Endocrine & Oncology Surgeon at Houston Methodist Hospital, Helmi Khadra, MD, FACS, talks about a new robotic surgery for adrenal issues.
Interview conducted by Ivanhoe Broadcast News in 2023.
First question, can you explain the name of the operation and how the single port surgery came to pass?
Khadra: Yeah. So the name of the operation is robotic single port retroperitoneoscopic adrenalectomy.
And the two things that I noticed that were new, and please correct me if I’m wrong, are the single port and also the prone position.
Khadra: Correct, yeah. So the adrenal glands sit on top of our kidneys. They’re like little hats that sit on top of our kidneys. And our kidneys are located more at the back of our body. And so doing it through the posterior approach or the back approach allows the surgery to be a lot quicker, and usually the recovery is a lot easier as well. And so what we do is we make a very small incision in your back, and we are able to use the robot with long instruments in the camera to take out the adrenal gland that way versus the traditional way is going in through your abdomen and using multiple amount of ports to take out the adrenal gland.
Can you describe to us what you’re seeing when you’re using, is the Da Vinci robot, correct?
Khadra: So, with that approach, the patient is in the prone position, meaning they’re on their tummy essentially, and we go in through the back and you go in through the back muscles to get into the space between the kidney in a space called the retroperitoneum, and so we essentially just stay over the kidney until we get to the adrenal gland and then we’re able to dissect the adrenal gland off of the major veins and the arteries that feed into the adrenal gland.
What is the trickiest part for you as a surgeon? Is it getting to the site or once you’re in there, trying to disconnect that adrenal gland?
Khadra: The trickiest part is because conventionally we take out the adrenal gland through the abdomen, and so throughout our training, we’re very used to the anatomy and the anatomy of going in through the abdomen to get to the adrenal gland. But when you’re going in through the back, everything is backwards. What’s deep is actually superficial and what’s superficial is actually deep and even what’s right is what’s left, and so getting used to the different planes and how it looks is probably the toughest part. But then once you do enough cases, you obviously get used to it.
It’s almost, to me, for a regular person, looking in the mirror and trying to do things backwards and that is very tricky, as you said, even the depth of what you’re looking at. So once you go in there, you have a fair idea of what you’re going to do. Have you predicated that with working, say, on some a visual screen technique or like a neurosurgeon in Baltimore used a blue head with a stylus and practiced brain surgery. Do you do that before the surgery?
Khadra: So, no. The technique, I was trained to do the surgery laparoscopically initially. And usually, the learning curve is about 30 surgeries before you become used to it and adequate during the surgery. The main advantage is laparoscopically, we usually make three, or even sometimes four small incisions to do the surgery to go in through the back. And the advantage of this robot is making only one incision and all of your instruments go in through that one little incision, and using the high-definition camera of the robot and lung instruments were able to do that.
What is the length of the time that the patient is actually on the table and also, what is the recovery time for them?
Khadra: So the operation is about an hour, hour-and-a-half, which is around the same time how long it takes when you do it in the other techniques. The main advantage is they usually do have less pain and the recovery is either same day or next day they go home.
That’s amazing.
Khadra: Yeah.
So when you’re doing this, you’re removing the adrenal gland and maybe the next day, that patient is actually going home. As a physician, how gratifying is that to you?
Khadra: It’s great. It’s one of the reasons I went into this field because you get an immediate gratification of removing a tumor that’s debilitating a person by producing too many hormones and immediately you cure them and they feel great and they usually are able to get home either the same day or next day, 95% of the time.
Can you describe to us how a person can recognize that they’re suffering from adrenal issues or adrenal cancer?
Khadra: Yeah. Well, the majority of adrenal masses that we have are actually caught up what we call incidentally, meaning they go into the ER and they’re having abdominal pain or they even fell and broke a bone and just by CT scan, they find that they have an adrenal mass. And so what we- there’s actually another name for it called an incidentaloma because they’re so common. And then when we get an adrenal mass, what we worry about is whether or not it’s cancerous or it’s producing any one of the hormones that the adrenal gland produces. And so adrenal cancer, luckily, is a very serious cancer, but it’s extremely rare. The majority of the time they’re not cancer and they’re not functioning and producing any one of these hormones. But what we do is we test them to see if they’re producing any one of the hormones that the adrenal gland produces. Now, the adrenal gland usually produces hormones that work for adrenaline, blood pressure hormones, some of the sex hormones, and the stress hormone. And so these patients if they’re producing any one of these hormones, they can have very high blood pressure, they could have weight gain, hypertension, worsening of their diabetes, and so if it’s a functional tumor that they get usually, their symptoms get a lot better immediately, especially the ones with the blood pressure where they come in and they’re in a lot of blood pressure meds, where immediately after the surgery sometimes they’re going home on off of all of them.
That’s amazing. So when these hormones get out of control, how does this interact to get that all with the hormones that the thyroid produces?
Khadra: They don’t interact so much with the thyroid other than it’s also an endocrine gland. There are some syndromes, though that with some people that have genetic mutations where they have something wrong with their thyroid that they also have something also with their adrenal gland or their pancreas or their parathyroid hormones. And what we call those are the multiple endocrine neoplesions. Those are rare, but the majority of people with adrenal masses don’t have any one of those syndromes.
