Latest / Behind The Knife: The Surgery Podcast / Clinical Challenges in Endocrine Surgery: Adrenal Cases
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- BTK Endocrine_Adrenal Cases 7-2026 === Speaker: [00:00:00] Hi, everyone. Welcome to another episode of Behind the Knife. We've got our UW Wisconsin endocrine surgery team here for another episode to discuss adrenal cases today. So my name is Amanda Doubleday. I am a fellowship-trained endocrine surgeon affiliated with University of Wisconsin Health, practicing in both Waukesha and Madison, Wisconsin. We have Dr. Simon Holoubek here, also a fellowship-trained endocrine surgeon affiliated with the University of Wisconsin Health, practicing both in Northern Illinois and Madison, Wisconsin. Thanks for being here, Simon. Speaker 2: Great to be here with you today. Speaker: And for our senior guest and expert surgeon, we've got Dr. John Porterfield, a previous professor at University of Alabama. And, uh, thanks for being here, Dr. Porterfield. I understand you've had some changes in your practice recently. Speaker 3: Yes, Amanda, thanks so much. I appreciate it. Simon. Yeah. So, um, I retired from UAB a year ago and, um, founded a private practice, uh, focused on endocrine surgery here [00:01:00] in Birmingham. And, um, I've also continued Informed Surgical, which was a company that I founded with, uh, Sal Bronja, who designed the Da Vinci robot, uh, back... Uh, he and I founded a company called Informed in twenty twenty-one that matches patients with surgeons based on their risk-adjusted outcomes. Speaker: Great. All right. Well, Simon, you wanna jump into a couple cases here? Speaker 2: Uh, yeah. So our focus is gonna be on adrenal disease today. Uh, Cushing's, uh, with adrenal origin is a challenging topic, especially in a population like the United States where obesity is incredibly common. However, it's an important topic with a lot of incidental findings, uh, that we have in modern medicine, and I think it's really up to endocrinologists and endocrine surgeons to help provide sound advice for patients as they undergo functional workups. Uh, let's get into our first case. I have a 45-year-old female with type 2 diabetes, osteopenia, and a BMI of [00:02:00] 41 who had a recent CT chest, abdomen, and pelvis after MVC. Uh, no injuries were found, and she was discharged after a brief stay and was told to follow up with a surgeon because she was found to have a 2.5 centimeter right adrenal nodule. So she came to my office. She would have a dedicated CT adrenal, uh, and a workup consisting of aldosterone, renin, serum metanephrines, DHEA sulfate, ACTH, uh, and a low-dose dexamethasone test to determine if she, uh, has a properly suppressed cortisol. Let's say for the purposes of this case, let's just say her workup is unremarkable except for a, uh, dexamethasone-suppressed cortisol level of 2.9 and a suppressed ACTH. Uh, Dr. Porterfield, what's your diagnosis, uh, to, at this point, and how would you approach this patient? Speaker 3: Yeah, this is-- And I think this is really a, a timely patient scenario because, you know, Alabama is one of, if not the most obese states in America. [00:03:00] And so we see a tremendous amount of patients like this that set up with basically an incidental oma with obesity, and then they get a proper workup. And we see that this is, you know, hypercortisolism with an adrenal source with a suppressed ACTH. So, I'm pretty old school from my training at Mayo. I'll get a twenty-four-hour urine in all of these patients. So I really like to see an elevated twenty-four-hour urine cortisol. It's over three hundred that I'm really convinced, um, that, that we don't need to repeat a DEXA or something like that because I'm pretty skeptical. And I have a low threshold to repeat studies. But with that and confirming that it's a adrenal in origin I think it's really important as endocrine surgeons to look at-- to be a fantastic adrenal radiologist and to really carefully examine that other gland. If I'm perfectly confident that other adrenal gland is perfectly [00:04:00] normal, like it's just skinny as a rail, it doesn't have a single abnormal bump on it, then I'm gonna have a lower threshold to just go right ahead. And I forget if you said which side, but I would remove the side that had the two and a half centimeter mass on it. Yeah. Right, Speaker 2: right side. Yep. Mm-hmm. Speaker 3: Yeah. Yeah. So I would, I would probably move pretty quickly to a robotic right adrenalectomy a lateral