Removing an adrenal tumour through the back — keyhole surgery that never enters the abdomen

Most people have never given their adrenal glands a thought until a scan finds something on one of them. The two glands sit deep at the back of the abdomen, one on top of each kidney, tucked against the spine. They are small, they are awkward to reach, and when one has to come out, how the surgeon reaches it makes a real difference to the recovery.

Dr Pieter Marais performs adrenal gland removal by two keyhole routes. The first is the familiar one, through the front of the abdomen. The second reaches the gland directly from the back, through the space behind the abdominal cavity, without entering the abdomen at all. It is called the posterior retroperitoneoscopic approach, and relatively few surgeons in South Africa offer it routinely.

Why an adrenal gland is removed

There are a handful of common reasons:

• An incidentaloma — a growth found by chance on a scan done for something else, which needs removing if it is large, growing or has worrying features.
• Conn’s syndrome — a small gland tumour making too much aldosterone, which drives high blood pressure that resists medication.
• Cushing’s syndrome — a tumour producing excess cortisol, causing weight gain, thinning skin, diabetes and bone loss.
• Phaeochromocytoma — a tumour making adrenaline, causing episodes of racing heart, sweating, headaches and blood pressure spikes.
• A growth suspicious for cancer, or a secondary deposit from a cancer elsewhere.

For the hormone-producing tumours, removing the gland often cures the problem outright. Blood pressure medication is frequently reduced or stopped afterwards.

What “through the back” actually means

The abdominal organs — bowel, liver, spleen, stomach, pancreas — sit inside a lined cavity. The adrenal glands sit behind that lining, in what is called the retroperitoneum. Reaching them from the front means first moving other organs out of the way to get to the back wall.

The posterior approach skips all of that. With the patient positioned face-down, three small cuts are made in the flank and a working space is created directly around the gland. The camera and instruments go straight to where the gland is. Nothing inside the abdominal cavity is touched or moved.

Why it matters to the patient

• The bowel is left alone. Handling the intestines is what usually slows the gut down after abdominal surgery. When they are never touched, eating and normal bowel function tend to return sooner.
• Less to undo. No organs are mobilised and put back, so there is less tissue disturbed overall.
• A short, direct route. The distance from skin to gland is shorter from behind than from the front.
• Typically less discomfort and a shorter hospital stay than the equivalent operation done from the front.

Who the back route suits best

It comes into its own for:

• Patients who have had previous abdominal operations. Scar tissue inside the abdomen can make the front approach slow and difficult. Coming from behind bypasses that scarring completely — a prior laparotomy, caesarean sections or a difficult previous keyhole operation are no obstacle.
• Patients needing both glands removed, where the position avoids turning the patient halfway through.
• Smaller, benign, hormone-producing tumours — Conn’s adenomas in particular.

When the abdominal route is still the right choice

Neither route is simply “better”. The approach from the front gives more working room, and Dr Marais will recommend it for larger tumours, for growths suspected of being malignant where wider clearance is needed, for unusual anatomy, and in some patients where the back route would be technically constrained. The decision is made for each patient after reviewing the scans and the hormone results, and it is discussed with you before the day.

Recovery

Most patients having a keyhole adrenalectomy are up and walking the same day or the next morning, eating normally soon afterwards, and home within a short hospital stay. Driving and desk work usually resume within a couple of weeks, heavier physical work a little later. The small flank incisions heal to marks that are easy to miss.

If the gland was producing hormones, blood pressure and hormone levels are rechecked after the operation, and medication adjusted — often downwards, sometimes stopped entirely. Where cortisol was involved, a short course of steroid cover may be needed while the other gland wakes up.

Questions worth asking at your consultation

• Which route do you recommend for my gland, and why that one?
• Have my hormone tests been completed and what did they show?
• Will I need medication afterwards, and for how long?
• How long before I can drive, work and exercise again?

For referring doctors

Referrals for adrenalectomy are welcome, both transperitoneal and posterior retroperitoneoscopic.

• Best suited to the posterior approach: benign functioning adenomas, tumours up to roughly six centimetres, bilateral cases, and any patient with significant prior abdominal surgery or dense intra-abdominal adhesions.
• Better served transperitoneally: larger lesions, suspected adrenocortical carcinoma requiring wider clearance, and patients where the retroperitoneal working space would be limited.
• Work-up expected before referral: cross-sectional imaging (CT or MRI adrenal protocol), and biochemical assessment appropriate to the presentation — plasma metanephrines, aldosterone-renin ratio, and an overnight dexamethasone suppression test or equivalent cortisol screen. Phaeochromocytoma must be excluded or medically prepared before theatre.
• Higher BMI is not a barrier to the posterior approach and is often an argument in its favour.

Scans and results can be sent through ahead of the consultation so the approach can be planned before the patient is seen.

Talk it through

Read more about adrenal surgery and keyhole surgery at this practice. Every adrenal gland, and every patient, is different — the best way to know which approach fits your case is to book a consultation and go through the scans together.