Adrenal surgery

The adrenals glands are found at the top of the kidneys, at the back of the abdomen. They produce hormones which are substances that help support a number of the body’s functions such as growth and sexual development, digestion of food, response to stress, chemical balances in the blood, blood pressure, immune response, and mood.

The adrenal glands can sometimes produce too much hormone and this can caused a wide range of symptoms and complications.

The adrenal glands can also get bigger. In most cases these abnormal growths do not require urgent treatment.

However a small number of people develop a cancer in the adrenal gland or a secondary cancer (metastasis) in the adrenal gland after it has spread from another part of the body.

There are a number of treatments for patients with adrenal gland conditions. The treatment we offer will depend on the type of problem you have. Surgery to remove the affected adrenal gland (adrenalectomy) can help when:

• the adrenal gland is producing too much of a certain hormone.
• the adrenal gland is abnormally large.
• there is evidence that you may have adrenal cancer. We may sometimes offer you surgery even if we cannot be certain that you have cancer.

Most patients will only have one adrenal gland removed. The one which is left can often produce enough hormone for the body. Surgery to remove both adrenal glands is very rare.
 

Adrenal surgery can be done using an open or laparoscopic (keyhole) technique. Your surgeon will explain which option is best for you:

Laparoscopic adrenalectomy

This is the most common approach. This is done through three or four small cuts in the abdomen. One of these cuts may need to be enlarged at the end of the operation to remove the gland once it has been disconnected from blood vessels and the surrounding structures.

Open adrenalectomy

This method involves a large cut in the abdomen. It is usually recommended for patients who have a very large adrenal gland (six centimetres or more) or to remove an adrenal cancer (to make sure the gland is completely removed).

Both operations are done under general anaesthetic which means you will be asleep during the procedure.

The operation will usually take between one and three hours, depending on the type of surgery and the size of the gland.
 

As with any operation, there are risks associated with adrenal surgery. These include:

• bleeding: any operation carries a risk of bleeding, either during or after the procedure. Very rarely patients may need a blood transfusion.
• infection: any abdominal surgery carries a risk of wound infection, as well as chest or abdominal infection. This is very rare in adrenal surgery and can be treated with antibiotics.
• hernia: this can happen if the muscles do not heal together where the cut or cuts were made in your abdomen. You may need another operation to repair a hernia.
• damage to surrounding structures: your adrenal glands are surrounded by multiple organs which are at risk of being damaged during surgery. These include blood vessels, the kidneys, the liver, the pancreas, the bowels, the stomach, the spleen and the diaphragm. These potential complications are very rare but may require more extensive surgery to repair the injury.
• Conversion to open surgery: if you are having keyhole surgery the surgeons may decide to convert to an open approach. This can happen when the operation is technically too difficult or when there has been an unexpected complication and it is not safe to continue with keyhole surgery.
• adrenal insufficiency: sometimes after one adrenal gland has been removed, the remaining one does not produce enough hormone for your body. This is rare and if it does happen, is usually temporary. The blood tests performed after surgery will determine if you need steroid replacement tablets to help the remaining adrenal gland. If both adrenal glands are removed, you will need to take steroid tablets for life. In this case, you will be supported by the Endocrinology Team (non-surgical doctors who deal with endocrine problems).

There are also risks associated with having a general anaesthetic which we will discuss with you before your surgery. You will also see an anaesthetist on the day of your operation.
 

There are several alternatives to surgery available but they may not be right for you. Alternatives for some patients with certain conditions include:

• if an adrenal gland is producing too much hormone, you can sometimes be treated with medication. This can reduce the symptoms and consequences of the excess hormone but it will not cure the problem.
• an adrenal gland which is growing can sometimes be monitored with scans and blood tests. However, there is a risk the gland will continue to grow and also that a cancer will develop inside it.
• chemotherapy or radiotherapy are sometimes treatment options for adrenal cancer. These may slow the growth of the cancer but there is no evidence that they can cure it.

We will tell you if we believe one of these treatments will be of benefit. Please do ask if you would like to discuss alternatives.
 

