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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 incredibly important structures, and it is absolutely crucial that the adrenal surgeon is experienced in dealing with them. If the surgeon is off by just millimeters, the operation can very rapidly end with a tremendously bad outcome.

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, when irritated or inflamed, can cause significant sickness and even death. Thus, once again it is exceedingly important that surgery in this area is performed very gently by incredibly experienced surgeons. If the surgeon is off by mere millimeters, the operation may end poorly.

FIGURE: A normal adrenal gland demonstrating the adrenal medulla (inner layer), and the adrenal cortex (outer layer). The two different layers product 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 and supplements to provide the necessary hormones.

The adrenal cortex produces hormones that controls sex (androgens, estrogens), salt balance in the blood (aldosterone), and sugar balance (cortisol). 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" symptoms, 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). Adrenaline as we call it generically can be broken down into two different hormones that the adrenal medulla produces: epinephrine and norepinephrine.


What is the function of the adrenal cortex?

The adrenal cortex produces a handful of hormones necessary for fluid and electrolyte (salt) balance in the body such as cortisol and aldosterone. 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 as well as some small amounts of progesterone (a sex hormone). The mineralocorticoid aldosterone is produced here.
  • The zona fasciculata (ZF) is the middle zone of the adrenal cortex, and it primarily produces cortisol.
  • The zona reticularis (ZR) is the inner most zone of the adrenal cortex and it is adjacent to the adrenal medulla. Functions of the zona retularis are to store cholesterol for steroidogenesis (the making of steroid hormones) and the secretion of sex hormones such as estrogen, and testosterone (in small amounts).

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 thus a simple Mini Back Scope Adrenalectomy (MBSA) can cure the symptoms by removal of the adrenal tumor. This website discusses adrenal tumors and adrenal surgery in great detail. Dr. Carling is the world's most experienced adrenal surgeon.

When you have an adrenal tumor, you can have numerous symptoms. Since many doctors (even smart ones) are inexperienced and only see a handful of adrenal tumors during their careers, they don’t have significant experience with these tumors. Thus, it is very important for patients to know about the symptoms of adrenal tumor disease. A great doctor will always perform a very careful history and physical examination to identify signs and symptoms of adrenal tumor disease.

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 (aldosteronoma or Conn's tumor) and cortisol-producing tumors (causing 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, Conn’s Syndrome, Cushing Syndrome, Pheochromocytoma, Adrenal Metastasis and Adrenal Cancer.

Each of these will be detailed below.


Are adrenal tumors common?

Adrenal tumors are common, occurring in 2-3% of adults in their lifetime. The most common adrenal problems are the development of benign, non-cancerous tumors 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?

The size of the adrenal tumor is very important for determining whether the tumor is potentially cancerous (malignant), or not. Very small tumors (meaning 1 to 2 cm; less than an inch) are almost never cancerous. However, larger tumors are much more frequently cancerous. As discussed above, any adrenal tumor of any size should be removed if it is making excessive hormones. However, even if the tumor is NOT making too much hormones, tumors that have grown to more than 4 cm in an adult should be removed.

Recommendations: we recommend removing any adrenal tumor that is 4 cm (1.75 inch) or larger. For younger patients, we would use a 3 cm (1.25 inch) cutoff. If you have a tumor that is 3 to 4 cm in diameter (1.25 to 1.5 inches in diameter) or larger you probably need adrenal surgery. This is a general guide, and there are exceptions to this rule. This is why it is vitally important for you to seek the advice of experts and especially a surgeon that has EXTENSIVE experience in adrenal gland surgery. This is NOT something to chat about with your local general surgeon that performs gallbladder surgery and hernia operations.


Should the adrenal tumor or adrenal mass be biopsied?

