Laparoscopic Adrenalectomy

 

This information sheet is designed to answer questions you may have on admission and discharge from hospital.

What is the adrenal gland?

We all have two adrenal glands. One is on top of the right kidney and the other over the left kidney. The kidneys lie at the back of the upper part of the abdominal (tummy) cavity. The right is covered by the liver and the left by the spleen. The adrenal gland is usually removed because there is an abnormal growth in either or both of them. These growths are benign in the vast majority of cases, though about 1 in 10 can be cancerous. You will usually be asked to have the gland removed because it is functioning abnormally.

What do the adrenal glands do?

The adrenal glands are important in that they make a number of vital hormones (chemical messengers) which help us to maintain a normal blood pressure, deal with everyday events and provide the adrenaline that we feel from time to time when in a -flight or fight' situation. Their function is normally tightly regulated by the nervous system; indeed they provide one way in which our brain can interact with the rest of our body. Problems may occur with the adrenal glands in that they occasionally make their hormones in large quantities; these are rare but important events as the extra hormones cause physical changes such as raised blood pressure, weight changes or a change in body shape.

How will you be prepared for the operation?

When will this happen?
Your doctor will usually refer you to a hormone specialist (endocrinologist) who will use a combination of blood and urine tests together with special scans to decide how well the adrenals are functioning. If excess hormone production is found, it will often be necessary to use tablets to counteract the effects of the hormone concerned before performing an operation. This is needed in order to ensure that the operation can be carried out safely. If it is felt that your adrenals are not working well enough, tablets may be needed to replace the missing hormones before your operation.
Such treatments are not always needed; this is something, which will be decided upon by your doctor. In some cases it is very important to continue medication several weeks before surgery in order to control the hormone levels, this can of course be a little frustrating but is a vital part of your treatment.

What happens before the operation?

The Pre-assessment clinic. It is probable that a week or two before the operation you will be asked to attend a pre assessment clinic at the hospital where you will be seen to check that all arrangements for your operation are in place, that blood test are up to date and that you are on appropriate medication and fit enough for surgery. You will also have swabs taken to ensure that you do not carry mrsa bacteria going into surgery and if necessary you will be given antiseptic washes to ensure that everything is as safe as it can be for your surgery. There will be an opportunity for you to clarify any questions you may still have and the precise arrangements for your operation will be confirmed.

Welcome to the Ward. You will be welcomed to the Ward by either nurses or the receptionist. You will be shown to your room and will be asked to change. Some basic tests such as your pulse, temperature, blood pressure, weight and urine examination will be performed. You will need to hand in any drugs or medicines you may be taking, so that your drug treatment in hospital is adjusted accordingly.

Visits by the Surgical Team. The Consultant and house surgeon will visit, interview and examine you. This may have been carried out prior to admission in the pre-admission assessment clinic. The doctors may wish you to have some special tests such as blood tests or a heart tracing (E.C.G). Your operation will again be explained to you and you will be asked to sign a consent form. If you are not clear about anything, you must as the doctor for more details. The side of the abnormal adrenal gland will be marked on your skin with an indelible marker whilst you are awake to confirm the operation takes place on the appropriate side. If you think there is any discrepancy in this it is essential that you query this before going to the operating theatre.

The Consent form
You will be required to sign a form giving your consent to the precise operation planned and that this consent is freely given and fully informed. Without such consent your operation cannot proceed. In order to be fully informed you must understand the treatment proposed, the alternative treatments which may be available (or the probable consequences of not having surgery) and the potential complications and pitfalls of surgery. You will also be advised as to any additional surgery which may be occasionally required such as conversion to open surgery if the operation cannot be safely completed laparoscopically.

Possible Complications
These will be discussed again with you as you are asked to sign the consent form. Complications are uncommon after laparoscopic adrenalectomy but as with any operation there are some risks which include:

  1. Adverse reaction to general anesthesia
  2. High blood pressure
  3. Bleeding
  4. Injury to other organs
  5. Wound problems, blood clots, heart attacks, and other serious complications are uncommon after laparoscopic adrenalectomy

Visit by the Anaesthetic Team. You will be seen by a member of the Anaesthetic Team, who will again interview and examine you. They will explain about the anaesthetic you will be given and will also talk to you about pain relief in the post-operative period.
Shaving. You may be asked to shave your abdomen.
Diet. You can expect to be eating normally up to 6 - 12 hours before your operation, and to be drinking up to 2 - 4 hours and then to have nothing by mouth. This is to allow your stomach to empty for the operation.
The Bowels. No special preparation is needed.
Stockings. You will be asked to wear elastic stockings (T.E.D) to prevent thrombosis (clot) during your stay.
Timing of the Operation. The nursing staff will be able to tell you approximately when you can expect to go to theatre. Do not be surprised, however, if there are changes to the exact time.
Premedication. It is uncommon to be given pre-medication but hospitals do vary and if you feel strongly about this please raise this with the team.
Transfer to Theatre. You will be taken to the operating theatre on a trolley by a ward nurse and a porter. You will have been asked to change into a cotton theatre gown; wedding rings fastened with tape and other jewellery removed. Dentures will be left on the ward. There will be several checks of your details on the way to the anaesthetic room, where your anaesthetic will begin.

