April 12, 2025
The rate of adrenalectomy in the United States has risen nearly 50% in 20 years. The reason is twofold: Advances in imaging help healthcare professionals detect more adrenal masses, and minimally invasive approaches allow surgeons to perform complex operations more confidently and with better outcomes.
Statistically, the best adrenalectomy outcomes occur when a surgeon performs a high volume of operations — six or more annually — as evidenced in a study published in Best Practice & Research Clinical Endocrinology & Metabolism. Surgical outcomes at Mayo Clinic in Florida are outstanding — minimal complications with no conversions to open surgery — in part due to the high volume of adrenalectomies performed each year. However, Fernando F. Elli, M.D., chair of Advanced GI and Bariatric Surgery and professor of surgery at Mayo Clinic in Jacksonville, Florida, says success with treating adrenal dysfunction is about more than surgical volume.
"Yes, the higher volume does help us gain expertise operating in both simple and complex adrenal cases," says Dr. Elli, who performs most of the center's adrenalectomies. "But treating adrenal gland dysfunction is not only about the operation — that's just one part of the patient journey."
An integrated, comprehensive approach to adrenal gland conditions
Adrenal masses rarely exist on their own. Adrenal gland dysfunction can cause or occur alongside chronic conditions, including hypertension, diabetes and obesity. Patients may have complex surgical histories. The underlying causes of adrenal gland dysfunction also can be complicated and may include:
- Cancer.
- Cushing syndrome.
- Hyperaldosteronism.
- Pheochromocytoma.
As a result, a multidisciplinary team is essential to diagnose, manage and effectively treat people with adrenal gland dysfunction. That core team may include:
- Endocrinologists.
- Pathologists.
- Radiologists.
- Surgeons.
Dr. Elli says the team expands depending on individuals, their health risks and their treatment plans. "In surgery, we have specially trained anesthesiologists who can manage patients with adrenal gland dysfunction and severe hypertension," he says. "And we can call other surgical oncologists in case someone requires a multiorgan resection."
Mayo Clinic in Florida's adrenal team also meets monthly with a multidisciplinary board spanning all three Mayo Clinic locations. "This is a three-site endeavor that includes our campus partners in Minnesota and Arizona," Dr. Elli says. "Our patients have access to specialists across the network. We accumulate the experience and expertise of all our surgeons, radiologists, pathologists and endocrinologists to help make decisions about complex cases."
The referring physician is a key player on the team. Mayo Clinic seeks to maximize information sharing between the referrer and the adrenal surgical care team. Referring physicians and their patients can get the clinical answers they need and have unparalleled, collaborative experiences.
"We try to accommodate patients right away and expedite the visits whenever possible," says Dr. Elli. "But we don't take over. Our constant communication with the referring physician ensures seamless care and transition for patients."
Precise evaluation of adrenal gland function
Once the right team is in place, getting an accurate diagnosis is critical to effective treatment. This process typically includes advanced imaging and, for some people, adrenal vein sampling. When bloodwork and imaging do not clearly identify which gland is producing excessive hormones, an interventional radiologist inserts a small catheter through the leg, stimulates the adrenal glands and collects hormones. The samples help localize the source of overproduction. Dr. Elli says the complex study is critical.
"Adrenal vein sampling requires advanced expertise and isn't available in many places. But it guides the treatment and surgical path for many of our patients." As leaders in the space, the team at Mayo Clinic in Florida recently published its experience with selective adrenal vein sampling over an 11-year period. The results from this study were published in a 2023 issue of the Journal of Laparoendoscopic & Advanced Surgical Techniques.
Selective is the key term, though: Not every patient with a mass requires adrenal vein sampling. "Our MRIs and CT scans are high quality," says Dr. Elli. "They are often enough, allowing us to perfectly differentiate the adrenal tissue and arrive at a precise diagnosis."
Pioneers in robotic adrenalectomy
Dr. Elli credits the positive surgical outcomes at Mayo Clinic in Florida to an ability to handle complex adrenal operations with minimally invasive, often robotic, approaches. Approximately 98% of adrenalectomies are minimally invasive, with close to 90% of those operations performed robotically.
Dr. Elli recently performed pioneering work with the Da Vinci 5 (DV5) robot to see if it would help improve surgery times. "With the DV5, I can complete most operations 15 minutes faster," says Dr. Elli. "While 15 minutes may not seem like much, it can make a big difference." Shorter operations mean less time spent under anesthesia, less recovery time and a shorter length of hospital stay.
Understanding how to approach an adrenal mass surgically also is critical. Dr. Elli says Mayo Clinic surgeons most often use an anterior approach but opt for a posterior approach in patients who have had multiple prior abdominal surgeries. In people with suspected malignancy, open surgery is the recommended approach.
"We have the expertise to provide any type of surgical care for our patients," says Dr. Elli. "That flexibility and a wide range of surgical options help us achieve good outcomes, especially for complex cases."
Commitment to improving adrenal dysfunction treatment
The study of robotic surgery with the DV5 isn't the only way the adrenal team at Mayo Clinic in Florida is improving treatment for adrenal gland conditions. In addition to the team's 11-year account of adrenal vein sampling, researchers have recently published papers studying adrenalectomy.
A 2024 study published in the Journal of Laparoendoscopic & Advanced Surgical Techniques analyzed minimally invasive adrenalectomy outcomes for people with a body mass index (BMI) of 35 or more and concluded that BMI has no significant impact. A study in Surgery Open Science examined the outcomes of partial adrenalectomies to treat benign tumors. Research showed that the procedure is safe and beneficial for patients when indicated.
"We are always looking for ways to improve the treatment of adrenal gland dysfunction," says Dr. Elli. "Adrenal masses are not common, but every person, regardless of surgical history, physical health and underlying issue should know that treatment is available."
For more information
Kazaure HS, et al. Volume-outcome relationship in adrenal surgery: A review of existing literature. Best Practice & Research Clinical Endocrinology & Metabolism. 2019;33:101296.
Asbun D, et al. Eleven-year experience with selective adrenal vein sampling in management of primary adrenal hormonal hypersecretion. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2023;33:129.
Knewitz DK, et al. Impact of body mass index ≥35 kg/m on minimally invasive adrenalectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2024;34:359.
Hla DA, et al. Improving adrenalectomies: Safe outcomes of partial adrenalectomies and suitable characteristics. Surgery Open Science. 2024;20:230.
Refer a patient to Mayo Clinic.