NO! A biopsy of the adrenal tumor is almost never helpful and most of the time it can cause significant problems! Important rule: DO NOT PERFORM A BIOPSY OF AN ADRENAL MASS. In fact, it can be very dangerous if the patient has a pheochromocytoma. The biopsy may produce 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. Thus, sticking needles into an adrenal tumor can decrease the chance of curing the patient, so do not do it. Also, a fine needle biopsy can never distinguish between a benign and malignant adrenocortical tumor, and is thus a wasteful and meaningless, invasive procedure. If your doctor wants to biopsy your adrenal tumor, then please give us a call--you need to seek better advice. The only time to consider a biopsy of an adrenal tumor is if the patient has another cancer, typically of the lung, kidney, breast, colorectal or melanoma and one is suspecting an adrenal metastasis.

The rule is to never biopsy an adrenal tumor. As with all rules, though, there are some rare exceptions. The only time to consider a biopsy of an adrenal tumor is if the patient has another cancer, typically of the lung, kidney, breast, colorectal or melanoma and one is suspecting an adrenal metastasis. Now you understand why patients with adrenal tumors should be seen by expert surgeons 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?

Yes, anytime you have a functional tumor, it needs to be removed. Not primarily because of the concern for cancer, but the damage caused to the body due to excess of these "toxic" hormones. You need an adrenalectomy. You can learn more about adrenal surgery on other pages of this website. Dr. Carling is the world's leader in performing minimally invasive surgery for functional adrenal tumors, performing this operation almost every day.


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

If the adrenal tumor is overproducing aldosterone, then you have a disease called primary hyperaldosteronism, also called Conn's Syndrome (Conn's tumor) after Dr. Conn, who first described this disease. The signs and symptoms associated with Conn's Syndrome (primary hyperaldosteronism) include low potassium in the blood (causing frequent urination), muscle cramps and heart palpitations (feeling your heart racing). High blood pressure is also associated with excess production of aldosterone (Conn's Syndrome). If you ever have high blood pressure and low potassium, you should definitely be investigated to make sure you don’t have an aldosterone-producing adrenocortical tumor. We have an entire section of this website dedicated to the diagnosis and treatment of primary hyperaldosteronism (Conn's Syndrome).

Most patients with primary hyperaldosteronism (aldosteronoma or Conn's tumor) have high blood pressure. If you have high blood pressure especially if you’re relatively young and have no other risk factors such as diabetes or a family history of high blood pressure, you need to make sure you don’t have an adrenal tumor overproducing aldosterone. It is important to know that almost 50% of all patients with primary hyperaldosteronism (aldosteronoma or Conn's tumor) are asymptomatic. They don’t have any significant symptoms. They may feel normal and maybe the only sign is high blood pressure. However, if they don’t have their adrenal tumor removed, the patients are at a tenfold increased risk of heart arrhythmias, stroke and heart attacks.


How common is Conn's syndrome and hyperaldosteronism? 

Conn's Syndrome and the adrenal tumor that causes it are much more common than you would think--with many people undiagnosed. It is estimated that almost 10% of patients who have elevated blood pressure (hypertension) have underlying primary hyperaldosteronism as the cause and thus all doctors should be on the lookout for it. It is very important to identify these individuals since a simple operation (adrenalectomy; Mini Back Scope Adrenalectomy (MBSA) can dramatically reduce the risk of dying prematurely from heart disease and stroke.


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

If the adrenal tumor is overproducing cortisol, you will develop symptoms of 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 Cushing’s syndrome have high blood pressure (hypertension), 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. Many patients with adrenal tumors that overproduce cortisol may be asymptomatic (have no symptoms). That means they may not have any obvious symptoms. These patients are often referred to as having subclinical Cushing’s syndrome. The term "subclinical" means that there is a hormone disturbance, but it has yet to be overt and easily diagnosed clinically; i.e. by a history and physical exam performed by a doctor. However, an astute doctor can often identify that when a patient has slight to obvious underlying obesity, hypertension, hyperglycemia, pre-diabetes, or frank diabetes, thus can be due to subclinical Cushing’s syndrome. 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 overt or subclinical Cushing’s syndrome) since a simple operation (adrenalectomy; Mini Back Scope Adrenalectomy (MBSA) can dramatically improve the patient’s quality of life, cure hyperglycemia (pre-diabetes), hypertension and prevent the risk of dying prematurely from heart disease and stroke.


