Adrenal Surgery: Frequently Asked Questions

What are adrenal glands?

Adrenal glands are orange-colored glands that are located on the top of both kidneys. Adrenal glands are about the size and shape of fortune cookies, sitting on top of the kidneys like hats. Everyone has two adrenal glands that make several important hormones that are required for healthy life.

Where are adrenal glands located?

Everyone has two adrenal glands, and they are located on the top of both kidneys.

The Right Adrenal Gland: The adrenal gland on the right side is located on top of the right kidney and is very close to the inferior vena cava (IVC). The IVC is the biggest vein that brings blood back to the heart from the entire body. The right adrenal gland is also very close to the liver. The kidney, IVC and liver are very important structures, and it is crucial that the adrenal surgeon is experienced in working around them. The margin for error is a matter of millimeters.

The Left Adrenal Gland: The left adrenal gland is located on top of the left kidney. It is very close to the splenic artery, which is the major artery that goes to the spleen, and the tail of the pancreas. The pancreas is a very sensitive organ that can cause serious illness when it is irritated or inflamed. Thus, once again it is important that surgery in this area is performed very gently by an experienced adrenal surgeon.

FIGURE: A normal adrenal gland demonstrating the adrenal medulla (inner layer), and the adrenal cortex (outer layer). The two different layers produce different hormones.

What do adrenal glands do?

Adrenal glands secrete several types of hormones to help maintain blood pressure, salt balance and help in times of stress. Humans cannot live without adrenal glands, so if both adrenal glands are removed (very rarely necessary), then the patient needs to take medications every day to replace the necessary hormones.

The adrenal cortex produces hormones that control salt balance and blood pressure (aldosterone), the stress response and blood sugar (cortisol), and small amounts of sex hormones (mainly androgens). The adrenal medulla produces hormones involved in the fight-or-flight response (catecholamines, or adrenaline type hormones such as epinephrine and norepinephrine).

What is the function of the adrenal medulla?

The adrenal medulla is responsible for producing catecholamines, or adrenaline type hormones such as epinephrine and norepinephrine. We have all experienced that sudden panic feeling and anxiety when something happens suddenly and unexpectedly, and we get scared. All of a sudden, we have tingles, and we feel like we need to run away or stand up and fight. This is the "fight-or-flight" response, and it is caused by the sudden release of adrenaline from our adrenal glands. (Yes, adrenaline is called this because it comes from the adrenal gland.) What we generically call adrenaline is really two different hormones that the adrenal medulla produces: epinephrine (adrenaline) and norepinephrine (noradrenaline).

What is the function of the adrenal cortex?

The adrenal cortex produces a handful of hormones the body needs, such as aldosterone (for fluid and salt balance) and cortisol (for the stress response and blood sugar). The adrenal cortex also makes small amounts of sex hormones, but this only becomes important if overproduction is present (most sex hormones are produced by the testes and ovaries). The three layers of the adrenal cortex are:

• The zona glomerulosa (ZG) is the most superficial layer of the adrenal cortex and it produces the hormone aldosterone, which controls salt balance and blood pressure.
• The zona fasciculata (ZF) is the middle zone of the adrenal cortex, and it primarily produces cortisol.
• The zona reticularis (ZR) is the innermost zone of the adrenal cortex and it is adjacent to the adrenal medulla. The zona reticularis makes small amounts of weak sex hormones (androgens such as DHEA and DHEA-S), which the body can convert to testosterone and estrogen.

What are Adrenal Symptoms?

There are many symptoms associated with the adrenal gland which are related to the over-production or under-production of the adrenal hormones. Over-production of adrenal hormones is usually due to an abnormal growth of one of the adrenal glands and the symptoms that appear are due to which hormone is being made in excess. Most commonly these symptoms come from a benign adrenal gland tumor, and removing the tumor with a Mini Back Scope Adrenalectomy (MBSA) can often cure or improve them. This website discusses adrenal tumors and adrenal surgery in great detail. Dr. Carling is one of the world's most experienced adrenal surgeons.

When you have an adrenal tumor, you can have numerous symptoms. Many doctors see only a handful of adrenal tumors during their careers, so it is very important for patients to know about the symptoms of adrenal tumor disease. A careful history and physical examination will help identify the signs and symptoms.

High Blood Pressure Symptoms: One of the hallmarks of adrenal tumors is high blood pressure, also known as hypertension. Tumors that overproduce catecholamines (called pheochromocytoma), as well as aldosterone-producing tumors (causing primary aldosteronism, also called Conn's syndrome) and cortisol-producing tumors (causing adrenal hypercortisolism, or AHC, which in its severe form is called Cushing's syndrome) can all cause high blood pressure.

What are the most common problems related to the adrenal glands?

