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Adrenal Surgery at Johns Hopkins

Tumors of the adrenal glands can be either malignant (cancer) or benign (non-cancer). These tumors can cause different symptoms.

Some patients are diagnosed with primary hyperaldosteronism, a condition where too much aldosterone is produced by the adrenal glads, which can cause lower levels of potassium in the blood. In 80% of these patients it is caused by an adenoma (benign tumor) in the adrenal cortex that releases too much aldosterone. Symptoms may include high blood pressure, low blood potassium levels and muscle weakness.
Cushing's syndrome is also caused by an adrenal cortex tumor. Symptoms may include moon face (round, puffy face), buffalo hump (an increase in fat pads just below the back of the neck), truncal obesity (increase in weight around the abdomen), wasting of your muscles, easy bruising, facial hair, purplish "stretch marks" on your abdomen, high blood pressure and changes in emotions from feelings of high to low.

Another type of adrenal tumor is called a pheochromocytoma. Pheochromocytomas are usually located in the adrenal medulla. About 85- 90% occur at random, but some may occur in families. Symptoms can include headache, sweating, palpitations (rapid heart beats), and high blood pressure.  There will also be high levels of catecholamines (epinephrine and norepinephrine) in the urine and blood.
 
Most adrenal tumors can be removed by a surgical procedure called laparoscopic adrenalectomy. In a small number of patients it may be necessary to convert a laparoscopic adrenalectomy to an open adrenalectomy. For some patients, an open adrenalectomy may be preferable initially. Your surgeon will explain your specific surgery and why it is recommended in your case.

As with any surgical procedure, there are risks involved. There is a risk of bleeding and extreme changes in blood pressure. The risk of infection is so low that antibiotics are not routinely used. There is also a very low risk of pneumonia, injury to bowel, spleen, pancreas or liver. There is also a small risk associated with anesthesia. However, the relative risk of complications is very low and is usually outweighed by the potential benefits of having the surgery. Your surgeon will go over this information with you and answer any questions you might have.

Before Your Appointment

Our physicians want to make sure we are prepared for your visit and therefore, before we can schedule an appointment, we will need you to provide us with the following:

  • Medical records
  • Radiology images (CT/CAT or MRI) on a CD and reports
  • Lab test results (cortisol, aldosterone, metanephrines, catcholamines), if available

Before Surgery

Once the surgery has been scheduled, arrangements will be made for your pre-operative evaluation by your surgeon's secretary. You will meet with a nurse practitioner or physician's assistant in the Preoperative Evaluation Area at the Johns Hopkins Outpatient Center. The pre-op evaluation can include a history and physical, laboratory studies, chest X-ray, a urine test and EKG.

A bowel preparation is also necessary 48 hours prior to your surgery. Purchase Fleets Prep Kit # 1 with phospho-soda and follow the directions. This may be purchased without a prescription at the pharmacy counter of your local drug store. You will also be on a clear liquid diet 24 hours before surgery. This includes Jell-O, broth, popsicles, tea, coffee, and soda. You should not drink milk, cream, milkshakes, orange or tomato juice, cream soups or oatmeal. Prior to surgery, you may be prescribed medications for your blood pressure. It is important to take them as directed. If you take aspirin or nonsteroidal anti-inflammatory agents you should stop taking these one week before surgery. The night before surgery, do not have anything to eat or drink after midnight.

The Day of Surgery

Your doctor's secretary will let you know where your surgery will be and what time you need to arrive at the hospital on the day of surgery. It is very important to arrive at least 2 hours before surgery. During the surgery, your family can wait in the family waiting area. They will be kept updated by the patient representative and operating room staff.  Your surgeon will speak with them after surgery has been completed.

What will happen in surgery?

You will be given general anesthesia. You are placed on your back or on your side depending on how the adrenal gland is being removed. You will have a foley catheter inserted into your bladder to drain your urine. Also, a small tube will be inserted through your nose or your mouth into your stomach. This will keep your stomach empty and prevent nausea and vomiting. You will also have one or more intravenous (IV) tubing to give you fluids. If you are having a laparoscopic adrenalectomy, four to five small incisions will be made into the side of your abdomen. These small incisions are used for the laparoscopic instruments to extract the adrenal gland. For an open adrenalectomy, one long incision is made in the middle or across the abdomen. The incision is stitched closed and is then covered with white tapes called steri-strip tapes and a dry gauze dressing. The operation generally lasts from two to four hours.

After Surgery

You will stay in the recovery room for several hours. You will be monitored closely as you recover from the anesthesia. The evening of surgery you will have a liquid diet for dinner. You will be offered regular food the next morning. If you need something for pain, your nurse will give you pain medicine as needed. You will be encouraged to get out of bed and walk the night of surgery. You may also have a sore throat. This is a result of placement of anesthesia tubes during surgery. Throat lozenges and spray usually help. Many patients who have had a laparoscopic adrenalectomy are ready to go home after breakfast. Patients who have had an open adrenalectomy usually stay three to five nights.

Discharge Instructions

  • Diet:  class="Apple-converted-space" You may resume your regular diet.
  • Medication:  class="Apple-converted-space" You may resume any medications you were on prior to surgery. If any new medications are needed, you will be given a prescription for them along with instructions.
  • Pain Control:  class="Apple-converted-space" You will be given a prescription for pain medication which should be taken as directed.
  • Activity:  class="Apple-converted-space" You may resume normal activity. You may be tired when you return home. You may walk up stairs and ride in a car. Walking is encouraged to reduce abdominal discomfort and assist in normal bowel movements. You should not drive while on narcotic pain medicine or until you can safely and quickly apply brakes. Some muscle soreness may be noted from how you were positioned on the operating room table for the surgery. Do not to lift anything greater than 20 pounds.
  • Showering:  class="Apple-converted-space" You may shower but keep the incision clean and dry.
  • Suture Line Care:  class="Apple-converted-space" The steri-strips should be removed seven days after discharge. The incision will be red and raised initially but will fade with time.

Signs of Infection

  • Temperature greater than 100 degrees F for more than 24 hours
  • Swelling, tenderness, redness, unusual drainage from your incisions
  • Nausea, vomiting, or shaking chills

When to Call the Surgeon

Contact your surgeon for any signs of infection or if your pain is not controlled by your pain medications.

Follow-Up Care

Call the surgeon's office to arrange a follow-up appointment.

Routine Recovery

Most patients take 1 to 2 weeks to recover from the laparascopic surgery and 5 to 6 weeks from an open adrenalectomy.

 

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