to ensure all the cancer is removed. This is especially true if they are invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel, or major vessels such as the inferior vena cava. Sometimes, cancerous adrenal tumors are not appropriately removed using the new minimal or laparoscopic operations. Many times, we do not know for sure whether the adrenal tumor is cancerous or not until during the operation. An experienced adrenal surgeon will use his/her best judgment to decide which operation is the most appropriate.
- The appearance of the tumor on CT, MRI, PET or other imaging studies. Adrenal tumors are imaged well with various imaging technologies. Cancers tend to look different on these tests than do benign tumors. We have an entire page on imaging of adrenal tumors.
- A history of previous abdominal operations. If a patient has had previous abdominal operations then the laparoscopic transabdominal adrenalectomy (the scope operation through the FRONT of the abdomen) can be more technically difficult or impossible. One of the beautiful things about Mini-Posterior Retroperitoneal Adrenalectomy (Mini-PRSA, or the Mini BACK Scope Operation) is that the surgeon does not enter into the abdominal cavity from the front and does not need to deal with scar tissue (adhesions) from a previous operation. If your surgeon does not routinely use the "Mini-Back-Scope" technique, he/she is unlikely to be experienced or a high-volume adrenal surgeon. We now have a large page dedicated to this new and best technique.
- The surgeon's experience with different operations. Many surgeons do not know how to perform adrenalectomies well. We say this on multiple pages of this website because we see every day patients hurt by their local general surgeon or urologist who have no expertise in adrenal surgery and just adapt an operation that they know how to do (like removal of a gallbladder or prostate) to the removal of an adrenal gland. How in the world are they going to learn how to perform an advanced operation like the mini-back-scope operation when they only do a few a year?
What About the Biopsy of My Adrenal Tumor / Mass?Remember, a biopsy of the adrenal tumor is almost never helpful... Remember our most important rule on this website: DO NOT PERFORM A BIOPSY OF AN ADRENAL MASS. It can be very dangerous to biopsy an adrenal mass or adrenal nodule if the patient has a pheochromocytoma. If the patient has an adrenocortical carcinoma (adrenal cancer) the biopsy may spill tumor cells. The tumor cells can then implant, and cause local recurrence. Also, a fine needle biopsy can never distinguish between a benign and malignant adrenocortical tumor, and is thus a wasteful, meaningless, invasive procedure that may cause significant harm.
A note about previous abdominal surgery. Previous abdominal surgery is NOT a contraindication to advanced minimally invasive adrenal surgery since surgeons who perform these advanced operations are typically supremely excellent at operating through a scope so they can usually deal with the scars inside the abdomen which is a result of previous operations. Intra-abdominal scars (known as adhesions) may be from previous operations, such as bariatric surgery (weight loss surgery), gallbladder surgery, liver surgery, stomach surgery, bowel surgery of any kind (colectomy, appendectomy, etc) or any previous kind of gynecological operations. The presence of abdominal scars and their locations will be considered, however, when deciding who can have a minimally invasive versus open adrenalectomy. Again, whenever possible, the Posterior Retroperitoneal Adrenalectomy (PRSA, Mini-Back-Scope) is the preferred surgical approach for >95% of patients with adrenal tumors.
What You Need to Know in Two Sentences
Many low-volume adrenal surgeons only know how to do the laparoscopic transabdominal adrenalectomy (LTA) (the FRONT scope operation) and do not know Robotic adrenal operation, he/she is likely to be inexperienced or a low-volume adrenal surgeon. You should seek more expertise.
Bottom line about finding the best adrenal operation:The best surgery technique is less about the technology being used, but rather for the patient to identify the smartest, most knowledgeable, thoughtful surgeon who has the most superior understanding of adrenal anatomy, disease, tumors and the one with the most experience in adrenal surgery. Reading the pages of this large website you have come to understand that the adrenal gland and its functions may appear complex, and indeed many patients and doctors struggle to obtain a comprehensive understanding of adrenal function, and adrenal tumor disease. For us at the Carling Adrenal Center, though, this is easy. This is what we do, day in and day out. We live, and breath adrenal tumor disease every day. The number one priority is to achieve a perfect and safe operation without complications, cure the patient, and secondarily do it fast (minimizing anesthesia time), efficient, and with a superior cosmetic result.