A range of medical conditions can affect the adrenal glands. The most common conditions related to the adrenal glands that we see are adrenal tumors, primary aldosteronism (Conn’s syndrome), adrenal hypercortisolism (including Cushing’s syndrome), pheochromocytoma, adrenal metastasis and adrenal cancer.

Each of these will be detailed below.

Are adrenal tumors common?

Adrenal tumors are common: about 4–7% of adults have an adrenal tumor, more with age. The most common adrenal problem is a benign, non-cancerous tumor inside the adrenal gland. When you have a tumor of the adrenal gland, the first thing you need to figure out is whether it’s overproducing any adrenal hormones. These hormones are aldosterone, cortisol and catecholamines (also known as epinephrine and norepinephrine; adrenaline), and, more rarely, sex-steroid hormones (androgens and estrogens). A tumor that is overproducing any of these hormones is called a "functional" (or endocrine active) tumor. It is called a functional tumor because it is over functioning, i.e. overproducing hormones.

Does the size of the adrenal tumor matter?

Size matters, but size alone does not decide what should be done. Very small tumors (meaning 1 to 2 cm; less than an inch) are almost never cancerous, and the risk of cancer rises as tumors get larger. What matters more is how the tumor looks on imaging and whether it is making too much hormone. A tumor that makes excess hormone should be evaluated for surgery whatever its size. A tumor that makes no excess hormone and looks like a benign, lipid-rich adenoma on a CT scan without contrast (a density of 10 Hounsfield units or less) can usually be watched.

Recommendations: tumors over 4 cm (about 1.6 inches) deserve particular attention, and we often recommend removing them, especially when the imaging appearance is not clearly benign or the patient is young. This is a general guide, and there are exceptions. This is why it is important to seek the advice of experts, especially a surgeon with extensive experience in adrenal gland surgery.

Should the adrenal tumor or adrenal mass be biopsied?

Almost never. A biopsy of an adrenal tumor is rarely needed and rarely helpful, and it can cause significant problems. It must never be done before a pheochromocytoma has been excluded with blood or urine tests (metanephrines), because a needle in a pheochromocytoma can set off an adrenergic crisis (read about adrenergic crisis in the pheochromocytoma and paraganglioma section of this site). If the patient has an adrenocortical carcinoma (adrenal cancer), the biopsy may spill tumor cells into the surrounding tissues. The tumor cells can then implant in these nearby tissues and cause local recurrence, which can decrease the chance of curing the patient. Also, a needle biopsy cannot reliably distinguish between a benign and a malignant adrenocortical tumor. If a biopsy of your adrenal tumor is suggested, ask whether a pheochromocytoma has been excluded first, and consider a second opinion.

The rule is to avoid biopsy of an adrenal tumor. As with all rules, though, there are some rare exceptions. The main time to consider a biopsy is if the patient has another cancer, typically of the lung, kidney, breast, colon or melanoma, an adrenal metastasis is suspected, and the result would change the treatment. This is why patients with adrenal tumors should be seen by doctors who have extensive experience with adrenal tumors. It can be somewhat tricky to know in advance of surgery whether the adrenal mass is cancerous, or not. Fortunately, the vast majority of adrenal tumors turn out to be benign. It is important to understand that sometimes surgery (adrenalectomy) is indicated just to prove that the adrenal tumor is not cancerous.

Do functioning adrenal tumors need to be removed?

In most cases, yes. Not primarily because of the concern for cancer, but because of the damage caused to the body by an excess of these hormones, and adrenalectomy (removal of the adrenal gland) is the only cure. There are exceptions: mild primary aldosteronism, or disease in both glands, is often treated well with medication, and in mild adrenal hypercortisolism the decision is made individually. You can learn more about adrenal surgery on other pages of this website. Dr. Carling performs minimally invasive surgery for functional adrenal tumors almost every day.

What are the symptoms of excess aldosterone secretion (primary aldosteronism, Conn's Syndrome)?

If the adrenal gland is overproducing aldosterone, then you have a disease called primary aldosteronism (PA), also called primary hyperaldosteronism or Conn's Syndrome (Conn syndrome) after Dr. Conn, who first described this disease. The main sign of PA is high blood pressure. Some patients also have low potassium in the blood, which can cause frequent urination, muscle cramps and heart palpitations (feeling your heart racing). Low potassium is not required, though: most patients with PA have normal potassium. Everyone with high blood pressure should be screened for PA with two blood tests, aldosterone and renin. We have an entire section of this website dedicated to the diagnosis and treatment of PA.

