Adrenal Awareness 2023: Today’s Adrenal Surgery Techniques (and Tomorrow’s)

Conversations and Curbsides - a Podcast between DoctorsDr. Catherine McManus is an endocrine surgeon at Columbia University Medical Center. In light of Adrenal Awareness Month 2023, Dr. McManus joined Dr. Hyesoo Lowe on an episode of Columbia Surgery’s podcast Conversations and Curbsides. The two doctors discuss the most up-to-date adrenal surgery techniques, and the reasons medical innovations continue to unfold.

The following is a transcription of the discussion, and is lightly edited for context and clarity. 

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Dr. Hyesoo Lowe:

Today I'm having a conversation with Dr. Katie McManus, endocrine surgeon here at Columbia Adrenal Center. We're talking on the topic of adrenal surgery. Welcome back, Dr. McManus. We wanted to extend some of our earlier conversations we had on the adrenals, and get into a little bit more detail about adrenal surgery, so welcome back.

Dr. Catherine McManus:

Thank you. Great to be back.

Dr. Hyesoo Lowe:

This is really for the person who wants more detail on adrenal surgery. Maybe a situation where a person has been told they need adrenal surgery. 

Adrenalectomy: Removing The Entire Adrenal Gland

Dr. Hyesoo Lowe:

Are there different kinds of surgeries on the adrenal gland? For example, would there be a time where you just need to remove part of it, maybe just the tumor part, or are there times you need to remove the entire adrenal gland? Tell us about that.

Dr. Catherine McManus:

Yeah, that's a great question. I always talk about the adrenal glands as a pair. You have two of them. The short answer is that it depends on what we're doing the operation for. But I would say that, largely, when we're talking about adrenal surgery, we're talking about taking out the entire adrenal gland. 

The reason is because, oftentimes, the tumor or the thing that we need to get out of the adrenal gland is really embedded inside of it. So it's really challenging to make sure that we get that part if we were to just take part. So we really want to get the entire gland out. Especially if we're concerned about the potential of something suspicious, or adrenal cancer, it's really important that we get the entire adrenal gland out in one piece so that we don't spread anything around.

Dr. Hyesoo Lowe:

That's helpful to know. We're really talking about adrenalectomy then, not just lumpectomy, for example.

Dr. Catherine McManus:

Correct. Yes. Unlike with other parts of the body, like the breast where you can do a lumpectomy, with the adrenal gland, we're talking about taking out the entire adrenal gland.

Surgical Techniques: Minimally-Invasive vs. Open AND Front vs. Back

Dr. Hyesoo Lowe:

In the United States, what's the most common way to do an adrenalectomy?

Dr. Catherine McManus:

I would say that most surgeries have evolved in the last twenty, thirty years. We are doing the majority of these operations laparoscopically, which is minimally invasive. We use a camera and long instruments to take out the adrenal gland. You have small incisions on the abdomen or on the back. We'll get to that in a little bit when we talk more specifically about individual techniques, but you'll have small incisions and take out the adrenal gland in the minimally invasive approach. I would say that is the majority of the way that we take out the adrenal gland in the United States.

That said, if we are worried about cancer, then we have a very low threshold to do an open operation, meaning that we make a larger incision in order to get the adrenal gland out. The reason that that's so important for a cancer operation is because we don't want to spread anything around. We really want to have enough room, so it means making a larger incision to get that out safely.

Dr. Hyesoo Lowe:

Can you talk us through the various techniques?

Dr. Catherine McManus:

Yes, absolutely. I was just mentioning the open technique, which is where you make a larger incision along the rib cage in the front or in the midline, in the middle of the abdominal wall or the belly. The size of that incision really depends on how large the tumor is. For the minimally invasive approach, there are really two ways. One is where we go through the front, so we go through the belly. That's called a transabdominal approach. 

In that situation, we make small incisions right underneath the ribcage, depending on which side it's on. So the left side would get small incisions under the left rib cage. And we use the small incisions to place our instruments and the camera, so that we can get exposure to the adrenal gland and remove it safely. 

The second approach is to take it out through the back. That is called retroperitoneal. Essentially, what that means is that we make three small incisions also right underneath the ribcage, but the incisions will be right next to the spine, in the back. That's another approach that we can take out through the minimally invasive technique.

The Challenge of Adrenal Surgery

Dr. Hyesoo Lowe:

It seems challenging because the adrenal gland is really socked into the middle of your body, isn't it?

