Laparoscopic Adrenalectomy

Laparoscopic Adrenalectomy / Robotic Adrenalectomy are minimally invasive or Key Hole surgery. It is a safe and effective way of removing the Adrenals, and the results are comparable with the open surgery. It has the advantage of minimally invasive surgery in the form of less pain, shorter hospital stay, smaller scar, better cosmesis, and early return to work.

What to expect during your preoperative consultation

In the first consultation with the surgeon, he usually reviews all the documents, images and investigations. He does a physical examination and Asses the fitness for the surgery. In case there is an adrenal tumour, the surgeon would like to know the functional status of the tumour and its size. He usually advises a battery of tests to know the functional status as it is very important to know this before the surgery. Once the surgery date is finalized, he may advise you to do a few tests for the surgical fitness and meet an anaesthetist and a physician.

What to expect before the surgery

Usual preop investigations have done are:

Physical exam
ECG (electrocardiogram)
CBC (complete blood count)
PT / PTT (blood coagulation profile)
Comprehensive Metabolic Panel (blood chemistry profile)
Viral Markers
Urinalysis
2D Echo in elderly

Preparation for surgery

Medications to Avoid Before Surgery

Aspirin, Warfarin, Clopidogrel and some other blood thinner need to be stopped before elective surgery (5-7 days) after approval from the prescribing physician.

The patient is kept nill by mouth (NBM) at least 6 hours before the surgery.

The Operation Laparoscopic Adrenalectomy/ Robotic Adrenalectomy is a Keyhole surgery performed through 3-to 5 small incisions on the abdomen. Various instruments and a telescope are inserted after distending the abdomen with gas. On the right side, the liver is retracted to see the adrenal. The IVC, Tumor is identified, the adrenal vein is dissected, clipped and cut, and finally, the adrenal is mobilized. The bowel and spleen are reflected medially on the left side before the adrenal can be seen. An adrenal vein usually drains into the left renal vein on the left side. It is identified at the junction where it enters the renal vein and dissected, ligated and cut. The adrenal is mobilized after that. The final specimen is retrieved after inserting in a plastic bag, either extending a port or putting a separate incision (Pfannensteil)

Open Procedure Laparoscopic Procedure

Although this procedure has stood the test of time, it also carries some risk of complications like any other surgical procedure.

The usual blood loss is less than 50 cc, and need for blood transfusion is rarely needed.

Infection: all the patients are given preop / intra op antibiotics and are usually continued 24-48 hours post-surgery. The risk of the infection is less compared to open surgery. However, it may happen.

Tissue / Organ Injury: The risk is small if done by an experienced hand. Still, large tumour or an inflamed kidney, there can be an injury to the surrounding organs or vasculature requiring open conversion or other intervention.

Hernia: Hernias are quite rare because of smaller incisions, but they may occur.

Conversion to Open Surgery: Conversion to open surgery is not the failure of the surgeon to do a keyhole surgery but is a wise decision for the safety and better outcome of the patient. If there is failure to progress because of dense adhesion to surrounding structure or bleeding or injury to surrounding viscera, it may be needed.

During your hospitalization

The patient is shifted to the recovery room after surgery, where he is kept for observation for 4-6 hours. If vitals and other parameters are normal, he is usually shifted to his room post-surgery on the same day unless any other comorbidities exist requiring ICU care.

Postoperative Pain: There may be a transient pain in the shoulder due to the carbon dioxide insufflation. The wound is usually infiltrated with local anaesthesia during surgery, and postoperatively patients receive adjuvant Intravenous analgesics in consultation with the anaesthetist.

Nausea: It may happen because of the medications or the anaesthetic drugs.

Urinary Catheter: Urinary pipe may be present for a couple of days to monitor the urine output, and it is usually removed by the second postoperative day.

Diet: Most of the patients are given clear liquids by evening and a normal diet the next day once he starts tolerating the liquids well.

Fatigue: Generalized weakness and fatigability can be there because of the anaesthetist or other drugs. Usually subsides in 5-7 days.

Incentive Spirometry: Many patients hold their breathing because of the pain, resulting in some lung-related complications. Incentive spirometry is advisable to expand the lung and prevent post.

Ambulation: The patient is ambulated on the eve of the surgery. Early mobilization reduces the risk of blood clots in the leg veins and speeds up the recovery and bowel movement.

Hospital Stay: The usual hospital stay is 2-3 days in Laparoscopic / Robotic Nephrectomy

Constipation / Gas Cramps: The patient can have mild abdominal distention and constipation due to the anaesthetic drugs and other medications, especially analgesics. Patients are usually given a laxative, and early mobilization helps in reducing bowel discomfort.

Pain Control: There may be mild incisional discomfort, and usual oral analgesics are sufficient to care for that.

Showering: The patient can take a shower three days post-surgery. They can wet the surgical site but have to pad it dry immediately after taking a bath.

Activity: The patient starts walking on the eve of surgery, and he can climb stairs after a day. The patient should avoid exercise and gyming for 4-6 weeks. Usually, they can resume their normal office work 2-3 weeks after the surgery.

Diet: It is advisable to take low salt, low protein diet post kidney removal. Dieticians and nephrologists should be consulted for the proper dietary advice.

Pathology Results: The pathology report is usually available after 5-7 days of the surgery. The patient needs to review with the surgeon again with the histopathology report.

Follow up: Patients need to be on regular follow up as advised by the surgeon and the endocrinologist.