Screening matters most if your blood pressure is hard to control, if you’re relatively young, or if you have low potassium or an adrenal tumor. It is important to know that many patients with PA don’t have any significant symptoms. They may feel normal and the only sign is high blood pressure. However, untreated PA is more harmful than ordinary high blood pressure of the same severity: the risk of stroke is about 2.5 to 4 times higher, the risk of heart attack 2.6 to 6.5 times higher, and the risk of atrial fibrillation (an irregular heart rhythm) 3.2 to 12 times higher.

How common is primary aldosteronism (Conn's syndrome, hyperaldosteronism)? 

Primary aldosteronism (PA), also called Conn's syndrome or primary hyperaldosteronism, is much more common than you would think. PA affects an estimated 5–20% of people with high blood pressure (hypertension), and fewer than 1% of cases are diagnosed, so everyone with high blood pressure should be screened with aldosterone and renin blood tests. It is very important to identify these individuals, since treatment lowers the risk of heart disease and stroke: an operation (adrenalectomy, usually a Mini Back Scope Adrenalectomy, MBSA) when one gland is the cause, or medication for mild disease or disease in both glands.

What are the symptoms of excess cortisol secretion (adrenal hypercortisolism, Cushing's Syndrome)?

If the adrenal tumor is overproducing cortisol, you have adrenal hypercortisolism (AHC), formerly called MACS (mild autonomous cortisol secretion) or subclinical Cushing syndrome. Severe AHC is called adrenal Cushing’s syndrome. The symptoms of Cushing’s syndrome include weight gain and central body obesity (you store fat especially around your abdomen). Your face might develop more round features and you develop fat deposits above your collar bones and on your back (called buffalo hump). Patients may develop problems with bruising easily, thin skin and poor wound healing.

Other symptoms of excess cortisol production from the adrenal gland include stretch marks on the skin that tend to be purple (often on the abdomen) and muscle weakness in your extremities (arms and legs). It can also affect how you feel and how your brain works. Excess cortisol can cause depression and anxiety symptoms. It can cause hirsutism in many women (facial hair formation). Many patients with AHC, even mild AHC, have high blood pressure (hypertension) and weak bones (osteopenia and osteoporosis). The blood sugar may be increased, and patients can even develop diabetes. Also, many patients have low potassium and high white blood cell (WBC) counts.

Do all patients with excess cortisol production have symptoms? 

Actually, they do not. Most patients with adrenal tumors that overproduce cortisol do not have the obvious features of Cushing’s syndrome. This is mild or moderate adrenal hypercortisolism (AHC), formerly called MACS (mild autonomous cortisol secretion) or subclinical Cushing’s syndrome. The term "subclinical" meant that there is a hormone disturbance that is not easily diagnosed by a history and physical exam. It is not harmless, however. When a patient with an adrenal tumor has weight gain, hypertension, pre-diabetes or diabetes, or weak bones, these can be due to AHC. This constellation of signs and symptoms often is referred to as metabolic syndrome.

It is very important to identify patients with overproduction of cortisol (whether mild or severe), since adrenalectomy, usually a Mini Back Scope Adrenalectomy (MBSA), is the only cure. It can improve the patient’s quality of life, blood pressure and blood sugar, and in a randomized trial it controlled blood pressure better than conservative care. In mild AHC the decision is made individually, based on cortisol-related health problems, age, surgical risk and patient preference.

What are the symptoms of excess adrenal medulla hormone production (Pheochromocytoma)?

A pheochromocytoma is a tumor growing from the inner part of the adrenal gland (the medulla) and it overproduces fight-or-flight hormones (catecholamines: epinephrine, also called adrenaline; norepinephrine, also called noradrenaline; and sometimes dopamine). Thus, the symptoms of a pheochromocytoma resemble the symptoms of panic and anxiety. Of note, a paraganglioma is a similar tumor to a pheochromocytoma, but it grows from similar cell types outside the adrenal gland, for instance, along the major vessels of the abdomen, in the chest and neck. Paragangliomas can cause similar symptoms.

These are hormones that are involved in our fight-or-flight mechanism. If you ever remember getting scared, you can probably remember your heart racing and beating very hard and your face flushing or getting very pale (pallor) and sweating. This is the function of the fight-or-flight hormones of the adrenal gland. These hormones are produced in the medulla (core; inner layer) of the adrenal gland.

Symptoms of pheochromocytomas often come and go. Many patients with a pheochromocytoma have a variety of symptoms. They can have spells that are extremely variable with differing symptoms each time, but the symptoms typically include heart palpitations, pallor, flushing, tremors, headaches, and sweating. In other words, the patients have a feeling of impending doom and anxiety. They get sweaty and their heart races. These periods of symptoms are often referred to as “spells”.

