by Professor Titus Augustine
Our Expert Witness, Professor Titus Augustine, has recently published two papers on laparoscopic adrenalectomy:
- Laparoscopic approaches to adrenalectomy for large adrenal tumours: a systematic review – published in Laparoscopic Surgery.
- Laparoscopic hand‐assisted adrenalectomy for tumours larger than 5 cm – published in Clinical Endocrinology
The gold standard for removing small, benign adrenal tumours (both functioning and non-functioning) is by laparoscopic (keyhole) surgery, with open surgery being reserved for large (>5cm) or malignant tumours. Notably, the open surgical approach for larger tumours is evolving, with more teams using the laparoscopic approach as evidenced in the review above. However, each approach has particular risks and benefits, with the laparoscopic approach for removal of large adrenal tumours thought to carry it’s own risks such as haemorrhage, trauma to surrounding structures, and inadequate clearance of cancer. Both papers above explore the use of hand-assisted laparoscopic (HAL) adrenalectomy as a less invasive approach to open surgery for the removal of large adrenal tumours.
See below for an overview of the adrenal glands and adrenalectomy.
What are the adrenal glands?
The adrenal glands are endocrine glands located above the kidneys, in the posterior (back) of the abdomen, just below the diaphragm. They function by secreting hormones directly into the blood. Each adrenal gland is surrounded by a capsule, with the outer portion of the gland being referred to as the cortex and the inner portion of the gland known as the medulla.
What hormones do the adrenal glands secrete?
The adrenal glands secrete several different hormones from the cortex and the medulla.
The cortex secretes corticosteroids, mineralocorticoids, and androgens pre-cursors. The androgen pre-cursors are converted to the sex hormones in the gonads.
Corticosteroids secreted by the adrenal cortex include:
- Cortisol – helps regulate carbohydrate, fat, and protein metabolism, regulates inflammation, regulates blood pressure, increases blood glucose levels, regulates sleep, increases energy in response to stress.
- Corticosterone – converted to aldosterone (see below).
Mineralocorticoids secreted by the adrenal cortex include:
- Aldosterone – regulates blood pressure by adjusting the levels of sodium and potassium in the blood.
The medulla secretes catecholamines including:
- Adrenaline – involved with the ‘fight or flight’ response.
- Noradrenaline – increases and maintains blood pressure, even at rest.
What can go wrong with the adrenal glands?
The main conditions affecting the adrenal glands include:
- Addison’s disease
- The adrenal glands produce insufficient volumes of cortisol.
- Cushing’s syndrome
- The adrenal glands produce too much cortisol.
- Adrenocortical carcinoma
- Congenital adrenal hyperplasia
- Hereditary paraganglioma-pheochromocytoma
- Adenoma
- Hyperaldosteronism
What is an adrenalectomy?
An adrenalectomy is the surgical removal of the adrenal gland. This may be performed laparoscopically (keyhole surgery) or via open surgery.
What are the indications for adrenalectomy?
The adrenal glands are removed in several circumstances:
- Confirmed malignant tumour
- Suspicion of malignancy
- Large non-functioning, benign tumour
- Functioning tumour e.g., phaeochromocytomas (Cushings syndrome), aldosteronoma (Conns syndrome)
- Adrenal cyst
- Solitary metastases
What types of laparoscopic adrenalectomies can be performed?
There are several approaches to a laparoscopic adrenalectomy:
- Transperitoneal – this provides the greatest visual field.
- Lateral retroperitoneal – this avoids the intra-abdominal organs with direct access to the adrenal gland, however this has reduced visibility of the operational field and may not be suitable for large tumours.
- Posterior retroperitoneal
- Hand-assisted laparoscopic adrenalectomy (HAL) – this allows the tactile benefits of the hand to contribute to laparoscopic dissection for large tumours through small incisions. This approach is also used in laparoscopic donor nephrectomy for living donor kidney transplantation and in laparoscopic hepatobilliary surgery.