What is Robotic Adrenalectomy 

(Removal of Suprarenal Gland)?

Diagnosing the diseases of adrenal glands and planning the best treatments for these disorders are the most important processes that should be carefully carried out prior to a surgical treatment. 

Adrenalectomy (surgical removal of the suprarenal gland) is performed for adrenal tumors that produce excess amount of hormone, and for all the suspected adrenal malignant tumors. With the radiological imaging techniques used for diagnosis of adrenal gland disorders, all the pre-operative provisions necessary for the treatment can be taken; and thanks to technological advancements, adrenal gland disorders can be treated successfully via laparoscopy technique. However, today, owing to the technologic advantages offered by ‘’daVinci Robotic’’ technology, suprarenal (adrenal) gland surgeries can also be performed via robotic surgery technique. Since adrenal gland operation is not a reconstructive surgical practice but an ablative approach –which aims for removal of the organ– , robotic technique does not have very significant advantages over conventional laparoscopic technique, apart from these listed below:

What are the advantages of Robotic Adrenalectomy?

• Three of four small incision scars
• Operation performed with 3 dimensional (3D) displays, which offer depth perception
• Thanks to High Definition display system, being able to see even tiniest capillary vessels while operating
• Being able to perform a surgery even in the deepest parts of the body, thanks to steady and multi-directional maneuvering robotic arms
• Very little post-operative pain
• Short hospitalization period after the operation – patients are generally discharged on 1st or 2nd post-operative day –
• Fast recovery and being able to carry out daily routines at a very short time
  
  

What is Laparoscopic Adrenalectomy (Removal of Suprarenal Gland)? 

Diagnosing the diseases of adrenal glands and planning the best treatments for these disorders are the most important processes that should be carefully carried out prior to a surgical treatment.

Adrenalectomy (surgical removal of the suprarenal gland) is performed for adrenal tumors that produce excess amount of hormone, and for all the suspected adrenal malignant tumors. With the radiological imaging techniques used for diagnosis of adrenal gland disorders, all the pre-operative provisions necessary for the treatment can be taken; and thanks to technological advancements, adrenal gland disorders can be treated successfully via laparoscopy technique. Today laparoscopic technique is accepted as the standard practice in surgical treatment of adrenal glands. These important glands which secrete various vital hormones are bilaterally located in the deepest and most protected part of our body (on both left and right sides). 

The one on the right side is nestled below the liver, on top of the right kidney and sits next to the right side of vena cava. Left adrenal gland is located below the spleen, on top of the left kidney and just on the left side of the aorta. With open approach, when we also take into account the size of adenoma, it will be necessary to make a really big surgical incision in order to surgically remove such a small structure. Besides, it is really hard to see this deep-seated gland even through that kind of a big incision; so, open surgery is a really challenging option to perform. However, with conventional laparoscopic and robotic techniques, adrenal gland along with the adenoma can easily be removed through a hole, without any surgical incisions. And what’s more, with the advantages of laparoscopic technique, surgery of this deep-seated organ can be performed with very clear, 10-15 times magnified and high-definition view of the area.

What are the advantages of Laparoscopic Adrenalectomy?

• Three or four very small surgical incision scars instead of a large surgical incision
• No risk of developing surgical hernia at incision area, as is the case for open surgery
• Considerably lesser risk of developing long-term chronic pain, which is resulted from the damage caused by cutting muscle layers and nerves.
• Less post-operative pain
• Short hospitalization period following the operation – patients are generally discharged on 1st or 2nd post-operative day –
• Fast recovery and being able to carry out daily routines at a very short time

In the surgical treatment of adrenal diseases, due to the minimal surgical damage, very little post-operative pain and fast recovery advantages, laparoscopic surgery has become the standard first step surgical practice worldwide, as we have mentioned above. While open surgery can be preferred especially in the treatment of adrenal tumors that are bigger than 6cm, experienced surgeons can also use laparoscopic technique successfully in the treatment of adrenal tumors measured up to 10 cm. But laparoscopic adrenal tumor surgery is accepted as the best surgical option in the treatment of active or inactive adrenal tumors that are smaller than 6 cm.

In order to watch how a giant mess is removed from left adrenal gland using conventional laparoscopic surgery technique, please CLICK HERE 

What is partial removal of an adenoma with laparoscopic technique?

Instead of totally removing the suprarenal gland which has benign adenoma, our aim in this approach is only to separate the overgrown adenoma from suprarenal gland, and leave the healthy part of the gland in its place. This technique is called ‘’Laparoscopic Partial Adrenalectomy’’. The aim here is to preserve the adrenal gland as well as possible, which secretes a wide range of hormones and is very valuable for the patient.

Partially removing an adenoma from adrenal gland using laparoscopic technique is a procedure requiring an extensive laparoscopic surgery experience and it should be performed with ultimate care; for, adrenal gland has a high rate of blood flow and it is located very close to major blood vessels. For ‘’Laparoscopic Partial Adrenalectomy’’, after evaluating the computed tomography result, surgical plan should be made by me in advance, and we have to discuss every detail of this technique with patients.

Robotic or Laparoscopic Technique: Transperitoneal? or Retroperitoneal?

Peritoneum is a special membrane made up of two layers, which covers and protects abdominal organs such as stomach, bowel, liver and spleen. Kidneys and suprarenal glands, just like other urologic organs, lie outside of the peritoneum. While using laparoscopic technique, passing through peritoneum in order to reach the organs that will be operated, such as kidney and suprarenal gland –  is called transperitoneal technique (which means, operating by passing through peritoneum). When this operation is performed without touching peritoneum, with no perforation, and not getting in direct contact with other organs, this technique is called retroperitoneal technique (which means operating from the outside, or behind the peritoneum). 

If laparoscopic technique will be performed through peritoneum (transperitoneal), patient is will be positioned with lateral position angled at 45° to 60°.  If laparoscopic technique will be performed from outside the peritoneum (retroperitoneally), without touching intestines, patient will be positioned with lateral position angled at 80° to 90°. In image 1 you can see the type of incision generally made for operating on suprarenal gland tumors using open surgery technique; and in image 2 you can see small surgical incisions made for transperitoneal laparoscopic surgery, one of which is 1.5cm, and the other 2 or 3 incisions are about 0.5cm and 1cm. In retroperitoneal laparoscopic technique, these holes are on the back side of the waist; no scars from the holes can be seen on abdominal wall. Both transperitoneal and retroperitoneal techniques are successfully being performed by Prof. Dr. Tibet Erdogru.

Prof. Dr. Tibet Erdogru will be deciding whether to perform robotic or laparoscopic transperitoneal or retroperitoneal approaches by taking into consideration 

* body weight 

* body structure 

* previous abdominal surgeries 

* size of the adrenal mass

* location of the mass in the adrenal gland. 

Not having to stick to only one technique provides a big advantage in both large adrenal adenoma removals and partial adenoma removals. For instance, while in the video of giant mass removal transperitoneal technique was used, retroperitoneal technique was used in the other video during which the adenoma is partially removed and the remaining healthy adrenal gland is preserved.