Dr. Catherine McManus:

It is. It's actually toward the back, which is why the retroperitoneal approach, where you have the incisions on your back, was developed in the last 10 years.  The thought being that it is the most straightforward approach to the adrenal gland. Rather than going through the front where you have all of your other organs and intestines sort of in the way.

Dr. Hyesoo Lowe:

Yeah, that makes sense. I'm wondering, why wasn't it done that way to begin with, do you think?

Dr. Catherine McManus:

That's a great question. I think that has to do with laparoscopic surgery, in general, and how it evolved. Laparoscopic surgery started with taking out gallbladders, appendixes, intestines, and stomachs, laparoscopic from the front. 

We in the field who do the approach from the back know that it just looks different when you're taking it out through the back. Whereas when you go through the front, it's familiar anatomy. So there is definitely a learning curve, and that's why you want to make sure that you go to a high-volume center where they do a lot of adrenal operations, if you're going to have the technique done through the back.

Finding Centers that Offer Retroperitoneal Surgery

Dr. Hyesoo Lowe:

I see. I'm guessing that many centers continue to do transabdominal approaches. As the retroperitoneal approach becomes more commonplace., if that's possible, that will be offered, to start, at specialty centers, before it becomes more widespread. Is that right?

Dr. Catherine McManus:

Yeah, I think that's definitely fair to say. I think that's exactly what's happening across the country. The technique was actually invented in Germany. The teaching has sort of dissipated across the United States. 

I would say that most centers that have dedicated adrenal centers, such as we do with a multidisciplinary team, will offer the retroperitoneal approach through the back. They'll also offer the transabdominal. 

When you get to the point where you are able to do both, you've gone through the so-called learning curve where you've gotten used to the different approaches and how each looks, then it's really a case-by-case basis for which you offer the patient. For example, some patients have had prior abdominal surgeries, so they may have some scar tissue in the front, by the other organs. When that's the case, we'd ideally like to avoid that scar tissue. So going through the back is an ideal approach.

Recovery Times, Complications, & Hospital Stays

Dr. Hyesoo Lowe:

Makes sense. Makes sense. Is there any difference in recovery time or any other pros and cons of doing either approach?

Dr. Catherine McManus:

Yeah, most of the data out there says that they are pretty equivalent in terms of complication risk, which is both low, fortunately, in either approach. Length of stay is also low.

In our anecdotal experience, I would say that we think that the approach from the back, the retroperitoneal approach, tends to have a little bit of a faster recovery because patients don't have the other organs that have had to be looked at, per se, during the operation or kind of pushed to the side.

So everything sort of wakes up a little bit faster when you go through the back, and you don't have to move the other organs aside in order to get access to the adrenal gland.

Dr. Hyesoo Lowe:

I see. Is the operative time about the same?

Dr. Catherine McManus:

I would say that once a surgeon performs about twenty-five, thirty of these per year, the time is probably about an hour and a half to two hours to take it out through the back. That's probably about the same amount of time as taking it out through the front.

Cortical Sparing Procedure (A Type of Partial Adrenalectomy)

Dr. Hyesoo Lowe:

Amazing. Now I'm going to bring up some terms that have been sort of brought up by patients from time to time, or you may read about these on the internet or something. I'm sure you get questions about this all the time. What is meant by a cortical-sparing procedure? Is that a thing?

Dr. Catherine McManus:

Yes, that is a thing, and that's a great question. This was getting at, actually, your first question where we were talking about taking out the entire adrenal gland or taking out part of the adrenal gland. 

The adrenal gland has sort of two layers, the outer layer, which is the cortex, and the inner layer, which is called the medulla. When we're talking about a tumor in the adrenal gland, for example, it may be in one of those layers. So when we're talking about a cortical-sparing adrenalectomy, we're talking about essentially a partial adrenalectomy. In that case, you are sparing part of the cortex, which is why it is named that way. You're taking out the part of the adrenal gland where you know there is either a tumor, mostly a tumor, or abnormal cells.

Now, like I said before, the cortical-sparing approach is used in only very select cases. Typically, if patients have some sort of genetic syndrome where they are prone to growing tumors on the adrenal gland, and we want to preserve as much adrenal gland as possible because we know we're probably going to be operating on both adrenal glands at some point during their life, we don't want to leave someone without any adrenal gland. Because again, we have two. So most of the time, if you have one removed, the other one will do the job for both. But if you know you're going to have to address or operate on both adrenal glands, you like to preserve as much adrenal tissue as you can. In which case, we may consider doing what's called a cortical-sparing adrenalectomy.