The symptoms may be completely spontaneous but are sometimes precipitated by a change in posture, anxiety, certain medications, or maneuvers that increase the intra-abdominal pressure (for instance going to the bathroom). The physical signs when you examine patients with pheochromocytoma may include hypertension, which may occur just occasionally (paroxysmal, or spells) or be sustained, as well as orthostatic hypotension (meaning the blood pressure drops when you stand up). Patients may develop tremors, pallor or in extreme cases, even retinopathy (damage to the retina of the eye), fevers, cardiogenic (heart) shock and failure. We have an entire section of this website dedicated to the diagnosis and treatment of pheochromocytomas.

What are the symptoms of adrenal cancer?

Adrenocortical cancer (ACC) can cause many symptoms. Common symptoms are due to a "mass effect", which simply means the tumor is growing big, so it pushes on surrounding structures and organs in the abdomen. This can manifest itself as flank, or abdominal pain or as an increase of girth (a growing waistline). Fluctuations in weight can also be seen, both weight loss and weight gain.

About half of all adrenocortical cancers overproduce cortisol. Thus, patients can develop signs and symptoms of Cushing’s syndrome (See symptoms of Cushing’s syndrome).

Adrenocortical cancer can also overproduce sex steroid hormones (androgens and estrogens). In women, increased androgen can lead to hirsutism (development or increase of facial hair), acne, absence or changes in the menstrual cycle and increased libido (sex drive). In men, increased estrogen can cause gynecomastia (enlarged and tender breasts), problems with libido (sex drive) and erectile dysfunction.

If you have an adrenal tumor and overproduction of sex steroid hormones, this almost always occurs in the setting of a cancerous tumor, so that is very important to know. Aldosterone-producing adrenocortical cancer, although rare, can lead to signs and symptoms of primary aldosteronism (see symptoms of primary aldosteronism). Patients with adrenocortical cancer can also be completely asymptomatic (30 to 50%) but also have hypertension, osteoporosis, diabetes and low potassium. We have an entire section on the diagnosis and treatment of adrenal cancer.

What are rare adrenal problems?

Certain adrenal tumors and diseases are common. In contrast, here is a list of rare adrenal problems:

• Rare tumors/masses of the adrenal gland
• Rare tumors of the retroperitoneum that may mimic an adrenal tumor
• Rare genetic variants of primary aldosteronism (Conn's syndrome)
• Rare genetic variants of adrenal hypercortisolism (Cushing's syndrome)
• Rare genetic variants of pheochromocytoma and paraganglioma
• Rare genetic variants of adrenocortical cancer

There are also a number of rare adrenal masses. The differential diagnosis may include adrenal myelolipoma, amyloidosis, ganglioneuroma, granuloma, hamartoma, hematoma, hemangioma, leiomyoma, lipoma, neurofibroma, adrenal pseudocyst, lymphoma and teratoma.

What are some of the tests I may need for an adrenal mass?

First, in addition to the CT scan you already had, it is important for you to meet with your doctor to assess via a History and Physical Examination (H&P) whether you have any adrenal-specific signs and symptoms of adrenal disease. One of the hallmarks of adrenal tumors is high blood pressure, also known as hypertension. Tumors that overproduce catecholamines (called pheochromocytoma), as well as aldosterone-producing tumors (causing primary aldosteronism, also called Conn's syndrome) and cortisol-producing tumors (causing adrenal hypercortisolism, or AHC, formerly called MACS or subclinical Cushing's syndrome) can all cause high blood pressure.

Many patients with a pheochromocytoma have a variety of symptoms. They can have spells that are extremely variable with differing symptoms each time, but the symptoms typically include heart palpitations, pallor, flushing, tremors, headaches, and sweating. They get sweaty, their heart races and they have anxiety. If the adrenal tumor is overproducing a lot of cortisol, you may develop symptoms of Cushing’s syndrome, such as weight gain around your abdomen, a rounder face, fat deposits above your collar bones and on your back, easy bruising, thin skin and poor wound healing. Milder cortisol excess often causes no obvious symptoms, which is why every adrenal mass needs hormone testing. To read more, see our page on adrenal symptoms.

Second, there are a number of blood and urine tests that need to be measured, each tailored to identify overproduction of any of the hormones, catecholamines (adrenaline), aldosterone and cortisol. To read more, see our page on adrenal lab testing. At a minimum you need to have the following laboratory tests:

Tests for Pheochromocytoma in adrenal masses

Plasma (blood) free metanephrines (high)

AND/OR 24-hour urine fractionated metanephrines (high)

Tests for adrenal hypercortisolism (AHC, Cushing's syndrome) in adrenal masses

1-mg overnight dexamethasone suppression test (DST): a cortisol above 1.8 µg/dL the next morning is abnormal; 1.2 to 1.8 µg/dL is possible AHC and worth repeating

ACTH (low)

DHEA-S (typically low)

24-hour urine cortisol and late-night salivary cortisol are usually normal in mild and moderate AHC, so normal results do not rule it out

Tests for primary aldosteronism (Conn's syndrome) in adrenal masses, if you have high blood pressure or low potassium

Potassium (K+; low in some patients, but normal in most)

Plasma aldosterone (high)

Renin (low)

Aldosterone-to-renin ratio (ARR; high)

Third, the imaging itself is important. A CT scan without contrast measures the density of the tumor: 10 Hounsfield units or less means a lipid-rich, benign adenoma. Sometimes additional imaging is needed, but in most cases a good CT scan is all you need. To read more, see our page on adrenal imaging.

