Choosing the Best Adrenal Surgeon: How to Find the Best Adrenal Surgeon and Operation for Your Adrenal Tumor

Who is the Best Adrenal Surgeon for Me?

The best adrenal surgeon is going to be the surgeon with the most skill and experience. Adrenal operations are difficult and complicated by the adrenal hormones they produce. Since surgery is the only possible cure for adrenal tumors, you should find the surgeon with the most skill and experience with all types of adrenal surgery so your specific needs are met. It is well worth your time to find a very high-volume adrenal surgeon. Lower volume surgeons (performing fewer than 6 adrenal operations per year) may have a complication rate that is 10-20 times higher than a high-volume adrenal surgeon.

Editorial note: Some surgeons will tell you that 6 adrenal operations per year makes a surgeon an "expert". Dr. Carling’s experience, training dozens of endocrine surgeons as the Chief of Endocrine Surgery at Yale University, is that a surgeon should perform AT LEAST 50 adrenal operations per year to be a true high-volume surgeon. Only these select, handful surgeons can offer the best operation with the lowest complication rate and highest cure rate. In the world, there are very few expert adrenal surgeons.

What are some of the things you should know about adrenal gland surgery? Read more on our adrenal surgery blog

The Importance of Surgeon Volume and Experience at Adrenal Surgery

If you have an adrenal tumor, the most important factor for you to have a good outcome is your choice of adrenal surgeon. Typically, the best adrenal surgeon is the one with the most experience. That does NOT mean the surgeon with the most experience in your city! For almost all people, this means you will need to tavel to another city to be operated on by an expert.

Unfortunately, the median (average) number of adrenal operations performed by adrenal surgeons in the United States per year is… 1 (one). You read that correctly. Most people have their adrenal tumor removed by a surgeon that performs ONE adrenal operation per year. Yes, we are not kidding. Indeed, it would be a joke if it were not for the fact that you, or your loved one, depends on having an experienced surgeon for optimal outcomes. When your surgeon tells you he/she is an expert at adrenal surgery because they perform up to 6 adrenal operations (adrenalectomies) per year it is self-serving. This is akin to stating that you are an expert airline pilot if you fly an aircraft only 6 times a year. In a single day, the surgeons of the Carling Adrenal Center may perform more adrenal operations than your average surgeon in a career. It may seem that this paragraph is self-serving with respect to ourselves, but unfortunately, as a referral center for patients worldwide, we see complications from low-volume adrenal surgeons EVERY DAY--and it breaks our hearts.

Don't endocrine surgeons perform adrenal surgery? Yes, but unfortunately, a recent publication by several endocrine surgeons showed that endocrine surgeons in the United States perform fewer than 3 adrenal operations per year on average--this clearly does not make them the "best". They concluded that 5 adrenal operations per year would make somebody "high-volume". It is our opinion that nobody would let a surgeon operate on them if they knew their surgeon performed 5 of these operations per year. You must ask your surgeon the obvious question: "How many adrenal operations did you perform in each of the last 3 years?". If they can't look you in the eye and give you a satisfactory answer, then please, seek a second opinion. For most of you, this means you will need to travel, but let's face it: few people know anybody that had an adrenal operation.

We realize we cannot operate on every patient in the world needing an adrenal operation, but you should identify the highest-volume adrenal surgeon in your area. Ideally, the best surgeon for adrenal tumors is an endocrine surgeon with a special emphasis on adrenal tumors.

Why Are There so Few Adrenal Surgery Experts?

The reason there are so few experts who do lots of adrenal surgery is because 1) there aren't many adrenal operations to be done, and 2) there are, at least, 4 different types of surgeons who perform an occasional adrenal operation. In any big city, there are 25 surgeons who perform 1 or 2 adrenal operations per year instead of 1 surgeon who performs 100 per year. This is most unfortunate, and frankly, the reason the Carling Adrenal Center has patients referred to us by doctors from all over the world. The following doctors are known to occasionally perform adrenal surgery and who you will get if you don't seek an expert:

• Endocrine surgeons
• "Minimally invasive surgeons" who also perform hernia, intestinal, bariatric, weight loss, gallbladder, gastric, and reflux operations
• Surgical Oncologists who also operate on breast, melanoma, intestine, liver, sarcomas, pancreas, colon, rectum, and other organs
• Urologists, who treat urinary tract infections, erectile dysfunction, kidney stones, prostate and bladder problems, as well as kidney disease and tumors

What is the best way to choose your adrenal surgeon? Read more on our adrenal surgery blog

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Which Adrenal Operation is Best for Me? How Does the Surgeon Decide?

The best adrenal surgeons will consider a number of factors when determining which adrenal operation is best for each patient as an individual. Although 95% of patients are best served by a the Mini Back Scope Scope Adrenalectomy (MBSA), the surgeon must look at multiple things to make sure the operation chosen is the best in that circumstance. Things to consider include:

FDG-PET and MIBG scans demonstrating recurrent pheochromocytoma in the right adrenal bed (arrow) due to tumor spillage at the first operation. Dr. Carling achieved a cure after re-operative “cleaning up” surgery. Of note, the first operation was performed at a world-famous hospital, ranked in the top 3 of the U.S. News Best Hospital Honor Roll.