transparent to Neal. And I would have a very f- a very clear discussion with the family. I want to hear them, like, teach it back to me that they could not be cured. That's the, that's the absolute critical step here that I cannot guarantee them just off of those imaging results. But I'd love to chat about adrenal vein sampling for hypercortisolism too. Um- Sure. Speaker 2: Let's get into that. Speaker 3: Yeah, it's been a hot topic. So, I think that it's, Where I sit, I think that it's, um-- I don't do it in every scenario. If we added a one centimeter nodule to the contralateral side, right? [00:05:00] I'd probably do it. I've, you know, obviously we've been deep in the data many conversations with Herb and Vanessa and Sophie and the, you know, the whole team down here. But I think there's a piece that's, that's missed in those-- the data and those studies, and that what does it mean for the patient? You know, what are the nuances in the conversation in that we've done all that we can do? Is there anything else we could do to help decide should we take out the right? Should we take out the left? Do we take out the, the right because it's big? You know, those type of things. So I really think it, it adds to the conversation tremendously. And then the-- I feel like I'm giving too long of an answer, but it's the other piece I really look for is do we have any other imaging? We found this one because of a motor vehicle crash. We know trauma is a recurrent disease. You know, I'd love to be able to see some old CT scans, and so I'm a, I'm a big fan of, like, I'll dig up CT scans from a decade ago [00:06:00] to look at them. Speaker 2: Let's say for the purposes of this case, it, that it, there was an old CT scan, and it wasn't you know, it had bilateral normal adrenals at the time. Uh, so this is a new finding just in the last, you know, twelve months. Speaker 3: Yeah. It, it a hundred percent comes out, and I would not pursue any adrenal vein sampling. Anything that grows by a half a centimeter a year in a low-risk surgical patient or even a moderate-risk surgical patient the, uh, I've never been accused of watching adrenal tumors too long. So, and I tell patients that, that I'm, I'm a surgeon. I'm biased toward taking it out, and, um, I have a low threshold to take things out whenever we can do it in a, in a low-risk way. Speaker 2: Amanda, would you do anything different here? Would you also favor a, uh, robotic approach? Speaker: Yeah, absolutely. I'm, I'm most comfortable with that. When I was in fellowship, we did a lot of laparoscopic cases, and when I started [00:07:00] at my new job here after I finished learned robotics, found it was extremely helpful in many ways for both me and the patient. Um, obviously surgeon ergonomics, but I also found patients had a lot less pain. So I don't know what we were doing with lap cases that maybe just more torque on the ports, but a lot of patients had pain control issues, and once I started doing them robotic, I found that elderly patients even who weren't even in great shape were, like, had received no pain medication and were ready to go even the same day or the next day. Speaker 2: I also find that, you know, my interest in converting to open when I have, uh, you know, the robot docked in the patient is just so much different because I, I never think that opening or rarely think that opening is gonna somehow, uh, make my case easier. Just because the robot is, you know, is so good and adds so much to the, to the case that I also favor the robotic approach Speaker 3: Yeah, I've, I've looked at, I've looked at our experience, and [00:08:00] I've done over three hundred and fifty robotic adrenals now, and I've never opened an adrenal. And, and for that matter, I've never opened a robotic case. So I think that it's really important from a perspective of, like, w- there was always an option to open lap cases because laparoscopy is so limited, and there's just so little that you can do with severe torrential bleeding. There's so little you can do with like big tumors and, you know, difficult anatomy. And, you know, as you cross through each kind of tier of cases, like five hundred, a thousand, fifteen hundred, two thousand and more cases, I'm shocked at how I'm still getting better, like thousands of cases in, where I felt like I had definitely reached a plateau quicker in lap. You know, the conversion to open is just, it's just not the [00:09:00] question. The question is, is what are my resources? Who else is around? You