What is an adrenal metastasis?

An adrenal metastasis is a cancer which has spread from another primary site to one or both adrenal glands. This is relatively common in many cancers. Nearly any cancer can spread to the adrenal glands, but some tumors are more likely than others to metastasize to this region. Having a cancer that has spread to the adrenal gland(s), means that the cancer is of advanced, Stage 4. However, if there is no other evidence of spread, the only potential cure is complete surgical removal of the adrenal metastasis. The diagnosis of adrenal metastasis would rightly cause anyone concern, but it is important to note that the condition has a better prognosis than other sites of metastases. Although prospective data (large high-quality scientific studies) are generally lacking, multiple retrospective (backwards looking) investigations have demonstrated that adrenalectomy in selected patients with isolated or oligometastatic (meaning one or few areas of spread) disease from primary sites including the lung, melanoma, and kidney can result in prolonged survival duration and improved survival compared with similar patients who do not undergo adrenalectomy.

What happens if I may need surgery for the adrenal mass?

The majority of adrenal tumors that are found incidentally on CT scan performed at a hospital ER will not need surgery. All will need to have their hormone production measured (a 1-mg dexamethasone suppression test with ACTH and DHEA-S, metanephrines, and aldosterone and renin if you have high blood pressure). A tumor that makes no excess hormone and looks like a benign, lipid-rich adenoma on a CT scan without contrast (a density of 10 Hounsfield units or less) can usually be watched, and your doctor will tell you whether another scan is needed. Surgery is usually recommended if the tumor is producing excess hormone or looks suspicious on imaging. Size alone does not decide, but tumors over 4 cm deserve particular attention.

If you need surgery, your doctors (usually the primary care physician and/or medical endocrinologist) will refer you for surgery. To read more, see our adrenal surgery overview. As you will read, it is very important to have a surgeon who performs adrenal surgery regularly, and unfortunately few surgeons do.

How is adrenal surgery performed?

Adrenal surgery can be performed in several different ways. The specific adrenal surgical technique used will be dictated by the situation at hand. It is crucial that your adrenal surgeon is comfortable with all different techniques of adrenal surgery since a customized, individual approach will give the best possible outcome. Adrenal surgery should be tailor-made for you and your specific tumor.

Most adrenal tumors can now be removed using minimally invasive techniques such as the Mini Back Scope Adrenalectomy (MBSA), which we use for more than 95% of our operations. This operation is also called "Posterior Retroperitoneoscopic Adrenalectomy". In our experience the MBSA is the best operation for most adrenal tumors since it is swift (about 20 minutes), safe, and patients have minimal pain, with a very rapid recovery (up and around walking a few hours after surgery).

In a small number of patients needing adrenal surgery, laparoscopic transabdominal adrenalectomy (LTA), with or without a hand-port, is used, typically when the adrenal tumor is very large.

Very large tumors and tumors that are known or suspected to be cancer, especially if they are invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel, or major vessels such as the inferior vena cava, may need a different approach. For these, an open standard adrenalectomy technique is usually required.

It should be noted that few surgeons have significant experience with all the different adrenal surgery techniques and understand the subtle pros and cons of each approach. This is why you should look for a surgeon who does adrenal surgery regularly. At the Carling Adrenal Center, Dr. Carling personally performs every operation. He has performed thousands of adrenal operations over his career, including more than 2,400 since January 2022 alone, and operates on people from around the world every week.

What kind of surgeons perform adrenal surgery?

Adrenal surgery is performed by general surgeons, endocrine surgeons and urologists. The experience of the surgeon in adrenal operations is, in our view, the most important criterion. Studies show that surgeons who perform many adrenalectomies (removal of the adrenal gland) have fewer complications, and their patients do better after surgery.

The bad news about adrenal surgery. Unfortunately, more than 80% of adrenalectomies in the United States are performed by low-volume surgeons. In fact, the typical surgeon who performs adrenal surgery does about one adrenal operation per year. Outcomes are better with surgeons who do it regularly, so this is a real problem for patients. One of the reasons is that many different types of surgeons each do very low volumes of adrenal operations. Endocrine surgeons (those specializing in adrenal, parathyroid and thyroid disease) tend to have the most experience. We realize we cannot operate on every patient, but you should identify the highest-volume adrenal surgeon available to you. We perform up to 750 adrenal operations a year, about one in eight adrenalectomies in the United States, which makes us one of the highest-volume adrenal surgery centers in the world.

