Laparoscopic Adrenalectomy / Robotic Adrenalectomy are the minimal invasive surgery or the Key Hole surgery. It is a safe and effective way of removing the Adrenals and the results are comparable with the open surgery. It has got the advantage of the minimal invasive surgery in the form of less pain, shorter hospital stay, smaller scar, better cosmesis, and early return to the work.
What to expect during you preoperative consultation
In the first consultation with the surgeon, he usually reviews all the documents, images and investigation. He does a physical examination and Asses the fitness for the surgery. In case there is adrenal tumor, the surgeon would like to know the functional status of the tumor and size. He usually advises battery of test to know the functional status as it is very important to know this prior to the surgery. Once the date of surgery is finalized, he may advice you to do few test for the surgical fitness and meet an anesthetist and a physician.
What to expect prior to the surgery
Usual preop investigation done are:
- Physical exam
- ECG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood chemistry profile)
- Viral Markers
- 2D Echo in elderly
Preparation for surgery
Medications to Avoid Prior to Surgery
Aspirin, Warfarin, Clopidogrel and some other blood thinner need to be stopped prior to an elective surgery (5-7 days) after approval from the prescribing physician.
Patient is kept nill by mouth (NBM) at least 6 hours prior to the surgery.
The Operation Laparoscopic Adrenalectomy/ Robotic Adrenalectomy is a Key hole surgery performed through 3-5 small incision on the abdomen through which various instruments and telescope is inserted after distending abdomen by a gas. On right side the liver is retracted to see the adrenal. The IVC, Tumor is identified , adrenal vein is dissected, clipped and cut and finally the adrenal is mobilized all around. On left side the bowel and spleen is reflected medially before the adrenal could be seen. Adrenal vein on left side usually drain into the left renal vein. It is identified at the junction where it enters the renal vein and dissected, ligated and cut. The adrenal is mobilized thereafter. The final specimen is retrieved after inserting in a plastic bag either extending a port or putting a separate incision (Pfannensteil)
Open ProcedureLaparoscopic Procedure
Although this procedure have stood test of the time , but like any other surgical procedure it also carries some risk of complication.
The usual blood loss is less than 50 cc and need for blood transfusion is rarely needed.
Infection:all the patient are give preop / intra op antibiotics and usually is continued 24-48 hours post surgery. The risk of the infection is less compared to open surgery, however it may happen.
Tissue / Organ Injury:Although the risk is small if done in experienced hand but in large tumor or a inflamed kidney there can be injury to the surrounding organs or vasculature requiring open conversion or other intervention.
Hernia :Hernias are quite rare because of the smaller size of incision , but may occur.
Conversion to Open Surgery :Conversion to open surgery is not the failure of the surgeon to do a key hole surgery but is a wise decision for the safety and better outcome of the patient. It may be needed if there is failure to progress because of dense adhesion to surrounding structure, or bleeding or injury to surrounding viscera.
During your hospitalization
Patient is shifted to the recovery room after surgery, where he is kept for observation for 4-6 hours. If vitals and other parameters are normal, he is usually shifted to his room post surgery on the same day unless any other comorbities exist requiring ICU care.
Postoperative Pain :There may be a transient pain in the shoulder which is due to the carbon dioxide insufflation. Wound is usually infiltrated with local anesthesia during surgery and post operatively patients receive adjuvant Intravenous analgesics in consultation with the anesthetist.
Nausea :It may happen because of the medications or the anesthetic drugs.
Urinary Catheter :Urinary pipe may be present for couple of days to monitor the urine output. It is usually removed by second postoperative day.
Diet :Most of the patient are give clear liquids by evening and a normal diet next day once he starts tolerating the liquids well.
Fatigue :Generalized weakness and fatigability can be there because of the anesthetist or other drugs. Usually subsides in 5-7 days.
Incentive Spirometry :As many patient hold there breathing because of the pain which can result in some lung related complication. Incentive spirometery is advisable to expand the lung and prevent post
Ambulation :Patient is ambulated on the eve of the surgery. Early mobilization reduces the risk of of blood clots in the leg veins , it also speed up the recovery and bowel movement.
Hospital Stay :The usual hospital stay is 2-3 days in Laparoscopic / Robotic Nephrectomy
Constipation / Gas Cramps :Patient can have mild abdominal distention and constipation due to the anesthetic drugs and other medications specially analgesics. Patient are usually given laxative and early mobilization helps in reducing the bowel discomfort.
Pain Control :There may be mild incisional discomfort, and usual oral analgesics are sufficient to care of that.
Showering :Patient can take shower 3 days post surgery, they can wet the surgical site but have to pad it dry immediately after taking the bath.
Activity :Patient starts walking on the eve of surgery. He can climb stairs after a day. Patient should avoid exercise and gyming for 4-6 weeks. Usually they can resume there normal office work 2-3 weeks after the surgery.
Diet :It is advisable to take low salt , low protein diet post kidney removal. Dietician and nephrologist should be consulted for the proper dietary advice.
Pathology Results :The pathology report is usually available after 5-7 days of the surgery. Patient needs to review with the surgeon again with the histopathology report.
Follow up :Patients need to on regular follow up as advised by the surgeon and the endocrinologist.