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; also called epinephrine, metanephrine, adrenaline, noradrenaline, and dopamine). Thus, the symptoms of a pheochromocytoma are the symptoms of panic and anxiety. Pheochromocytoma is a tumor that overproduces catecholamines. These hormones are also called epinephrine, metanephrine, adrenaline, noradrenaline, and dopamine. Of note, a paraganglioma is a similar tumor as a pheochromocytoma, but they occur in similar cell types outside the adrenal gland, for instance, along the major vessels of the abdomen, in the chest and neck. They 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 "freak out" and have a feeling of impending doom and anxiety. They get sweaty, their heart races and they have anxiety. These periods of symptoms are often referred to as “spells”.

The symptoms may be completely spontaneous but 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 sustained, as well orthostatic hypotension (meaning when you lay down the blood pressure goes down). 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 hyperaldosteronism. (See symptoms of primary hyperaldosteronism). 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 Conn's syndrome (primary hyperaldosteronism)
  • Rare genetic variants of Cushing's syndrome (primary hypercortisolism)
  • 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 myolipoma, 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. A great doctor will always perform a very careful H&P to identify signs and symptoms of adrenal tumor disease. One of the hallmarks of adrenal tumors is high blood pressure, also known as hypertension. Most adrenal tumors that are producing hormone will cause high blood pressure. Tumors that overproduce catecholamines (called pheochromocytoma), as well as aldosterone-producing tumors (aldosteronoma or Conn's tumor) and cortisol-producing tumors (causing 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 cortisol, you will develop symptoms of 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. To read more about adrenal symptoms Click Here.

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

Tests for Pheochromocytoma in adrenal masses

Plasma (blood) Metanephrines, fractionated (high)

AND/OR 24h Urine Catecholamines (high)

Tests for Cushing's syndrome in adrenal masses

A.M. Cortisol

ACTH (low)

Low dose dexamethasone test (high)

DHEA-S

Tests for Conn's syndrome in adrenal masses

Potassium (K+; low)

Plasma aldosterone concentration (PAC; high)

Plasma renin activity (PRA; low)

PRA/PAC ratio (high)

Third, sometimes additional imaging is needed to better address the adrenal mass. However, this is very rare. In almost all cases a CT scan demonstrating the adrenal tumor is all you need. To read more about adrenal imaging Click Here.


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, 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, and if none is being made, then all under 3cm will be able to be watched. All you may need to do is get another CT scan in 6 months or a year to make sure it is not growing. If the adrenal tumor is over 3 cm or is producing any of the above hormones then surgery will almost always be recommended.

If you need surgery, your doctors (usually the primary care physician and/or medical endocrinologist) will refer you for surgery. To read more about adrenal surgery Click Here. As you will read, it is extremely important for you to have a surgeon that performs adrenal surgery regularly, and unfortunately there are very few surgeons who do this.


How is adrenal surgery performed?

Adrenal surgery can be performed eight 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.

Almost all adrenal tumors (>95%) can now be removed using minimally invasive techniques such as the Mini Back Scope Scope Adrenalectomy (MBSA). This operation is also called "Posterior Retroperitoneoscopic Adrenalectomy". The MBSA is by far the best adrenal operation since it is swift (about 20-30 minutes, typically), safe, and patients have minimal pain, with a very rapid recovery (up and around walking a few hours after surgery).

In fewer than 5% of patients needing adrenal surgery, laparoscopic transabdominal adrenalectomy (LTA), with or without a hand-port is used, but typically only when the adrenal tumor is more than 8 cm (3 inches) in diameter.