What is the safest adrenal gland operation?

The safety of any adrenal operation is dependent upon the skill and experience of the surgeon doing the operation. The Mini Back Scope Adrenalectomy (MBSA), in experienced hands, involves very little blood loss and is, in our experience, the best operation for the great majority of adrenal tumors. The robot adds time and cost to adrenal surgery without proven benefit (a robotic adrenalectomy typically takes 3 to 5 hours, and a laparoscopic adrenalectomy 2 to 4 hours), and in our view it is not the best tool for this operation. The other advantages of the Mini Back Scope Adrenalectomy (MBSA) operation include that it is faster and avoids the manipulation of the abdominal organs that is required for any operation going through the front of the abdomen (which includes the robotic adrenal operations). All these factors lead to less pain for the patient with a shorter length of stay and a faster recovery and return to normal activities and work. The advantage of less manipulation of the bowel, spleen, stomach, pancreas and other abdominal organs leads to reduced risk of injury to the surrounding organs and major vessels.

What is the best adrenal gland operation for adrenal tumors?

The Mini Posterior Retroperitoneoscopic Adrenalectomy is our preferred adrenal surgery, and we use it for more than 95% of our operations. Since this can be hard to say, our patients typically call it the Mini Back Scope Adrenal Operation, or simply, MBSA.

There are many reasons we prefer this minimally invasive technique for most tumors; very large tumors or known adrenal cancers may need a different approach. The operation is performed with a scope (fiberoptic camera) via three small incisions in the lower part of the back of the patient. Since the adrenal glands are in the very back part of your abdomen, behind all the other organs, getting to them through the back with a small scope and fine endoscopic instruments makes total sense and has many benefits--but few surgeons are trained to do it. It is rarely taught in surgical residency because few training programs see enough adrenal surgery to teach it.

What are the advantages of the Mini Back Scope Adrenalectomy (MBSA)?

By going through the sides of the back the surgeon has a very direct approach to the adrenal gland with the Mini Back Scope Adrenalectomy (MBSA). Dr. Carling was an early adopter of this technique in the United States while he was Chief of Endocrine Surgery at Yale University Medical School and has since used this operative approach in thousands of patients. Note that this is an advanced technique--surgeons who operate on adrenal glands only a few times per year rarely offer it. If your surgeon is going to operate through the front of the abdomen to get to the adrenal gland located in the very back, and you don't have a very large tumor or an adrenal cancer (which is quite rare), then consider a second opinion from a surgeon who does this operation regularly.

Like you, we find it cumbersome to say "Mini Posterior Retroperitoneoscopic Adrenalectomy", so we often just call it the MBSA, or the "Mini Back Scope Adrenal Operation" since it describes the operation pretty well: a minimally invasive technique using a very small scope and fine instruments that go through the lower back to get the adrenal tumor out. In our experience this is the best operation for the great majority of adrenal tumors. We have another page that discusses the benefits of the Mini Back Scope Adrenalectomy (MBSA) and why we prefer it for most patients.

Is it possible to remove only part of the adrenal gland?

There are several circumstances where it is preferable to remove just the adrenal tumor without removing all of the normal adrenal gland with it. This is called an adrenal-sparing (partial) adrenalectomy. The goal is to leave some normal adrenal tissue behind so that we can avoid adrenal insufficiency (not enough adrenal hormones leading to the requirement to take hormone supplements). In other words, removing both adrenal glands would require the patient to take adrenal hormones and other medications every day for the rest of their life. If the surgeon can remove only part of one adrenal gland, preserving some normal adrenal cortex tissue, then the patient may not have to take any adrenal hormones or medications.

Of course, if the patient has two adrenal glands and the surgeon is going to remove just one, then an adrenal-sparing operation is not as necessary. The patient still has a complete normal adrenal gland on the other side--and all you really need is about one-third (30%) of one gland to live normally and not take medications every day. So, the adrenal-sparing operation is most relevant if the patient has tumors or hormone overproduction in both adrenal glands, has a hereditary condition that puts both glands at risk, or has already had the other gland removed.

Read more about adrenal-sparing (partial) adrenalectomy here.

Can an adrenal-sparing (partial) adrenalectomy be performed via Mini Back Scope Adrenalectomy (MBSA)?