know, and I've leaned on G1 oncologists, urologists, and thoracic surgeons who are the best robotic surgeons, you know, in my, in my world. And with them around, you know, I'll let them know. It's just like with a giant goiter, I would let the thoracic surgeon know. It's like, "Hey, I might need to open the chest." Do I open the chest very often to take out a thyroid? No. But it's always good to know that Ben Wei is around the corner, right? But, you know, the same thing with, with these, um, with robotic procedures. And I, I would add one other thing too. I mean, like we're, we're really biased here on the talk about doing these robotically. I am a huge believer in surgeons doing them exactly the way they are best. And I think the worst adrenal surgeons in the country would be surgeons that have like six ways to do this operation. Because even if they did sixty a [00:10:00] year, they would only do ten maybe with each of their approaches. So if you're gonna do them retroperitoneally, do them all retroperitoneally. But don't do thirty retroperitoneally and do five transperitoneal because they're too obese to do it through the back. Because those patients aren't gonna get the same operation. There's just no way. Versus if you're the retroperitoneal surgeon and it can't be done retroperitoneally, then give it to the person that can do it lateral transperitoneal robotic. It's just, you know, we should not be so prideful to not, you know, kick them to somebody that is really high volume in that approach that you as a surgeon aren't experienced with. Speaker: Yeah, that's a great point, and I think patients appreciate that too. They appreciate the honesty. You know, "Look- Speaker 3: Oh, yeah Speaker: this, I don't do it, but I'm gonna send you to my partner who does. You'll be in better hands." I do that all the time with other kinds of general surgery cases, so. Speaker 3: Yeah, I mean, if there's a patient that needs a-- If there's [00:11:00] a patient with bilateral adrenal nodules and a-- Putting the patient prone and doing it bilaterally or even doing it simultaneously, I sent one to Bernessa and Jess Faisadeen, and they did it at the same time. You know, Bernessa Lindeman did one side, and Jess Faisadeen did the other side. You know, it was great, right? And there's no reason for me to flip that patient and do two different operations or split it on two days, even worse. So there's-- But those cases are rare. So... But it's important to get the patient to the right surgeon. All Speaker 2: right. Amanda, do you wanna move into the second case? Speaker: Yeah, we can move. And just one quick comment, though, regarding cortisol tumors before we leave this topic. Just very briefly, if you had somebody with bilateral nodularity and there wasn't one that was really dominant- Mm ... would you consider doing an adrenalectomy on one side and then a partial on the other to get better control of their cortisol hypersecretion? Speaker 3: Yeah. Yeah, a hundred percent. Typically, the way I've approached those is to go take out the [00:12:00] right first assuming their abdomen is uniform, they haven't had a bunch of surgery. I would go take the right out. I would do a total on the right. Then a-and assuming their adrenal glands look similarly nodular on both sides, I would take out the right first. Then I would wanna re-study them at six weeks to prove that they still have hypercortisolism. I've seen several patients that just with one side out, their diabetes is way better controlled, they're in much better state and that type of thing, and maybe they don't even need another operation. If we've not made hardly any difference, then that is where I would go and do a subtotal on the left. And the, um, the modern energy devices, I've stapled adrenal glands. I've gone through them with, you know, with different types of kind of the wet cautery and stuff like that, and I think that the modern vessel sealer is safe for going through an adrenal gland for a partial adrenalectomy, so long [00:13:00] as you use a sealant. The one we use is VISTASEAL, but they all work really similarly. I think you have to use a sealant, not a hemostatic. Early in my career, I was just uninformed, and I was kind of equating hemostatics with sealants. And I think as adrenal surgeons, if we're gonna cut an adrenal, we really need a sealant on it. Speaker: Okay. That's a great point. Hadn't thought about that. All right, great. All right, so for time purposes, I'm gonna jump into case two right