What happens to the patient? You just mentioned that blood pressure, they go off all of the medications. Are they then on medications to simulate the hormones from the adrenal gland?
Khadra: That’s a great question. So no, because we have two adrenal glands. The majority of the time, the other adrenal gland is able to compensate and make it off. And so it’s rare that we need to give them any medications to simulate them.
And that’s the second time you used rare, and I want to ask the question if you can qualify that, is there a percentage of people who get this? And if so, is it primarily genetic mutation, or how does it happen?
Khadra: So it really factors more about the reason why they’re having the surgery. Now, the one that comes to mind that they may need some medications is cushings, where the stress hormone, which is cortisol. And so if they’ve had longstanding high cortisol, sometimes what happens is the other adrenal gland hasn’t worked in a long time, and so it takes a while for that other gland to start working again. Sometimes they need to be bridged by giving them actually- giving them the stress hormone medication for a few weeks or months.
So what I’m hearing, I know that people understand that cortisol is a result of severe stress, and this adrenal gland fatigue that I’ve heard before, is that what you’re referencing?
Khadra: It’s essentially that the adrenal gland is producing the cortisol in excess and ignoring the down regulation that we normally have of not producing too much. And so usually this tumor will just be uninhibited and produce the cortisol in way excess, and you get all the down effects of having too much stress.
What would you say to viewers? What advice would you give to them in case they suspect they have this?
Khadra: So if you have very high blood pressure, and you’ve had- you’re on multiple medications, and it’s getting worse and worse, I would talk to your primary care doctor, or your cardiologist, or neurologist, and see- if they’ve done testing to see if your adrenal gland is producing the blood pressure hormone that can be worsening their blood pressure because often it is undetected as long- but otherwise the majority of these are not really functional. And so if you do get diagnosed with an adrenal mask, the majority of time it is not producing any excess hormones, and it’s not cancerous, but they should be worked up. And so here at Houston Methodist, we have a huge team where we work them up, and we do some of the most adrenal surgeries in the country here. And we were the first to do this surgery, doing robotically in single port.
So the single port techniques, so I’m sure I have this right, is simply the single incision, right?
Khadra: Exactly.
Once you go through that single incision, what’s different about the multiple incision?
Khadra: The difference is just the number of incisions. The other thing is with the other technique where you use multiple ports, usually when we do it robotically, we can only fit three ports. So you only have a camera and two arms. And so with the single port technique, the other big advantage is I have three arms. I have a camera and then three arms, and that can help a lot with some of the difficult dissections. And with less incisions, there’s usually less pain as well.
I think people at home watching this will wonder where this idea originated, the single port surgery?
Khadra: So there’s a lot of different robotic companies out there that are all working on innovating new robotic techniques and everything. The single port was primarily more for urological surgery and gynecology, and it’s being adapted more and more into abdominal surgery as well. Now, for the adrenal gland, it’s really- it was a no-brainer for me to adapt it very early because we’re in a very tight space, and the ability to use a small incision and multiple arms made the surgery a lot easier, both for me and for the patient with having less incisions.
So we know that the recovery time is diminished with the single port. Can you describe what the recovery period for the patient is like for this versus the multiple incisions?
Khadra: The multiple incisions, both of them, they go home pretty much, either the same day or the next day. But usually they do have a little bit more pain along their ribs and their back because with every incision you’re going through the- if you think about you’re going through the muscle in different areas. And so you’re going to have a little bit more pain and discomfort. And so the recovery in terms of going back to your normal activities and everything is quicker with the single port.
Is this available across the country? How would people find it, say, in Seattle?
Khadra: Well, as far as I know, I think we’re the only place doing it, but every day I’m sure more and more people are getting trained to do it. But we’d be happy to have whoever is in Seattle to come down to Houston to do the surgery.
How long do you think it’ll take for this to filter out with all of its tentacles to cities across the nation?
Khadra: I think with increased training and even just doing the technique, retroperitoneoscopic meaning through the back, it just needs advanced training. And adrenal surgery doesn’t happen that often. What’s considered a high-volume adrenal surgeon is doing about two surgeries a year, and we do close to 100 a year here at Houston Methodist.
For the patient, you said the cancer is most rare. But for the patient whose hormone, let’s say cortisol, is spilling out into the body continually. How much better do they feel post-surgery?
Khadra: So I’m glad you brought that up, because for adrenal cancer, actually we do not offer these minimal invasive techniques. Adrenal cancer, we still do it with an open incision because it’s a very aggressive cancer, and we need to make sure that we remove all of the cancer. So that is one of the exclusion criteria of getting a minimal invasive technique, is if they have adrenal cancer.
And then what about just the hormone-driven removal?
Khadra: With the hormone-driven tumors, they are definitely eligible for getting these minimal invasive techniques.
But when they get home, they don’t take any medication?
Khadra: So most of the time- it all depends which hormone that it’s producing. If it was producing like the blood pressure hormone, like aldosterone, usually they’re off of all of their meds, or they’re off of 50 or 75% of their medications- blood pressure medications. Now, with the stress hormone- with cortisol, they’re usually not on any medications preoperative. But as I said, for some of the patients, they may need to be on a supplement for a few weeks or a month or two to augment them. But usually, they immediately feel the effects of their blood pressure gets better, their diabetes can get better, they get weight loss, and so the effects are pretty quick.
END OF INTERVIEW
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