Yes, but it requires a surgeon with a lot of experience. In our view, adrenal-sparing (partial) adrenalectomy is better suited to the Mini Back Scope Adrenalectomy (MBSA) approach than to the more traditional laparoscopic transabdominal adrenalectomy (LTA) and open (through the abdomen) adrenal surgery. The Mini Back Scope Adrenalectomy (MBSA) technique is ideal to address patients with bilateral disease (disease in both the right and the left adrenal glands) and can be utilized in patients with, for instance, bilateral pheochromocytomas in the setting of multiple endocrine neoplasia 2A (MEN2A), von Hippel Lindau (VHL) syndrome, or in patients who have had previous adrenal surgery. We have a video of Dr. Carling performing an adrenal-sparing adrenalectomy via the Mini Back Scope Adrenalectomy (MBSA) for you to watch here.

Adrenal-sparing adrenalectomy is a valuable option for patients with genetic syndromes associated with pheochromocytomas. These syndromes include MEN2, VHL, and neurofibromatosis type 1 (NF1), as well as others. Many patients with MEN2A or VHL develop pheochromocytomas in both adrenal glands, sometimes years apart, and these tumors have a low risk of spreading. As such, adrenal-sparing adrenalectomy can remove affected tissue, while leaving behind enough tissue to prevent adrenal insufficiency. The risk of recurrence is low, but lifelong yearly follow-up is needed.

In our view, staged adrenal-sparing Mini Back Scope Adrenalectomy (MBSA) is the best approach for most patients with adrenal hypercortisolism (AHC, including Cushing’s syndrome) due to tumors of both adrenal glands.

Who is a good candidate for an adrenal-sparing (partial) adrenal operation?

The best candidates are patients with tumors or hormone overproduction in both adrenal glands, such as bilateral adrenal hypercortisolism or hereditary pheochromocytomas. Most patients who are thought to be good candidates for adrenal-sparing adrenalectomy (based on preoperative imaging) will be able to undergo it. It is very important to consider the following 4 questions to determine whether an adrenal-sparing (partial) adrenalectomy can be performed:

• What type of tumor the patient has.
• The size of the tumor, as well as its relationship to the adrenal vein, and other structures such as the inferior vena cava (IVC).
• Whether there is sufficient tissue available to save (the tumor is not too big, and the blood supply to the remaining adrenal tissue can be saved).
• Whether the surgeon is skilled enough to do this more technically challenging operation.

Importantly, in a minority of cases, the surgeon can find something during the operation that indicates that an adrenal-sparing adrenalectomy is the wrong operation. Dr. Carling will not compromise the surgical resection margin and put his patients at risk of the disease coming back. This is where experience and surgical judgment play a large role.

What about patients who need bilateral (both) adrenal glands removed?

Removing both adrenal glands completely means taking steroid replacement (hydrocortisone, prednisone, etc.) for life, so we avoid it whenever we can. When adrenal-sparing (partial) adrenalectomy is performed for tumors of both adrenal glands, most patients can be saved from lifelong adrenal insufficiency. In most cases with bilateral tumors, we operate in two stages at least 6 weeks apart, usually removing the entire adrenal gland on one side and performing an adrenal-sparing resection on the other side. However, this has to be individualized in each scenario. The key to preventing adrenal insufficiency is to save at least about 30% of one gland.

Who is the best adrenal surgeon for me?

The best adrenal surgeon is going to be the surgeon with the most skill and experience. Adrenal operations are difficult and complicated by the adrenal hormones they produce. Since surgery is the only cure for most hormone-producing adrenal tumors, you should find a surgeon with skill and experience in all types of adrenal surgery, so your specific needs are met. It is well worth your time to find a high-volume adrenal surgeon. Lower volume surgeons (performing fewer than 6 adrenal operations per year) have significantly higher complication rates than high-volume adrenal surgeons, and the typical surgeon who performs adrenal surgery does about one adrenal operation per year. Dr. Carling’s view, after 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. There are few such surgeons, so it is worth asking any surgeon how many adrenal operations he or she performs each year.

What should I do to prepare for adrenal surgery?

1. Start walking and/or an exercise regimen for a few weeks prior to surgery. The best benefits are if the exercise increases your heart rate for at least 30 minutes, five times a week.
2. Tell us about all your medications, including blood thinners such as Coumadin, Eliquis and Plavix, and aspirin, ibuprofen (Motrin), Aleve, etc. We will give you individual instructions about blood thinners and other medications before surgery. Do not stop a blood thinner on your own without guidance from us and your prescribing doctor.
3. To allow for most efficient aftercare, ensure you have an appointment with your medical doctor (most commonly your endocrinologist, nephrologist, or primary care doctor) about 4 weeks after the operation.
4. Buy a blood pressure monitor and get into the habit of measuring your blood pressure and heart rate at least twice a day (morning and before bedtime) and keep a good record so you can compare how your blood pressure changes after surgery.

