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Why robotic adrenal surgery is not recommended

Robotic adrenal surgery is not recommended.

At the Carling Adrenal Center we do not use a robot for adrenal surgery. In our view, the robot adds cost and operating time without benefit for the patient. Some surgeons recommend robotic adrenal surgery because they usually use the robot for other operations, such as prostate surgery, which is a completely different type of surgery. If your surgeon recommends robotic surgery, we are here to explain why we believe you should ask about other options. This blog explains why we do not recommend robotic adrenalectomy.

Figure 1: In our view, robotic adrenalectomy and robotic adrenal surgery add cost without benefit. The typical surgeon who performs adrenal surgery does about one adrenal operation per year; Dr. Carling performs up to 750 adrenal operations a year. 

When considering adrenal surgery, there are two fundamental approaches, open or minimally invasive (laparoscopic or robotic). The open approach is typically reserved for very large tumors or known or suspected adrenal cancers that may be invading surrounding structures.  Under the minimally invasive umbrella, there are the laparoscopic and robotic approaches that go through the belly (trans-abdominal), or the scopes that go through the back (Mini-Back Scope Adrenalectomy, or MBSA). The Mini-Back Scope Adrenalectomy is, in our experience, the best option for the great majority of patients (we use it for more than 95% of our operations) and should be the option you ask about first.

We’ve discussed elsewhere at length the MBSA and its several advantages over the other minimally invasive trans-abdominal options. Robotic adrenal surgery is a technique adapted from surgeons that have used the robot elsewhere, namely in pelvic surgery: prostate, rectum, and uterus. The idea behind the robot is to give the surgeon the fine motor skills in tight spaces not typically afforded by the standard laparoscopic instruments. While the robot is excellent for these deep pelvic operations, and in particular remote access to the thyroid gland, avoiding a visible neck scar, the robot is not a great option for adrenal surgery.

Figure 2: We do not recommend robotic adrenalectomy and robotic adrenal surgery. The robot is, however, a great tool for scarless thyroid surgery as Dr. Suh (Dr. Carling’s partner and good friend) performs it. More on Dr. Suh and robotic thyroid surgery.

Robotic adrenal surgery takes longer and is more expensive

We do not recommend robotic adrenal surgery. A robot is not needed to perform an adrenal operation well: at the Carling Adrenal Center, Dr. Carling typically performs the Mini-Back Scope Adrenalectomy in about 20 minutes. Robotic adrenal surgery takes significant time to “dock” (set-up) the robot to use. Meanwhile, the patient is asleep, under general anesthesia.  In the time it can take to set-up the robot and change its instruments, the mini-back scope adrenalectomy can be well under way! A robotic adrenalectomy typically takes 3 to 5 hours. The longer the anesthesia time, the greater is the risk of complications such as blood clots, heart attacks, stroke, etc. In many things, and surgery is no exception, time is money. The most expensive piece of real estate in the hospital is the operating room. The longer time it takes for the surgeon to complete the surgery, the more overall cost of the operation. Further, longer operative times are associated with higher complication rates (risk of infection, increased blood loss, and anesthesia-related complications). Longer anesthesia times correlate with increased risk of post-operative nausea, disorientation, sleepiness, imbalance, memory loss, and other related complications from anesthesia.   

Robotic adrenal surgery through the belly is more painful, and the scars are bigger

Robotic adrenal surgery causes bigger scars. The ports are bigger than the ones used with the Mini Back Scope Adrenalectomy (MBSA).  Larger incisions (as encountered with robotic adrenal surgery) cause more postoperative pain, longer hospital stays, and longer time until return to normal activities and work. The reason robotic adrenal surgery is more painful than the MBSA is that the incisions are through the abdomen, passing through the muscles of the belly. This can lead to significant post-operative pain. Oftentimes, to make the pain bearable, narcotic pain medications are required.  Narcotics can not only cause dependency and addiction (we all know about the opioid epidemic in our country), but can also slow down bowel function, leading to higher rates of constipation. Not surprisingly, constipation after an operation leads to even more pain.

Increased pain = longer hospital stay = slower recovery, after robotic adrenal surgery, when compared to the MBSA.  More extensive surgery (longer anesthetic times, greater dissection to reach the adrenal glands sitting in the back of the abdomen), typically results in longer hospital stays when compared to the overnight stay after MBSA. In addition, it takes longer to return to normal activities such as walking, running, biking, tennis, golf, skiing, and other enjoyed physical activities.

Figure 3: Compared with the Mini-Back Scope Adrenalectomy, robotic adrenalectomy and robotic adrenal surgery through the belly mean more pain, longer anesthesia time, a longer hospital stay and scarring in the abdomen, with risk of hernia formation.