Robotic Techniques

Dr. Hyesoo Lowe:

I see. Thank you for that. How about robotic techniques? Is this something that is common practice? Is it something that's a special bells and whistles type of thing?

Dr. Catherine McManus:

Yeah. The robotic approach, just like with other laparoscopic approaches, is definitely applicable to the adrenal gland. When we're talking about a minimally invasive adrenalectomy, either through the front or the back, using a robotic approach is definitely an option.

The difference there is, essentially, you have the robot, which sounds very exciting and complex, and you attach the arms of the robot to those long surgical instruments and the camera, and then the surgeon sits at a separate console, is what it's called. They look through and they see the screen.

You have, essentially, these controls at the console, where you move your hand and the robot moves the hand. So you are still doing the operation, the robot is not moving independently, but it is a way that you can get access to more corners of the abdominal cavity, which can be helpful with the adrenal gland since we talked about it being very socked into the back of the abdomen. 

So the robotic approach is a great approach for an adrenalectomy, and I think that is something that is really up-and-coming.

Dr. Hyesoo Lowe:

I see. So the robotic, I guess, instruments allow for a little more agility?

Dr. Catherine McManus:

Yes. The key difference there is that they have a wrist, just like the human hand, except that their wrist spins all the way around, 360 degrees. This gives you a little bit more agility in terms of retracting things and creating the space where you need to see.

Dr. Hyesoo Lowe:

Fascinating. Are there times where the surgeon would decide, "This would be an appropriate case for a robotic procedure," versus, "Not necessary because this is pretty standard stuff"?

Dr. Catherine McManus:

Yeah, I think particularly among patients with obesity, the robotic approach is much easier in terms of getting access. So that can be a huge advantage among patients who have a higher body mass index. Also, if they have had prior operations, it may be another advantage to be able to have all of those instruments that can rotate around fully and give you a little bit better exposure.

Dr. Hyesoo Lowe:

Is there a trade-off, do you think, between the human touch of a procedure versus the greater range of motion that a robot could give?

Dr. Catherine McManus:

Great question. From the human touch aspect, there's really not too much of a difference between the laparoscopic and the robotic approaches.In the sense of laparoscopic surgery, the hand is still holding an instrument that is then going into the abdominal cavity. In this case, I guess the hand is one more degree removed, but it is still an instrument that is making contact with the organs. So laparoscopic and robotic are not terribly different in that regard.

It's really when you go over to an open approach where you definitely use instruments, but you do have your hands in there providing the retraction.

Techniques Offered at Columbia’s Adrenal Center

Dr. Hyesoo Lowe:

Great. Of course I'm going to ask, which procedures do we offer here at Columbia?

Dr. Catherine McManus:

Here, we do offer all approaches. We offer the laparoscopic approach through the front, transabdominal, and the laparoscopic approach through the back, retroperitoneal. We do both of those or offer both of those robotically as well. And we do, of course, the open adrenalectomy.

The Future of Surgical Techniques

Dr. Hyesoo Lowe:

My last question, and I think you've already kind of started to answer this, but do surgical techniques continue to evolve, or we've pretty much got it to a place where we're happy with how we're doing things?

Dr. Catherine McManus:

Yeah. Well, I would say definitely we continue to evolve. I think just the fact that we have, in the last ten years, popularized the retroperitoneal approach through the back is evidence of that, because we're always trying to think of different ways where we can do this operation safely, as our number one priority. But where it may be less invasive for the patient, they may have an easier, quicker recovery. So we're always looking for different ways and brainstorming ways that we can approach removal of the adrenal gland.

We've expanded our abilities to offer a variety of different approaches, which is wonderful. I think, then, it's really about the specific patient. When they come in, exactly what their disease is, why they need to get their adrenal removed, what their history is, whether they've had prior surgeries, and then we can talk about the different approaches that we can offer. 

I think the fact that asking this, maybe twenty years ago, you may not have thought that going through the back was a feasible option, and here we are. I think there's definitely room to grow. 

As innovation is taking over in our field, there is definitely room for new ideas and thinking outside the box.

Dr. Hyesoo Lowe:

Fantastic. I've learned so much on a topic that I thought was pretty simple, taking out an adrenal gland. Turns out that there's a lot to talk about there. Thank you so much for joining us, Dr. McManus, as always.

Dr. Catherine McManus:

Thank you for having me.
 

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