Robotic adrenalectomy

What the adrenal gland does

The adrenals are small triangular glands that sit on top of each kidney. They make cortisol and aldosterone (from the cortex) and adrenaline and noradrenaline (from the medulla). Surgery is considered when a growth on an adrenal gland makes too much hormone, is suspicious for cancer, or is larger than about 4 cm. See adrenal lesions for the clinical picture.

Who it suits

• Hormone-active tumours (phaeochromocytoma, Conn's syndrome, Cushing's syndrome, virilising tumour).
• Adrenal masses > 4 cm, or with indeterminate or concerning imaging features.
• Masses that grow on serial imaging.
• Adrenal metastases from other cancers in selected cases.

Very large or locally invasive tumours are sometimes better served by an open approach; this is decided after dedicated adrenal imaging.

What the operation involves

1. Positioning in a flank or anterior approach; ports placed; robot docked.
2. The colon and, where applicable, spleen, liver or pancreas are gently mobilised to expose the adrenal.
3. The adrenal vein is identified and divided early - important in phaeochromocytoma to minimise catecholamine release.
4. The gland is dissected free from the kidney and surrounding structures with careful attention to small arterial supply.
5. The specimen is placed in a bag and removed through one of the port incisions.
6. A drain is rarely needed; ports are closed.

Phaeochromocytoma preparation

Patients with phaeochromocytoma need medical preparation (usually alpha blockade, followed by beta blockade once adequate alpha blockade is achieved) for one to two weeks before surgery. This is coordinated with the referring endocrinologist. Intra-operatively, close anaesthetic collaboration is essential.

Hospital stay

Typical hospital stay is one to two nights. Return to normal activity over two to four weeks. Hormone testing is usually repeated four to six weeks post-operatively to document cure in functioning tumours.

Expected outcomes

• Cure of hormone excess in the large majority of unilateral functioning tumours.
• Blood loss, length of stay and time to recovery lower than open adrenalectomy.⁴
• Comparable results to laparoscopic adrenalectomy in overall series, with the robotic approach particularly useful for larger or right-sided adrenal tumours.

Potential complications

• Bleeding (uncommon) - including from the adrenal vein or small adrenal arteries.
• Injury to adjacent structures - spleen, liver, pancreas, kidney - all uncommon.
• Haemodynamic instability during dissection of a phaeochromocytoma (managed by the anaesthetic team).
• Adrenal insufficiency - expected after bilateral adrenalectomy; temporary after unilateral adrenalectomy for cortisol-producing tumours.
• Standard risks of abdominal surgery.

Alternatives

• Laparoscopic adrenalectomy - historical standard; robotic and laparoscopic are both minimally invasive.
• Open adrenalectomy - for very large, invasive or known malignant adrenal tumours.
• Medical management for some conditions (for example, bilateral aldosteronism).

Resources