1. The size of the tumor. Since very large adrenal masses and tumors are more likely to be cancer, they may require a larger incision and a more careful dissection. Unfortunately, it is not uncommon that inexperienced surgeons when operating on adrenocortical cancer or pheochromocytomas violate the capsule of the tumor and cause tumor spillage. This is a big problem since the tumor cells can then implant into the surrounding tissue and make the tumor grow back (local recurrence). Additionally, it may be difficult to remove a large adrenal tumor using scopes because the surgeon cannot see around the tumor with the camera. Sometimes, performing a laparoscopic hand-port assisted transabdominal adrenalectomy may be beneficial in this scenario. This is discussed on our Eight Types of Adrenal Surgery page.
2. The type of adrenal tumor. Many adrenal cancers (whether adrenocortical cancer, malignant pheochromocytomas or paragangliomas) may require a larger incision and therefore must be removed through a larger operation to ensure all of the cancer is removed. This is especially true if it is invading surrounding structures such as the kidney, liver, spleen, pancreas, bowel or major vessels such as the inferior vena cava (IVC). Sometimes, cancerous adrenal tumors are not appropriately removed using the new minimal or laparoscopic operations. Many times, we do not know for sure whether the adrenal tumor is cancerous or not until during the operation. An experienced adrenal surgeon will use his/her best judgment to decide which operation is the most appropriate.
3. The appearance of the tumor on a CT, MRI, PET or other imaging study. It is absolutely crucial that the surgeons is an expert in interpreting the findings of adrenal tumors on various imaging technologies. Cancers tend to look different on these scans from benign tumors. We have an entire page on imaging of adrenal tumors.
4. A history of previous abdominal operations. If a patient has had previous abdominal operations, then the laparoscopic transabdominal adrenalectomy (the scope operation through the FRONT of the abdomen) can be more technically difficult, if not, impossible. One of the beautiful things about the Mini Back Scope Scope Adrenalectomy (MBSA) is that the surgeon does not enter into the abdominal cavity from the front and does not need to deal with scar tissue (adhesions) from a previous operation. If your surgeon does not routinely use the Mini Back Scope Scope Adrenalectomy (MBSA) technique, he/she is unlikely to be experienced or a high-volume adrenal surgeon. We now have a large page dedicated to this new and best technique.
5. The surgeon's experience with different operations. Many surgeons do not know how to perform adrenalectomies well. We say this on multiple pages of this website because every day we see patients hurt by their local general surgeon or urologist who has no expertise in adrenal surgery and just adapts an operation that they know how to do (like removal of a gallbladder or prostate) to the removal of an adrenal gland. How in the world are they going to learn how to perform an advanced operation like the Mini Back Scope Scope Adrenalectomy (MBSA) when they only do a few a year?

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What About the Biopsy of My Adrenal Tumor?

Remember, a biopsy of the adrenal tumor is almost never helpful...The important rule on this website is DO NOT PERFORM A BIOPSY OF AN ADRENAL MASS. It can be very dangerous to biopsy an adrenal mass if the patient has a pheochromocytoma. If the patient has an adrenocortical carcinoma (adrenal cancer), the biopsy may spill tumor cells. The tumor cells can then implant, and cause local recurrence. Also, a fine needle biopsy can never distinguish between a benign and malignant adrenocortical tumor, and is thus a wasteful, meaningless, invasive procedure that may cause significant harm.

A note about previous abdominal surgery. Previous abdominal surgery is NOT a contraindication to advanced minimally invasive adrenal surgery since surgeons who perform these advanced operations are typically supremely excellent at operating through a scope, so they can usually deal with the scars inside the abdomen that are a result of previous operations. Intraabdominal scars (known as adhesions) may be from previous operations, such as bariatric (weight loss), gallbladder, liver, stomach, bowel (colectomy, appendectomy, etc) or any previous kind of gynecological operations. The presence of abdominal scars will be considered, however, when deciding who can have a minimally invasive versus open adrenalectomy. Again, whenever possible, the Mini Back Scope Scope Adrenalectomy (MBSA) is the preferred surgical approach for >95% of patients with adrenal tumors.

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Many low-volume adrenal surgeons only know how to do the laparoscopic transabdominal adrenalectomy (LTA) (the FRONT scope operation) or the robotic adrenal operation. He/she is likely to be inexperienced or a low-volume adrenal surgeon, and do not perform the best operation, i.e. Mini Back Scope Scope Adrenalectomy (MBSA). You should seek more expertise. We have a large page dedicated to this new and best technique.

Bottom line about finding the best adrenal operation. The best surgery technique is less about the technology being used, but rather for the patient to identify the smartest, most knowledgeable, thoughtful surgeon who has the most superior understanding of adrenal anatomy, disease, tumors and the one with the most experience in adrenal surgery. Reading the pages of this large website, you have come to understand that the adrenal gland and its functions may appear complex, and indeed many patients and doctors struggle to obtain a comprehensive understanding of adrenal function and adrenal tumor disease. For us at the Carling Adrenal Center, though, this is easy. This is what we do, day in and day out. We live and breathe adrenal tumor disease every day. The number one priority is to achieve a perfect and safe operation without complications and cure the patient. Secondarily, we aim to do it quickly (minimizing anesthesia time), efficiently, and with a superior cosmetic result.

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