away. So case two let's say you got a patient who is in the hospital. They were admitted for back pain and found to have a retroperitoneal bleed. They were recently started on anticoagulation for DVT. And now they've been scanned, and they're finding this new incidental finding of a very large, let's say, ten to 12 centimeter likely adrenal tumor. So first we get the patient through their hospitalization. They get discharged after their H and H is stable, and now they're coming to your [00:14:00] office and questioning, "What do we do?" Um, so obviously we're gonna need some repeat imaging after that bleeding has resolved, but-- And, and John, we were talking about this, it's kind of about timing. So what would your timing be in terms of re-imaging and with a tumor that's sort of concerning with this size? What would your timetable ideally look like? Speaker 3: Yeah. So I think there are a lot of factors here. You know, if this is the kind of a typical scenario where this is a thirty-four-year-old female that has a acute hemorrhage into, say, the right adrenal gland, and now she's got a ten centimeter, you know, hematoma tumor mix, in my mind, that's adrenal cortical carcinoma until proven otherwise. I would definitely want to see if we had any prior imaging that could kind of, um, lower my kind of lower my threshold for believing it's a cancer. 'Cause if we had a CT from three or four years ago that showed that she had a three or four centimeter tumor, [00:15:00] you know, now I would be thinking less that it's an adrenal cortical cancer. But assuming that all of those things are the, are true, then I'm gonna probably push to go ahead and get her into the OR within four to six weeks. I don't wanna operate on the acute bleed immediately. We are often in the scenario, in this scenario questioning should we embolize these when they come in with active X trav. When I've been involved in those cases with our interventional radiologist, I'm really careful to make sure that they use gel that I can fire a stapler through as opposed to firing metal coils. Speaker: Mm. Okay. Speaker 3: Yeah. Um, a-and generally they are using these, these gels because they're just getting the arteries off of the, the, uh, upper pole renal artery vessel or some direct branches off of the aorta because you really wanna be able to use a stapler in these cases, The, um, you know, when you get into the OR, these cases are extremely difficult. They're [00:16:00] welded onto the diaphragm and the liver or the pancreas and the spleen. They're welded. It doesn't get any easier if you open. I love that, you know, Simon, you and I have talked about that, that like open surgery doesn't mean easy surgery. Definitely have these patients typed and crossed. I've been in situations where I needed two robotic suction irrigators. At different times, I've had to add laparoscopic suction. It can be quite dramatic for the anesthesiologist. Speaker 2: The, um-- Speaker 3: i-in a patient, say that we do get it out, and it does pathologically prove to be an adrenal cortical carcinoma, that bleeding event likely triggered metastasis as well. So the chance of local recurrence versus metastatic spread of a hemorrhaged adrenal cortical carcinoma, I think, you know, we're kidding ourselves if we think we're getting every cell out after an ACC bleeds. So, I-I've, I've never done a nephrectomy for an ACC [00:17:00] that bled. I've done nephrectomies plenty of times for ACCs that didn't bleed to, to get a, you know, big en bloc resection. Speaker 2: Mm-hmm. Speaker 3: But but that-- those are kinda my thoughts on that. If-- I guess I didn't say if, if, if I had a low threshold for it being a, um, a cancer, say it occurred in like a sixty-eight-year-old man, and we had some prior evidence that it's been there for a while, but it bled into it. Say, say the tumor's been there for ten years, it's six centimeters, everybody's been ignoring it, but now it bled. I would probably give them a while, like six months or more before I would go back in to take it out, maybe even a year from that standpoint. And that'll be a much easier operation 'cause once you get beyond six months, you can generally pick around the hematoma and take it out en bloc. Speaker: Okay. Yeah, yeah, great [00:18:00] point. So would you primarily still use a vessel sealer then? Or like what, what's, what are some of your ticks and tricks, tips and tricks for when it's like, say, it's stuck to the diaphragm or stuck to the bed of the liver Speaker 3: Yeah. Yeah. So