Treating conditions of the Parathyroid, Thyroid and Adrenal Glands

Endocrine surgery is subspecialty of general surgery that treats diseases of the endocrine system, including the thyroid, parathyroid, and adrenal glands. Endocrine surgeons perform evaluation, diagnosis and surgical treatment of endocrine diseases, while educating patients throughout the process.

For many endocrine conditions, the first-line treatment is medication. But in certain situations – like when a part of the endocrine system is overactive or when a tumor is present – the patient may require surgery to remove all or part of the diseased gland. The endocrine surgery department at The Medical Center of Aurora has expertise in diagnosing thyroid, parathyroid, and adrenal gland disease, localizing the abnormal gland through advanced diagnostics, and employing the latest in minimally invasive surgical techniques to remove them.

Conditions Treated

The endocrine surgery department at The Medical Center of Aurora treat a variety of thyroid, parathyroid, and adrenal gland conditions that cannot be otherwise managed through medication. These conditions can include:

  • Thyroid nodules
  • Thyroid cancer
  • Hyperthyroidism
  • Graves' disease
  • Toxic nodules of the thyroid
  • Toxic multinodular goiter of the thyroid
  • Nontoxic multinodular goiter of the thyroid
  • Thyroid goiter causing compressive symptoms
  • Primary hyperparathyroidism (overactive parathyroid)
  • Secondary hyperparathyroidism
  • Parathyroid cancer
  • Adrenal incidentaloma (asymptomatic adrenal tumor)
  • Hyperaldosteronism
  • Cushing's syndrome
  • Pheochromocytoma (adrenaline-producing adrenal tumor)
  • Paraganglioma (adrenaline-producing tumor outside the adrenal gland)
  • Sex hormone producing adrenal tumor
  • Adrenocortical carcinoma (adrenal cancer)
  • Metastases to adrenal gland

Diagnosis

Many endocrine conditions can be identified through simple blood work done by your primary care physicians or endocrinologist. If lab work is abnormal, you may be sent to The Medical Center of Aurora’s endocrine surgeon for a complete work-up, which can include additional blood tests, urine tests, imaging studies, or localization tests.

Specialized imaging offered at The Medical Center of Aurora to diagnose endocrine conditions include:

  • Detailed thyroid ultrasound for thyroid cancer
  • Lymph node assessment for thyroid cancer
  • Parathyroid ultrasound
  • Thyroid nuclear scan and iodine uptake (6 and 24 hours)
  • Parathyroid nuclear scan (sestamibi scan)
  • 4D parathyroid CT scan
  • Post surgical follow up imaging
  • Radioactive iodine (whole body scans and treatment)
  • Bone density testing (DEXA-scan)

Other tests to diagnose or confirm endocrine conditions include:

  • Fine needle aspiration (FNA) biopsy of the thyroid
  • Molecular testing of the thyroid nodules
  • Parathyroid hormone (PTH) testing
  • Parathyroid venous sampling
  • Testing blood levels of phosphate, vitamin D or creatinine
  • Testing urine calcium levels
  • PAC:PRA ratio
  • Captopril Suppression Test
  • 24-Hour Urinary Excretion of Aldosterone Test
  • Saline Suppression Test
  • Adrenal venous sampling

Surgical Procedures

The Medical Center of Aurora’s endocrine surgery department is highly experienced in minimally invasive and traditional, open surgical techniques. The type of surgery recommened for you will largely depend on your specific diagnosis, the size and location of the diseased tissue, and your personal medical history. Surgical procedures performed by our team include:

  • Thyroid lobectomy
  • Total thyroidectomy
  • Completion thyroidectomy
  • Central neck dissection
  • Modified radical neck dissection
  • Focused parathyroidectomy
  • Minimally invasive parathyroidectomy
  • Bilateral neck exploration
  • Subtotal parathyroidectomy
  • Re-operative parathyroid surgery
  • Laparoscopic adrenalectomy
  • Open adrenalectomy

Your Endocrine System

The endocrine system is the collection of glands in the body that produce and secrete hormones. These hormones influence almost every cell, organ and function in the body, controlling everything from our metabolism, calcium regulation, and our “fight or flight” response. Some endocrine glands – including the thyroid, parathyroid, and adrenal glands – operate on a feedback loop that is much like a thermostat in your home. If a gland detects too little or too much hormone in the body, it will either speed up or slow down production of that hormone. This feedback loop allows healthy endocrine glands to maintain a proper balance of the body’s systems.

Thyroid Glands

The thyroid – a butterfly-shaped gland in the base of the neck – may be small, but it plays a major role in the body. The thyroid produces the thyroid hormone thyroxine, which controls the body’s metabolism. Thyroxine increases the heart rate and how forcefully the heart squeezes. It also affects how fast food moves through your GI tract, bone loss, and how fast sugar is made and used up in the body. A healthy thyroid helps us use energy, stay warm and keep the brain, heart, muscles and other organs working as they should.

The thyroid gland makes thyroxine from iodine from our diet, stores the thyroxine, and releases it into the blood stream as needed. The pituitary gland is responsible for regulating how much hormone the thyroid produces and releases. By producing thyroid stimulating hormone (TSH), the pituitary gland signals the thyroid to produce and release thyroxine. The absence of TSH signals the thyroid to store the thyroxine and slow production.

