Advanced Techniques for Safe Adrenalectomy in Patients With Obesity

Adrenalectomy is a complex, low-volume procedure — only around 7,000 are performed annually in the U.S. compared to about a million gallbladder surgeries.

In addition to being infrequently performed, this surgery is significantly more challenging when the patient has a high body mass index (BMI), because layers of retroperitoneal fat can make it difficult to access the adrenal gland and navigate surrounding tissues safely, notes Eres Berber, MD, surgical director of the Adrenal Center at Cleveland Clinic.

Providers should consider referring patients, especially complex cases, to a high-volume center, where surgeons have more experience and more advanced capabilities for treating patients with significant obesity, says Dr. Berber.

“This is a relatively niche operation. The average general surgeon only does one adrenal surgery a year,” he says. “According to recent guidelines, outcomes are better if patients are operated on at centers that have a high volume of experience.”

Robotic vs. laparoscopic surgery

Adrenal surgery traditionally has been performed laparoscopically, but robotic surgery is gaining popularity. Dr. Berber conducted a study in 2023 that compared the two approaches in patients with high BMI.

“Both options yielded a safe result, but patients who had their surgery done robotically had some additional benefits,” including shorter operative time and less blood loss, Dr. Berber notes.

Robotic surgery offers several advantages over traditional laparoscopic surgery, including a three-dimensional view, a more stable surgical setup, and articulating instruments.

“It’s almost like using your hand, including the wrist motion, so that allows you to do much more in a small space, with a more range of motion,” Dr. Berber says. That can be especially helpful in patients with obesity, where challenging anatomy can make it more difficult to achieve the correct angles for surgery with straight instruments, he added.

Tools for intraoperative imaging

Advanced imaging capabilities also play a role in improving safety and outcomes in adrenal surgery, Dr. Berber says.

These include laparoscopic ultrasound, which allows surgeons to see the tissue planes and critical structures compared to the adrenal tumors and guides a safe line of dissection during surgery.

Indocyanine green fluorescent imaging is another advanced approach that allows surgeons to clearly identify the borders of the adrenal gland, he says.

“Because the adrenal gland has such an abundant blood supply, the dye gives it a brighter green color compared to the surrounding tissues,” Dr. Berber says. “It gives you a roadmap so you can distinguish the borders during the whole surgery.”

This approach can also give surgeons a clue as to which tumors are malignant, since cancerous tumors tend to be more resistant to absorbing the dye, causing them to light up less than benign tissue.

“It helps you tailor the extent of surgery in a given patient,” Dr. Berber says. “So if you suspect cancer, you can plan to obtain a larger margin.”

Advantages of high-volume centers

As one of the highest-volume adrenal centers in the world, Cleveland Clinic performs around 150 adrenalectomies each year, Dr. Berber says.

Along with advanced techniques and specialized tools, surgeons use varying approaches, including lateral transabdominal and posterior retroperitoneal, to get the best results.

“We have a lot of different options for obese patients,” Dr. Berber says.

The key takeaway for providers who rarely perform this procedure is to consider a referral to a high-volume center, especially for patients with a high BMI.

“We are not just doing adrenals as advanced minimally invasive operations, but also doing other abdominal laparoscopic advanced surgical procedures, which helps us in being able to do these procedures with more innovative options,” he says. “We have experience in treating these patients and obtaining good results, and are also constantly working to improve patient care and find better ways of doing this operation.”