I start every case with the small Graspini retractor, like on the right or left. The small Graspini retractor is, is gonna be against the, the liver or against the pancreas and spleen. And then my right hand is always gonna be a hook cautery, and then my left hand is gonna be the robotic suction irrigator. And I think it's an absolute critical piece that you don't put a grasper in your left hand because if you do, you're gonna pick stuff up, and what you're gonna pick up is gonna be the edge of the adrenal. And as soon as you pick up the edge of the adrenal, you're gonna create a capsular disruption. And so, it is more difficult to operate with just a suction irrigator in your left hand, but you learn to use it like a Kittner, and you learn to spread with it. Um, you know, oftentimes people have the Maryland bipolar and they spread with that, and then they work between it, but [00:19:00] you can do the same thing with the suction irrigator. And then you, you stay with the hook cautery as long as you can. And what that forces you to do, and this is a good conversation I think for like what do you do with like these sixteen centimeter tumors? You just pick around them as long as you can, and just go where it's easy, go where it's easy. You don't care about the adrenal vein at all. You just keep going. And I've even told patients that I'm gonna do everything I can to mobilize it, and if I can mobilize it, but I can't deal with it, I would open and finish the case open. And what's happened in a hundred percent of those cases is that I was patient. You know, we picked around it and picked around it and picked around it. I let the fellow work. I went to the restroom, I came back, we kept picking on it. Like, we just literally spent several hours, maybe two hours mobilizing an adrenal mass that's big, and then the next thing you know, you get down to something that's very manageable that could be managed with a s- you know, with a stapler along the [00:20:00] cava or parallel to the renal vein. So, but your question was do I switch? So the last thing I do is, is switch to a vessel sealer. When I switch to the vessel sealer, it's either like after the adrenal vein is clipped, and now I'm just going through retroperitoneal fat, so it's just super easy, or I've gotten into bleeding, and now I need to be able to move more quickly through larger, uh, steps because now I've established a rate of blood loss. And if-- and I may be losing, you know, I may be losing five cc's a minute, or I might be losing thirty cc's a minute, and that's a big difference. So I just need to be able to, to follow the pace of blood loss, and that's why I, I-- that's why I keep the suction irrigator in there because I wanna suck up every drop of blood that comes out. I don't want any of it pooling in the pelvis because I wanna know what my blood loss is. And, you know, the anesthesiologist tell me every time we cross over two [00:21:00] fifty, Speaker 2: Okay. - Speaker 3: another two fifty. So, I mean, I've lost two liters of blood in an adrenal, and she went home the next morning Right? So like that's crazy, but that's-- yeah, we can lose that and replace that very effectively if you're communicating really well with your anesthesiologist Speaker: Yeah. Yeah. All right. Great. Well, I'm gonna try and quickly talk about a third case here. Yeah. Um, for the sake of time, we'll move on. Let's say we've got a, a young female, 40-year-old female. She's got a history of hypertension, but it's pretty well controlled. Mm-hmm. And there's some sort of retroperitoneal mass that they've seen incidentally on imaging. It's adjacent to the right adrenal, but it appears like it may be separate, and it's sort of behind the IVC. It doesn't appear to be invading, but it's causing a mass effect on the IVC posteriorly and inferiorly. So, let's say biochemical workup is pretty normal except slight elevation in normetanephrines, but [00:22:00] metanephrines are normal. So this might, might make you think that it's a paraganglioma. She's maybe got some episodes of hot flashes with sweating tachycardia, so it kinda fits the picture. So with a mass being behind the IVC like this Dr. Porterfield, how would you approach it the same way? Would you get a vascular surgeon involved? Would you alpha blockade this patient? Speaker 3: Hmm. That's a great question. So, um, so I would block them with calcium channel blockers, and then beta blockers as needed for their tachycardia in anticipation of running them on IV