Adrenal Gland Surgery: What You Should Know

When faced with adrenal gland surgery, a few questions come to mind as to what you should know and expect before and after your operation.

• How should I prepare for adrenal gland surgery?
• How quickly can I return to work and my normal activities after adrenal gland surgery?
• What can I expect at home after adrenal gland surgery?

How should I prepare for adrenal gland surgery?

By now, you should have had a discussion with your doctor regarding the need for adrenal gland surgery, picked your surgeon and surgeon-driven team, and have a general understanding of the planned approach to removing your adrenal gland.

If you haven’t picked your adrenal surgeon yet, make sure you read one of my previous blogs on The Top 4 Worries for Adrenal Gland Removal. This will help you pick a surgeon, choose the correct operation for you, and a few other items you need to know if you are about to have adrenal surgery.

Checklist in Preparation for Adrenal Gland Surgery

In preparing for your adrenal gland surgery, here is a checklist we give to our patients to consider:

1. Start (or hopefully continue) walking or exercise regimen for a few weeks prior to surgery. The best benefits are if the exercise (walking, housework, gardening, etc) increases your heart rate for at least 30 minutes, five times a week. It may initially be hard to do a full ½ h, so work up to this if difficult at first, and always seek medical attention should you develop chest pain or significant shortness of breath with increased activity. If your adrenal gland tumor is a pheochromocytoma (pheo), very strenuous exercise causing increased heart rate is not advised, and you will be taking medication to reduce the work of your heart (see link below). Overall, preoperative exercise improves stamina allowing for safer administration of anesthesia during surgery, and faster recovery after the operation.
   
   Check out our recent blog post discussing pheochromocytoma (pheo) here.
   
   
2. Stop blood thinners for the appropriate time frame based on the medication, (always under the guidance of prescribing doctor), including Coumadin, Eliquis, and NSAIDs such as aspirin, ibuprofen, Motrin, Aleve, etc. Typically, this is about 5 days prior to surgery—but ask your surgeon.
   
   
3. Make sure to have your overnight bag packed (essentials: toothbrush, change of clothes, underwear, good book, tablet, etc). Most patients having an adrenalectomy will spend a night in the hospital. Since we do almost all of ours through the mini-back-scope operation, almost nobody spends more than a single night. If you are having an operation through the front of your abdomen, then plan for 3 or more days in the hospital. (most people should not have their adrenal glands out through the front of their abdomen).
   
   
4. To allow for most efficient aftercare, ensure you have an appointment with your medical doctor (most commonly your endocrinologist, nephrologist or primary care doctor) about 4-6 weeks after the operation.
   
   
5. Buy a blood pressure monitor and get into the habit of measuring your blood pressure and heart rate at least twice a day (morning and before bedtime), and keep a good record so you can compare how your blood pressure gets better after surgery. Adrenal gland hormones can have significant effects on your blood pressure, with the purpose of the operation to make your blood pressure better.

Regardless of why you are having adrenal gland surgery, typically for a large size tumor or for hormone over-production, there are certain things you can expect on the morning of your surgery. Plan on showing up early to the hospital on the day of your surgery, having a dedicated adrenal X-ray (typically a CT scan), so that your surgeon can review the pictures and see growth patterns, and finally, settling-in for an efficient day of meeting people dedicated to caring for you during and after your adrenal gland surgery.  You will meet your surgical and anesthesia teams on the day of surgery and have opportunities to go over any questions or concerns. Depending on your age and medical history, the anesthesia team may require an electrocardiogram (EKG) and/or basic lab tests.

Preparation for a Hormone Producing Adrenal Tumor Operation

If your adrenal gland surgery is for a large size tumor, there is not much more to do apart from that mentioned above. If your adrenal gland surgery is for hormone over-production, in addition to that mentioned above, there will be some things to do in preparation for surgery, depending on the hormone that is being over-produced.  You may be asked to obtain a preoperative heart evaluation with appropriate testing (chest X-ray, heart ultrasound, stress test, etc.) as deemed fit by the heart doctor.

• Aldosterone over-production (Conn’s syndrome or primary hyperaldosteronism)
  
  People with aldosterone producing adrenal tumors will typically require multiple medications to treat their high blood pressure, often including the potassium-sparing diuretic, spironolactone (or eplerenone).  You may also be taking potassium tablets.  It is important to stay on these medications up to the time of your operation, which will be weaned off by your surgeon-driven team after successful adrenal gland surgery.

• Cortisol over-production (Cushing’s syndrome)
  
  People with cortisol producing adrenal tumors will also need to continue taking their medications up to the day of surgery.  After removal of the adrenal gland that is responsible for the excess cortisol production you may require a short course of oral steroids.  If you have an endocrinologist, it is important to discuss this possibility with him/her and consider having the prescription filled prior to surgery.  Your surgeon-driven team will determine if a steroid after adrenal gland surgery is necessary and they will communicate with your endocrinologist.

• Adrenaline over-production (Pheochromocytoma)
  
  People with a pheochromocytoma will almost always need preoperative medication to block or dampen the “fight-or-flight” hormones that are being over-produced by the adrenal tumor.  Typically, doxazosin (a class of medications called an alpha-blocker) is used for at least two weeks to prepare your body for adrenal gland surgery.  Often, we have our patients eat more salty foods than normal and drink more water for a week or two prior to surgery.

Monitoring Your Blood Pressure After Adrenal Surgery

In all three of the above tumor types, removing the causative adrenal gland is likely to improve your blood pressure and heart rate (sometimes almost miraculously), so use your blood pressure monitor and measure your blood pressure and heart rate at least twice a day (morning and right before bedtime) and keep a good record so you can compare how your blood pressure gets better after surgery. Bring your records to all follow up appointments with your doctors.