What should I expect after adrenal surgery?

After the operation you will spend the next couple of hours waking up and you may not even remember much of this period of time. However, by lunchtime or in the afternoon most patients feel well. You will spend less than 23 hours in the hospital in most cases. You will be able to eat and go for a walk in the hospital hallway. Most patients have very little pain and usually just take plain Tylenol and ibuprofen.

The morning after the operation you will have what is called a cosyntropin stimulation test. This is a simple lab test that shows whether the remaining adrenal gland is making enough cortisol. Steroid replacement is given only if you need it, which is most often the case after surgery for a cortisol-producing tumor. Most patients leave the hospital around 9 o’clock in the morning.

What should I do with my small Band-Aids?

Dr. Carling does not leave any sutures in the skin. There are no stitches that need to be removed. Just leave the 3 small Band-Aids on for about a week. You can peel them off in the shower about a week after surgery. A little bit of redness and inflammation around the incisions is common. You can just leave them open to air and they will usually heal very well. Within a few months the scars are usually hard to see.

Will my medications change after adrenal surgery?

It depends on what type of tumor you have.

Aldosterone over-production (primary aldosteronism, also called Conn’s syndrome or primary hyperaldosteronism)

People with aldosterone-producing adrenal tumors will typically require multiple medications to treat their high blood pressure, often including the potassium-sparing diuretic, spironolactone (or eplerenone).  You may also be taking potassium tablets.  It is important to stay on these medications up to the time of your operation unless we tell you otherwise. Our team will guide you in weaning off them after surgery.

After surgery – You will be instructed by Dr. Carling and his team to start dialing back on these medications. It usually takes weeks to months to see the full effect of surgery. The excess aldosterone is cured in the large majority of patients with one-sided disease. Blood pressure becomes normal without medication in roughly a third to a half of patients and improves in most of the rest. Measure your blood pressure and heart rate at least twice a day and keep a good record so you can see how your blood pressure changes after surgery.

Cortisol over-production (adrenal hypercortisolism, AHC; Cushing’s syndrome)

People with cortisol-producing adrenal tumors will also need to continue taking their medications up to the day of surgery.  After removal of the adrenal gland that is responsible for the excess cortisol production, the other adrenal gland may be “asleep” and need time to recover. Your cortisol is tested the morning after surgery, and steroid replacement (typically hydrocortisone) is given only if you need it. 

After surgery – The more severe the cortisol excess, the more likely you are to need steroid replacement: roughly 30–50% of patients with mild AHC, 50–100% with moderate AHC and nearly all with severe AHC. Recovery of the other gland takes months, and Dr. Carling and his team will tell you how to taper the medication. Fatigue, aches and low mood (steroid withdrawal symptoms) are common and temporary. Your blood pressure, weight and blood sugar are likely to get better, so keep good records of all these and report back to your doctor 4 weeks after surgery.

Adrenaline over-production (Pheochromocytoma)

People with a pheochromocytoma will sometimes need medication before surgery to block or dampen the “fight-or-flight” hormones that are being over-produced by the adrenal tumor.  Typically, doxazosin (a type of medication called an alpha-blocker) is used for at least two weeks to prepare your body for adrenal gland surgery. 

After surgery – The high blood pressure in pheochromocytoma often improves quickly once the tumor is removed, and many patients can come off some or all of their blood pressure medications already in the hospital. Some patients also have ordinary high blood pressure and still need medication. You will be instructed by Dr. Carling and his team which medications you should stop when going home. Everyone who has had a pheochromocytoma needs a yearly metanephrine test for life.

When should I see my regular doctor (PCP) and endocrinologist after adrenal surgery?

To allow for most efficient aftercare, ensure you have an appointment with your medical doctor (most commonly your endocrinologist, nephrologist, or primary care doctor) about 4 weeks after the operation.

Do I need to travel back to the Carling Adrenal Center in Tampa for follow up visits?

No. About half of our patients come from outside Florida, including from around the world. There is usually no need to come back for a follow up visit. Dr. Carling and his team will give you and your doctor clear instructions. Most importantly, you need to follow up with your medical doctor (most commonly your endocrinologist, nephrologist, or primary care doctor) about 4 weeks after the operation.

When can I return to normal activities after surgery?

Already the same day or the day after the operation you can be up and walk around and do most normal activities. For patients who have a more sedentary job, you can usually get back to work within 2 to 4 days. For patients who have a more physical job, plan on being off for 7 to 10 days. Within a week you can do light exercises such as walking, light jogging on a treadmill or riding a stationary bike. Wait about 10-14 days before you do more heavy exercises such as weightlifting.

Read more about adrenal surgery, the Mini Back Scope Adrenalectomy (MBSA) and adrenal tumors.

Last updated October 2026.