clopidogrel intraoperatively. It can be run peripherally, it can run right next-- it can run in line with with norepinephrine levophed, and so that's, that's gonna be the biochemical setup. It's a hundred percent coming out, you know, in a, in a low-- in a medium-risk patient like you described. I put patients full lateral, so in any case, the, the shoulders are [00:23:00] 90 degrees to the floor. The hips tend to be just rocked back just a little bit in a standard adrenal, but in this case, I would set them up just perfectly perpendicular to the floor. And before we dock the robot, I would tilt the patient toward the front of-- anteriorly so that I would have even better, like, gravity pulling either the liver or vice versa if it was pancreas and spleen. But say we're going to the right, I would want that liver held over there. I'm gonna mobilize the liver all the way to the cava, so I'm gonna expose the right hepatic vein. I'm gonna see a ton of it. That's really gonna help me get tremendous amount of space. Initially, I'm gonna go find the cava, and I'm gonna go find the adrenal vein. I'm gonna take the adrenal vein, and I may take the adrenal out if I need to. I may take that adrenal out on that side to provide exposure and access. If I have to mobilize the kidney, I will mobilize the kidney, [00:24:00] but that's rare that you have to mobilize the kidney like that. And in this case, once I'm around-- once I'm at the paraganglioma, I would be using the vessel sealer exclusively. And, um, the one I have now, the new one has a little curved tip on it, and it's a little smaller, and it's just magical compared to the big wide vessel sealer that we used to have because cautery does not work very well. Scissors nor hook works very well at all around these paragangliomas. The little fibrous nerve bands are too strong, they're too tight. You're gonna get into a decent amount of bleeding. And, and I would be I would be very generous with how much of the cava I exposed above it and how much of the cava renal vein I exposed below it. I may vessel loop the cava in case I put a hole in it. It's a whole lot easier to pull those vessel loops down. If you double vessel loop it, you can pull it down and put a clip on it if you needed to get total vascular isolation of [00:25:00] it. Having unintentionally put holes in the cava, it's, um, that's traumatic, and I would-- I hope you all don't. But I was very glad I had control of it because even in that situation, you're still gonna have lumbar veins, so you're-- it's still gonna be, uh, still gonna be pretty intense whenever you have a hole in the cava there. So, the cava can handle a tremendous amount of electric cautery on it as far as, like, the spread from a bipolar. Um, I learned that from David Nagorni liver surgeon at Mayo, that he would cauterize right on top of the cava. But it's got-- it's such high flow that the internal, the internal lining of the vein actually doesn't heat up very hot there, so it can actually handle a fair bit of cautery. Speaker: Okay. Great points. Yeah, I think unfortunately not, uh, not all of us have access to that skinnier vessel sealer if we don't have the, the new five model. Um, so we're kind of stuck with- Mm ... the big bulky vessel [00:26:00] sealers. But yeah, it's still a good point Speaker 2: All right. Thank you for this, uh, fantastic discussion about, uh, adrenal pathology and, uh, adrenal surgery today. So again, thanks. I am Simon Holoubek, and also here with Amanda Doubleday as well as our expert senior surgeon, uh, Dr. John Porterfield. And so let's get into some quick hits. Okay. Number one, subclinical Cushing's is now called MAX and remains a controversial topic. Uh, surgery remains the preferred treatment in patients with clinical manifestations, um, of this disease, including diabetes, obesity, osteoporosis or cardiovascular disease. Two, large adrenal tumors can be successfully removed, uh, via minimally invasive approaches. Of course, we talked mostly today about transabdominal approach robotically. Um, and there are certainly experts in the field who are able to do this, and referral is very reasonable if you do not do this. Uh, and then third and [00:27:00] final, adrenalectomy can be performed open transabdominal via laparoscopic robotic approaches as well as retroperitoneoscopic approaches. Each appropriate approach can be, uh, acceptable in the right hands and in the right clinical setting. Thank you so much. Dominate the day Thank you, guys Speaker 3: Thanks, Simon