Adrenalectomy: why adrenal surgery is done, what to expect and recovery

The adrenal glands sit above the kidneys at the back of the abdomen and make hormones that support many body functions. BAETS explains that the cortex produces cortisol, aldosterone and other hormones, and the medulla produces adrenaline-like substances. An adrenalectomy is removal of an adrenal gland.

Most people have only one gland removed. UCLH says the remaining gland can often produce enough hormone for the body, and that surgery to remove both is very rare.

BAETS says nodules can be called lesions, lumps, masses or tumours, and that the words do not indicate the cause. An adrenalectomy may be performed if the nodule or gland is large or growing, if the cause is uncertain on scan, if it could be malignant, or if it makes excess hormones.

BAETS says investigations before surgery may include blood tests for cortisol and ACTH, an overnight dexamethasone suppression test, aldosterone and renin tests, plasma or urinary metanephrines, and imaging such as CT, MRI or an MIBG nuclear medicine scan. Not all tests are needed for every person.

Many hospitals have a pre-operative assessment clinic where you are reviewed by a nurse, usually with blood tests and an ECG. Some people with hormone-secreting tumours are given extra medication beforehand, and sometimes are admitted before surgery to stabilise the effects of the hormones.

BAETS describes laparoscopic adrenalectomy as usually involving three or four smaller cuts in the abdomen, approximately 7 to 15mm, with one possibly enlarged to remove the gland. A retroperitoneal keyhole approach can be performed through the back. Open adrenalectomy uses a larger cut and depends on previous operations and the extent of surgery. Some hospitals use robots. Any keyhole operation has a small risk of conversion to open surgery to remove the gland safely.

Leeds Teaching Hospitals says most patients who have laparoscopic surgery have less pain and recover quicker than those who have open surgery. The removed gland is sent to the laboratory, with results usually ready about two weeks after the operation, according to BAETS.

BAETS says the vast majority of patients have straightforward surgery without complications, but an adrenalectomy is a major operation with risks, and UCLH lists these.

• Bleeding, which very rarely needs a blood transfusion.

• Infection, including wound, chest or abdominal infection.

• Hernia where the muscles do not heal together.

• Damage to surrounding structures such as blood vessels, kidneys, liver, pancreas, bowel, stomach, spleen and diaphragm, which is very rare.

• Conversion from keyhole to open surgery.

• Adrenal insufficiency, where the remaining gland does not make enough hormone, which is rare and usually temporary.

• Nerve pain around the scars, which BAETS says usually settles over 6 to 8 weeks.

BAETS says people are encouraged to get up and about, usually on the first day after the operation, and that tenderness in the upper abdomen and around the scars is common and disappears in time. You may be able to return to office-based work after one or two weeks and heavier work after four to six weeks, and BAETS advises no heavy lifting for at least 6 weeks. UCLH advises avoiding strenuous activity such as heavy lifting or exercise for at least four weeks.

Before driving, you need to be able to wear a seat belt and perform an emergency stop comfortably, and you should tell your insurer and the DVLA if in doubt. A follow-up appointment within 2 months is likely to discuss the pathology results.

BAETS says whether you need extra hormone tablets depends on which operation you had and why. If the lesion was producing extra cortisol, you may need hydrocortisone after the operation, and some units test the other gland before you leave hospital. If both glands are removed you need lifelong steroid treatment. UCLH says blood tests after surgery determine whether steroid replacement is needed to help the remaining gland.

For aldosterone-producing tumours, kidney function and potassium are closely watched. BAETS says around two thirds of people with high blood pressure from Conn syndrome no longer need blood pressure medication after the operation.

On the NHS, adrenal surgery is usually done by an endocrine or urological surgical team working with endocrinology, and decisions are made at a multidisciplinary meeting. BAETS publishes leaflets and guidance for UK endocrine surgeons.

Private adrenal surgery is also available. Because adrenal surgery is uncommon, it can be sensible to ask the surgeon how many adrenalectomies they perform, and to ensure the hormone work-up and follow-up involve an endocrinologist.