Large tumors (>12 cm) and tumors that are suspected 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, are almost never removed by minimally invasive operations using scopes. Rather an open standard adrenalectomy technique is required.

It should be noted that very few surgeons in the world have significant experience with all different adrenal surgery techniques and understand the subtle pros and cons of each approach. This is why you need to identify the most experienced adrenal surgeon possible. The adrenal surgeons of the Carling Adrenal Center have the most experience in the world and perform operations on people from all over the world every week.


What kind of surgeons perform adrenal surgery?

Adrenal surgery is performed by general surgeons, endocrine surgeons and urologists. Experience of the surgeon in adrenal operations is by far the most important criteria. It is well known that surgeons who perform many adrenalectomies (removal of adrenal gland) perform the operation much faster, much more safely, have fewer complications and the patients do better postoperatively.

The bad news about adrenal surgeryUnfortunately, 90% of adrenal operations in the United States are performed by surgeons who only do 4 or fewer per year (yes, four or fewer). In fact, the bad news is that the median (average) number of adrenal operations performed by surgeons in the Unites States is 1 (one)! That's right, most adrenal operations are performed by surgeons who only do ONE of these operations per year and the outcomes are not nearly as good as they could be. This is a huge problem for patients. Very few surgeons have any meaningful experience performing adrenal surgery. One of the reasons is that many different types of surgeons do very low volumes of adrenal operations. Endocrine surgeons (those specializing on 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 in your area. We perform more adrenal operations than any hospital or university in the world, and more than 10 times more than any other center in the US.


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 way the Mini Back Scope Adrenalectomy (MBSA) is done, in experienced hands, should have near zero blood loss and is, by far, the best adrenal operation available anywhere in the world. Do not fall for the "Robot" surgery gimmicks--it isn't better and is far worse in almost every instance when operating on the adrenal. Yes, it's good for the prostate, but not the adrenal! The other advantages of the Mini Back Scope Adrenalectomy (MBSA) operation include that it is faster and leads to less manipulation of the abdominal organs during the operation, which is absolutely 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, faster recovery 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 the preferred adrenal surgery for >95 % of adrenal tumors. 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 this minimally invasive technique is preferred over any of the other adrenal operations that can be done. 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 tremendous benefits--but few surgeons know how to do it. It is not taught in surgical residency because no surgeons see enough cases of adrenal surgery to learn 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 popularized this technique while he was Chief of Endocrine Surgery at Yale University Medical School and has been using this operative approach for a decade on hundreds of patients. Note that this is a very advanced technique--surgeons that operate on adrenal glands only 4 times per year are not going to offer you this operation, so be careful. 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 large adrenal cancer (which is quite rare), then get a second opinion and find a surgeon that does lots of these--your local surgeon does not.

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. There is no question this is the best adrenal operation for almost everybody. We have another page that discusses the benefits of the Mini Back Scope Adrenalectomy (MBSA) and what makes it far superior to all other adrenal operations for almost everybody.


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 partial adrenalectomy or, more technically, a "cortical-sparing" 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 a partial cortical-sparing adrenal 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 of one gland to live normally and not take medications every day. So, the partial adrenal operation is most relevant if the patient has problems in both adrenal glands whereby they both must have some portion of a tumor removed.

Read more about partial adrenalectomy here.


Can a partial adrenalectomy be performed via Mini Back Scope Adrenalectomy (MBSA)?

Absolutely! But only if your surgeon has lots of experience--most surgeons won't even attempt this. Partial (or cortical-sparing) adrenalectomy is ideal to be performed by the more modern, advanced Mini Back Scope Adrenalectomy (MBSA) approach than 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 nice video of Dr. Carling performing a partial cortical-sparing adrenalectomy via the Mini Back Scope Adrenalectomy (MBSA) for you to watch here.

