A switch from operating through the front of the abdomen to the back has meant significant changes for surgery on adrenal tumours, benefitting patients and reducing recovery time.
Epworth Freemasons’ Associate Professor Julie Miller, an American specialist endocrine surgeon now based in Melbourne, is something of a pioneer in her field. She has introduced to
Australia an updated approach to adrenal surgery that’s fast becoming standard, with surgeons worldwide now making the transition.
The technique, known as PRA (posterior retroperitoneoscopic adrenalectomy) involves removing a tumour of the adrenal gland through three small incisions in the back of the body instead of the front – a reversal of a technique that’s been de rigueur since the 1990s. It was developed by German surgeon Prof Martin Walz, who has now performed over 2000 cases. Dr. Miller travelled to learn the operation from Dr Walz, before introducing the procedure in Melbourne three years ago.
Of course, in reality it’s not as simple as flipping a patient and getting stuck in. It’s a technique that requires a surgeon to essentially relearn the anatomy from a mirrored perspective – something that can be a challenge at first, but pays off after a short learning curve, says A/Prof Miller, who has now performed more than 100 PRA procedures.
“We’re accustomed to entering the abdominal cavity from the front, but the adrenals sit right at the back,” she explains.
“To expose an adrenal tumour from the front, we must first displace the bowel and the liver on the right, or the spleen and pancreas on the left. Many patients have had previous abdominal surgery, and the resulting scar tissue increases the risk of injuring the bowel or other organs.
“With PRA, however, we turn the patient face down, and access the adrenal tumour from the back. This way, there’s nothing in the way: no other organs and no scar tissue, so it’s a much more direct approach. You avoid the abdominal cavity altogether, eliminating common side effects of laparoscopy such as bloating, slowing of bowel function and shoulder-tip pain.”
The new technique requires less time under anaesthetic (average operating time is around 40 minutes), and the notable benefit of PRA is that access via three small incisions under the 12th rib results in less pain and more rapid recovery for the patient.
“Upon awakening, most patients say they have little to no pain, while some describe a bit of a dull ache,” says Dr Miller. “Just over half my adrenal surgery patients take no narcotics at all after the operation.”
On the evening ward round, patients are usually sitting up having dinner, asking when they can go home. Some patients go home the day of surgery, while others go home the next morning.
“Day case adrenalectomy is something I never thought I would see in my career,” says Dr Miller. “It’s great to see how well patients recover.”
Since performing her first PRA in 2011, Dr Miller has been visited by many other surgeons wishing to learn the procedure. A highlight has been mentoring other surgeons learning PRA across Australia.
“The journey has been very fulfilling on a lot of levels – to help my patients, and to help my colleagues develop skills in this new procedure, the way other surgeons have helped me.”