Also, other positive things are very likely for you after your surgery. If you have diabetes, it may be cured, or if not cured, often you can reduce your medications, including your insulin so keep a close record of your blood sugar. Your weight may also start to go down, especially in cortisol producing tumors (Cushing’s syndrome), so make sure to record your weight trends.

Start with the link below for additional links and information discussing the hormone over-producing tumors of the adrenal gland:

https://www.adrenal.com/adrenal-tumors/overview

How quickly can I return to work and my normal activities after adrenal gland surgery?

Fortunately, adrenal gland surgery is not meant to keep you down with a prolonged recovery.  Depending on the approach to your adrenal gland removal, particularly if you are able to proceed with the most popular Mini Back Scope Adrenalectomy ( >95% of patients can and should have this, the best operation—but it is an advanced operation that most surgeons do not know how to perform), you should plan to have your surgery early in the week and be back to work and typical activities early the following week.  Obviously, the more invasive the surgery, the longer the recovery, with laparoscopic adrenal gland surgery through the belly being the next quickest recovery (conservatively 2-4 weeks), and open surgery having the longest time (4-6 weeks) before typical activities and return to work.

Read more about the Mini Back Scope Adrenalectomy on our website where we have a lot of great information on this fantastic adrenal operation.

Recovery times can depend on how you prepare for your surgery, with patients who are better conditioned, preoperatively, bouncing back quicker than those in less optimal shape.  Recovery times are also very much dependent on your surgeon’s skill or expertise. Master surgeons, who can perform the operation more efficiently and safely, allow for shorter anesthesia times and less manipulation of surrounding structures, and thus, overall quicker return to preoperative routines.  Lastly, recovery times can depend on the type of adrenal tumor removed.  You will likely feel so much better after an adrenaline-, cortisol-, or aldosterone-producing tumor is removed that your recovery is a breeze compared to how you felt before your adrenal gland surgery. 

Plan to spend the night of your surgery in the hospital under the care of your surgeon and the team of nurses that work with him/her.  Basic blood tests will be drawn and your vital signs carefully recorded to show the improvement in your overall health after your adrenal gland surgery.  Immediately after surgery, you will be out of bed and walking the surgical floor with the help of your nurse as needed.  You will be on a regular diet and provided non-narcotic pain medication, both as tolerated.  If you had an adrenaline-producing tumor removed, you may require an overnight stay in a more monitored setting to ensure your team is aware of slight changes in your blood pressure and heart rate.  This is done as a precaution to ensure quickest return to your normal activities.

Short-Term Steroid Hormone Replacement After Adrenal Surgery

Short-term steroid hormone replacement (Hydrocortisone or Prednisone) is occasionally required after cortisol-producing tumors are removed, which can sometimes affect overall recovery. The best dose is determined by your endocrinologist and surgeon.  Based on a blood test the morning after your surgery, the steroid dose can be decided upon with good accuracy, setting you up for the best success and quickest return to work and the activities you enjoy. The steroid hormone replacement (Hydrocortisone or Prednisone) can be weaned off after a few weeks to months as your remaining adrenal gland starts producing cortisol normally. It has been suppressed (put to sleep) by the big adrenal tumor, so it needs some time to wake up and start producing cortisol again after the tumor is gone.

Medication changes after adrenal gland surgery will occur, but it is imperative that these changes are made under the guidance of your surgeon-driven team, NOT on your own.  You will feel better and notice significant improvements in your overall quality of life, with better blood pressures than you have seen in years. However, your body has become used to your medications, and thus, they must be changed or discontinued slowly, under physician guidance, or you could jeopardize your health.

What can I expect at home after adrenal gland surgery?

With roughly 95% of those needing adrenal gland surgery being good candidates for Mini Back Scope Adrenalectomy (MBSA), we will focus our discussion here.  After undergoing MBSA, you will be discharged from the hospital after breakfast the following morning.  You will eat a normal healthy breakfast, and likely have a regular bowel movement shortly after returning home.  No special diet is required; you are able to eat whatever you feel like eating.  Extra Strength Tylenol and Ibuprofen are best for pain control. 

Narcotic medications (Morphine, Codeine, etc) are rarely needed once you leave the hospital, since these can have negative effects on your energy levels, sleep, and can lead to constipation.  You may shower the day after surgery, keeping in mind your three small incisions over the side of your adrenal gland that was removed.  There will be small, white band-aids covering the incisions, called Steri-strips, which you can pat dry and allow to fall off on their own after roughly one week.

Returning to your typical daily activities the quickest is the best thing you can do to speed up your overall recovery. Those that tend to do the best after adrenal gland surgery are those that are re-entering their daily routine the fastest.  One day of lying around after surgery can equate to 3 days of deconditioning, so the idea of “move it or lose it” applies.  If your daily routine is running a marathon or dead lifting three times your body weight, then perhaps you would want to ease into these activities, since common sense after any surgery conquers all. 

Listen to your body.  If it hurts, then it is likely too soon to be doing that particular activity.  Walking, hydrating, and deep breathing are all imperative to clearing the anesthesia and letting your body know all is well.  The grind of work can usually wait, while you allow yourself the opportunity to bounce back the quickest without over-doing it.  We cannot emphasize enough, listen to your body.  If anything causes you to raise an eyebrow, rest assured that you have your surgeon-driven team only a quick phone call away if needed.