Partial adrenalectomy is an invaluable option for patients with genetic syndromes associated with pheochromocytomas. These syndromes include MEN2, VHL, and neurofibromatosis type 1 (NF1), as well as others. Approximately 40-80% of patients with either MEN2A or VHL will develop bilateral pheochromocytomas and these tumors are usually benign. As such, cortical-sparing adrenalectomy can remove affected tissue, while leaving behind enough tissue to prevent adrenal insufficiency with minimal risk of recurrence.

Partial Mini Back Scope Adrenalectomy (MBSA) is the best operation for almost all patients with Cushing’s syndrome due to tumors of both adrenal glands.


Who is a good candidate for a partial adrenal operation?

Typically, over 90% of patients who are thought to be good candidates for partial adrenalectomy (based on preoperative imaging) will be able to undergo it. It is very important to consider the below mentioned 4 concepts to determine the ability to perform partial (or cortical-sparing) adrenalectomy:

  • 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 about 10% of cases, the surgeon can find something during the operation that may indicate that a partial adrenalectomy is the wrong operation. Dr. Carling will not compromise the surgical resection margin putting his patients at risk of the disease coming back. This is where experience and excellent surgical judgment plays a huge role.


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

In cases where partial adrenalectomy is performed for bilateral adrenal tumors, >90% of patients do not require steroid supplementation (prednisone, hydrocortisone, etc). This means that >90% of patients undergoing partial bilateral adrenalectomy can be saved from developing adrenal insufficiency. In most cases with bilateral tumors, we would completely resect the entire adrenal gland on one side and then perform a partial resection on the other side. However, this has to be individualized in each scenario. The key to prevent adrenal insufficiency is to save at least 30% of one gland, or a total of 15% of both adrenal glands.


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 possible cure for adrenal tumors, you should find the surgeon with the most skill and 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 fewer than 6 adrenal operations per year) may have a complication rate that is 10-20 times higher than a high-volume adrenal surgeon. 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. Only these select, handful surgeons can offer the best operation with the lowest complication rate and highest cure rate. In the world, there are very few expert adrenal surgeons.


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. Stop blood thinners for the appropriate time frame based on the medication, (always under the guidance of prescribing doctor), including Coumadin, Eliquis, Plavix, and NSAIDs such as aspirin, ibuprofen, Motrin, Aleve, etc. Typically, this is about 3 days for Coumadin and Eliquis, and 1 week for the others.
  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 gets better 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, already by lunchtime or in the afternoon you will feel very good. You will spend less than 23 hours in the hospital in most cases. You will be able to eat, go for walk in the hospital hallway. Most patients have very minimal 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, but it is performed to assess the cortisol production which is proof that the remaining adrenal gland works perfectly. 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 Ban-Aids on for about a week. You can pel them off in the shower in about a week after surgery. A little bit of redness and inflammation around the incisions are common. You can just leave it open to air and it will turn about beautiful. Within a few months the scars will be almost invisible.


Will my medications change after adrenal surgery?

It depends on what type of tumor you have.

Aldosterone over-production (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, which will be weaned off by your surgeon-driven team after successful adrenal gland 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. Measure your blood pressure and heart rate at least twice a day and keep a good record so you can compare how your blood pressure gets better after surgery.

Cortisol over-production (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 you may require a short course of oral steroids (typically hydrocortisone). 

AFTER SURGERY – You will be instructed by Dr. Carling and his team whether you need to take this medication for a few weeks, or not. Your blood pressure, weight and blood sugar are likely to get better so keep good records off all these and report the improvements 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 class of medications 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 is usually immediately cured in the operating room. Thus, it is likely you can come off all your blood pressure medications already in the hospital. You will be instructed by Dr. Carling and his team which medications you should stop when going home.


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. Dr. Carling operates on patients from all 50 states and those from other countries. There is 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 for being off for 7 to 10 days. Within a week you can do light exercises such as walking, light jogging on a treadmill or a riding a stationary bike. Wait about 10-14 days before you do more heavy exercises such as weightlifting.