What does the operation consist of?
Three/four small incisions (cuts) are made in your abdominal wall (the tummy). An instrument called a laparoscope (this is a telescope with a camera attached to the outside end) is passed through one incision and instruments through the others. Carbon dioxide gas is used to inflate your abdomen and this creates a space to allow the surgeon to work in. The adrenal gland is then freed. Blood vessels to it are closed off with clips and divided. Once the gland is completely free it is placed in a bag and removed through one of the incisions. The incisions are then closed with stitches and/or clips. Using the laparoscope causes less damage to the abdominal wall, which therefore means a much quicker recovery from surgery.

What happens after the operation?

Coming round after anaesthetic. The Anaesthetist will have told you prior to your operation where you should expect to wake up. This will either be in the high dependency unit (HDU) or on the ward. Your blood pressure and pulse will be monitored and you will be given oxygen until you are fully awake.

Will it hurt? There may be some discomfort, but you will be given painkillers either by injection or in tablets (once you are able to tolerate them) if you let the nursing staff know.
As the abdomen has been distended with gas during the operation, it is not uncommon to experience some discomfort in the shoulder area. This will gradually ease, but can sometimes take up to one week to disappear.

Drinking and eating. You should be able to drink as soon as you are fully awake and the medical/nursing staff will let you know when you are able to eat. This is usually within 12-36 hours after your operation.

How long in hospital? Provided you make a good recovery you will be allowed home in 1 - 3 days. Please ask for a sick not if you require one.

After you leave hospital. You will find that you tire easily. It is best to have someone around until you feel able to cope comfortably. It will take between 2 and 6 weeks for this to wear off completely. It is advisable that you don't drive for at least 1 week. You must be able to make an emergency stop comfortably before you drive.

Exercise. It is important to exercise. You must try and do a bit more every day until you get back to normal fitness. Aim to get there between 3 and 4 weeks after surgery. Heavy lifting is best avoided until your exercise tolerance is well on the way to normal.

Diet and fluids. You should not require a special regimen. Try to eat and drink normally as soon as you get home. It is not uncommon for the bowels to be a bit sluggish after surgery, and a mild aperient can be obtained from the chemist to ensure that you have your bowels opened normally. You will be able to stop this once you return to normal.

Sex. You will be able to resume sexual intercourse as soon as you feel able.

Wounds. The wounds are most usually closed with dissolvable stitches. If they are not, the nurses will advise you when and where to have them out.

Drugs. In most cases, the drugs used to prepare you for the surgery will have been stopped at the time of your operation. Many people do however need to continue with other tablets; if you are in any way unsure as to how to use them please ask your specialist for advice.

When both adrenal glands have been removed or when the reason for adrenal gland removal was to stop excess steroid production by the adrenal gland it will be necessary to take replacement amounts of the adrenal gland hormones in order to keep you well. The time at which you take the tablets and the quantities needed are both very important; you should receive clear instructions from your doctor before you leave hospital. These treatments are usually needed for the rest of your left and you will need to carry a card, or special bracelet, to show that you take these tablets. You will also be told that whenever you develop another illness, such as flu or a stomach bug, you will need to increase the dose of some of your tablets, for a few days only, in order to cope with the new problem. This is again something that you must discuss with your doctor so that you know what to do at these times. If for any reason you are unable to keep your tablets down due to repeated vomiting, an injection of steroids will be needed.

If your adrenal operation was performed to help deal with high blood pressure, it may become possible for your specialist to reduce some of your blood pressure medication.

If only one adrenal gland was removed, the second gland is usually able to produce all the necessary hormones. Under these circumstances you will not normally need any new medication following surgery.

Work. Depending upon the nature of your work you will be able to return to work between 2 and 4 weeks after surgery. If in doubt please ask your doctors.

Advice. If you have any problems or queries, please ask the nurses or doctors. You will be given contact details before you are discharged.

WHEN TO CALL YOUR DOCTOR AFTER SURGERY
Be sure to call the ward, your surgeon or your GP f you develop any of the following:

  • Persistent fever (over 38O C)
  • A pulse rate of over 100 bpm for more than an hour or two
  • Bleeding
  • Increasing abdominal swelling
  • Pain that is not relieved by your medications or that is increasing in severity
  • It would be abnormal to need painkilling drugs stronger than paracetamol after the first three days.
  • Persistent nausea or vomiting
  • Chills
  • Persistent cough or shortness of breath
  • Purulent drainage (pus) from any incision
  • Redness surrounding any of your incisions that is worsening or getting bigger
  • You are unable to eat or drink liquids