Robotic adrenal surgery can cause scarring inside the belly and hernias, both of which can lead to bowel obstruction

Since robotic adrenal surgery, like laparoscopic adrenal surgery, is performed through the belly (trans-abdominal), the scars are not only greater through the skin and abdominal muscles, but also increased within the abdominal cavity. Belly scarring occurs from entering the abdomen surgically. The scarring is greater when a greater number of organs are manipulated. With the robotic instruments and scope (camera) going through the front of the abdomen (and with the adrenal glands sitting in the back, on top of the kidneys), the bowel, spleen, liver, and pancreas must be manipulated (increasing the potential for injury) just to visualize the adrenal glands.

Robotic adrenal surgery through the belly has the surgeon dissecting the small bowel (duodenum), the right colon, the liver, the vena cava, and the right kidney, just to get safe access to the right adrenal gland. On the left, the spleen, stomach, pancreas, left kidney, and left and transverse colons must be dissected. More dissection = more surgery, with more potential for problems and blood loss. This is a very important concept to understand.

Since intra-abdominal adhesions (scars) form from undergoing belly surgery if you have had prior

  • cholecystectomy (gallbladder removal)
  • bariatric surgery (gastric band, sleeve gastrectomy, gastric bypass)
  • liver, stomach, or pancreas surgery
  • bowel surgery (colectomy, appendectomy, etc.)
  • gynecological operations (C-section, hysterectomy, ovarian cyst excision, etc.)

the robotic adrenal surgery will force the surgeon to face this belly scarring before addressing the adrenal gland tumor. Cutting through these scars from the previous operation is risky to finally allow manipulation of the organs needed to reach the ‘back-located’ adrenal glands. In fact, robotic adrenal surgery through the belly will cause future intra-abdominal adhesions (scarring). The old surgical adage holds true, “surgery causes scarring, and scarring can cause more surgery.”

The number one reason for bowel obstruction, a devastating post-belly surgery complication, is adhesions (scarring from previous surgery). Bowel obstruction can cause vomiting, dehydration, emergency room visits, X-rays and CT scans, decompression tubes, hospitalizations, and need for additional surgery to break-up the scar tissue.

Robotic adrenal surgery is particularly not recommended if you have had previous abdominal surgery. Why would you want your surgeon to put you at increased risk while having to deal with any scarring, if the Mini-Back Scope Adrenalectomy is an option?

Another potential complication of intra-abdominal surgery is developing a hernia. A hernia is a defect (hole) in the abdominal wall. After any operation going through the belly, there can be a hernia if the abdominal wall does not heal properly after being violated. A hernia is another common cause of bowel obstruction, since the small bowel can become trapped within the abdominal wall defect, leading to a kink in the bowel. Similar to when a garden hose gets a kink, the water (bowel contents) cannot flow freely, leading to a back-up upstream from the kink, or obstruction.

Having the MBSA, 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.

With all that we discuss, let's summarize...

Reasons why we do not recommend robotic adrenal surgery through the belly, compared with MBSA:

  • Longer operative times (more time under anesthesia)

  • Increased cost

  • Increased pain (longer recovery and delayed return to activities and work)

  • Bigger incisions (increased risk for hernias, bowel obstruction)

  • Intra-abdominal (belly) adhesions (scarring), leading to bowel obstruction

If your surgeon is discussing robotic adrenal surgery, when you know MBSA can offer you a quicker surgery, with quicker recovery times and no belly scarring, consider consulting with a surgeon with extensive experience in adrenal surgery. To be clear, we believe using the robot for adrenal surgery adds cost without benefit, and that it is often used for marketing. Dr. Carling has performed robotic adrenal surgery and found it time-consuming and of no benefit to the patient. 

Robotic adrenal surgery is often offered by surgeons who do not perform the MBSA. Again, we believe the best adrenal operation for most patients is the Mini-Back Scope Adrenalectomy (MBSA). The access is through the back, allowing the adrenal gland to be encountered and dissected within minutes. The entire MBSA typically takes about 20 minutes.

Figure 4: The robot is helpful in some gynecological, prostate and scarless thyroid operations, but in our view it adds cost without benefit for adrenal surgery and adrenalectomy.

Additional Resources: 

Author

Dr. Andrew Rhodes, DO, FACS, FACOS

Dr. Rhodes is Chief of Surgery at the Hospital for Endocrine Surgery in Tampa, Florida. He is a board-certified endocrine surgeon and a Fellow of both the American College of Surgeons and the American College of Osteopathic Surgeons. He completed his general surgery residency at Mercy Catholic Medical Center in Philadelphia and an endocrine surgery fellowship at Yale University. Before joining the Norman Parathyroid Center in 2020, he served as Director of the Endocrine Center at HCA North Carolina/UNC and spent five years as a surgeon at Walter Reed Medical Center. Dr. Rhodes specializes in parathyroid, thyroid, and adrenal surgery, with expertise in minimally invasive techniques. He has performed thousands of endocrine operations and is recognized for his excellent outcomes and patient-first approach. A decorated military veteran, Dr. Rhodes is married and the proud father of two children.