Before your operation, we will organise a pre-assessment appointment. We will ask you for details of your medical history and carry out any tests we need to make sure you are fit for the anaesthetic and the operation. Staff in pre-assessment will tell you how to prepare for your operation when to stop eating and drinking and about the admission process.

Patients are usually admitted to the hospital on the day of the operation. Patients who have increased levels of specific hormones (catecholamines) may need to be admitted a few days ahead to prepare them for surgery. Your surgeon will let you know if this is needed in your case.

You will meet a member of the anaesthetic team and a member of the surgical team before the operation. They will explain the risks and benefits of the procedure and they will obtain your consent.
 

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

Sometimes, we may also ask you for consent to participate in research projects. If this is the case, we will discuss this with you in detail.
 

After the operation you will wake up in the Recovery Area. You may feel drowsy and sleepy at first, however this soon passes. You will have a cannula that will help us provide you with painkillers or any other medication you may need directly into your bloodstream. You may also have a urinary catheter. A recovery nurse will look after you until you are ready to go to the ward.

If you are having an open adrenalectomy, it is likely you will spend the first night in an Critical Care Unit, where you will be closely monitored.

A member of the surgical team will review you each day you are in hospital. The Endocrinology Team may also review, you depending on your condition.

You will need blood tests in to assess whether the remaining adrenal gland is producing enough hormone. If needed we will start you on steroid medication and organise Endocrinology follow-up as an outpatient.
 

Most patients go home two to three days after keyhole surgery. Patients having open surgery usually need to stay in hospital for five to seven days.

Medication

We will advise you to take over the counter medication (such as paracetamol or ibuprofen) to help you manage your pain. It is a good idea to have a supply at home before you come in for your operation.

Some patients need steroid tablets after an adrenal gland is removed. If we advise you to take steroids, it is very important that you take them every day and do not interrupt treatment unless you are told to do so by an Endocrinologist. Missing steroid medication can cause a serious medical condition which can be life threatening. If you cannot take your tablets for any reason, please contact your Endocrinologist or GP immediately.

Exercise and going back to work

You should rest for a week when you get home. It is normal to feel tired for a few weeks after surgery.

We advise you to avoid heavy lifting or heavy exercise for at least four weeks after the operation. Try to increase exercise gradually.

We usually advise patients to take one or two weeks off work once they get home, but this can vary, depending on the type of work you do.
 
Wound care

You may shower from the day after the operation but we advise you not to have a bath for at least two weeks. You will have dissolvable stitches which do not need to be removed.
If you have any concerns about your wound or medication please contact the Endocrine Surgery Team using the contact details listed at the bottom of this page.

If you have an urgent problem please come to the Emergency Department at University College Hospital.

Please seek urgent medical advice if:

• You develop redness, swelling or increasing pain around the surgical wound
• You experience unexpected weakness, fatigue, dizziness, lack of appetite, muscle or abdominal aches, vomiting, diarrhoea, low blood pressure or low sugar levels. These symptoms may represent a lack of steroids and you may need immediate medical attention.
   

We will organise an outpatient appointment to review you in clinic a few weeks after the operation. When you come to clinic, we will check your wounds and general recovery.

The endocrinology team may also organise follow-up in their clinic to monitor your symptoms and adjust your steroid medication if you are taking it.

A pathologist will look at the adrenal tissue which was removed during the operation. If needed, we will discuss the findings at a multidisciplinary team meeting. We will inform you of the results and we will also tell you if you need any further treatment or follow-up. Most patients will be discharged after their first follow-up appointment unless there is a reason that further follow-up is required.

If you have any questions or concerns about your surgery after you have read this leaflet please contact us.

Pathway Co-ordinator (Monday to Friday 09:00-17:00) Direct line: 0203 447 9460

Switchboard: 08451 555 000 / 020 3456 7890 ext. 79460 E-mail: uclh.giadmissionsteam@nhs.net

Address: Endocrine Surgery Department, Ground Floor West, 250 Euston Road, London, NW1 2PG

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