Simple blood tests can measure the amount of thyroxine (T4) and TSH in the patient’s blood stream. A low level of T4 and high level of TSH can indicate an underactive thyroid (HYPOthyroidism), while a high level of T4 and a low level of TSH can mean a patient has an overactive thyroid (HYPERthyroidism).

HYPOthyroidism occurs when the gland is not producing enough hormones and metabolism slows down. This can occur for a number of reasons but is most commonly caused by an autoimmune disorder, like Hashimoto's thyroiditis, or from previous treatment for hyperthyroidism. Resulting symptoms can include:

  • Extreme fatigue
  • Depression
  • Forgetfulness
  • Cold intolerance
  • Dry skin
  • Weight gain
  • Hair loss

Hypothyroidism cannot be cured, but can be completely controlled in most cases with thyroid hormone replacement medication (levothyroxine) taken once daily.

HYPERthyroidism or overactive thyroid, is a more rare condition that if left untreated can lead to various heart conditions and thinning of the bones. Symptoms of hyperthyroidism can include:

  • Irritability
  • Weight loss
  • Heat intolerance
  • Vision problems
  • Nervousness
  • Tremors

Determining the cause of hyperthyroidism will guide treatment. Most commonly, the hyperthyroidism is cause by an over production of thyroid hormone due to Graves' disease, toxic multinodular goiter (enlargement), or toxic adenoma (nodule). In some cases the hyperthyroidism is caused by excessive release of thyroid hormone from the thyroid gland due to inflammation and/or destruction. Treatments for hyperthyroidism include medication, surgery to remove all or part of the thyroid, or RAI ablation.

Parathyroid Glands

The parathyroids are four small glands in the neck that control the level of calcium in the body. Each gland is about the size of a grain of rice, and is responsible for producing parathyroid hormone or PTH. PTH maintains the appropriate balance of blood calcium in the body, which is crucial to the normal functioning of the heart, nervous system, kidneys, and bones. When blood calcium is too low, PTH is released to bring the calcium level back up to normal. If the blood calcium level is too high, a healthy parathyroid will stop releasing PTH.

When released by the parathyroid, PTH elevates blood calcium levels by:

  • Breaking down the bone (where most of the body's calcium is stored) and causing calcium release
  • Increasing the body's ability to absorb calcium from food
  • Increasing the kidney's ability to hold on to calcium that would otherwise be lost in the urine.

A diseased parathyroid can either cause insufficient levels of PTH to be released (HYPOparathyroidism) or an overproduction of PTH (HYPERparathyroidism). While hypoparathyroidism is rare, the condition can be managed with supplements to normalize your calcium levels. Surgery to remove the diseased parathyroid is the most common treatment for primary hyperparathyroidism.

Because of advances in medicine and diagnostics, primary hyperthyroidism is usually diagnosed before severe symptoms are observed. However, without treatment, abnormally high blood calcium levels can gradually damage every organ in the body over time, causing:

  • Bone and joint problems
    • Weakening of the bones
    • Joint and bone pain
  • Nervous system problems
    • Fatigue
    • Depression
    • Irritability
    • Worsening short term memory
    • Worsening concentration
    • “Brain fog”
  • Kidney Problems
    • Kidney stones
    • Urinating more frequently
    • Kidney disease
  • Muscle problems
    • Weakness
    • Muscle aches
  • Digestive problems
    • Abdominal pain
    • Nausea
    • Vomiting
    • Constipation
    • Ulcers
    • Pancreatitis

Primary hyperthyroidism is usually caused by either a benign growth (adenoma) on a gland, or by an enlargement (hyperplasia) of two or more parathyroid glands. In very rare cases, a cancerous tumor can cause a parathyroid gland to malfunction. Surgical removal of the diseased parathyroid(s) or tumor is the best treatment available to cure primary hyperthyroidism.

Adrenal Glands

The adrenal glands, located deep inside the abdomen and just above the kidneys, are two walnut sized glands responsible for producing several types of hormones. The glands themselves have 2 layers: the outer layer (cortex) and the inner layer (medulla). The different layers produce different hormones. The hormones made by the medulla are adrenaline and noradrenaline. The cortex produces cortisol, androgens and estrogen, and aldosterone. Each of these hormones has specific functions in the body:

  • Adrenaline and noradrenaline: these hormones are released during times of anxiety, pain, upright posture or cold. They control the body’s “fight or flight” response, raising blood pressure, heart rate and the amount of oxygen we breathe. Adrenaline can also cause the liver to release extra glucose (sugar) to give the body a quick boost of energy.
  • Cortisol: this is a steroid hormone that controls glucose production in the liver and protein breakdown in muscles. It affects many body functions, and plays a key role in regulating the body’s blood pressure, maintaining blood sugar and energy levels, and protecting the body against stress.
  • Androgens and estrogen: these are sex hormones that control the growth of reproductive organs and some behaviors. Androgens control the male reproductive system while estrogens control the female reproductive system.
  • Aldosterone: this hormone is called a mineralocorticoid, and regulates the body’s blood pressure by adjusting the sodium and potassium in the blood.

If the adrenal glands produce too little of these hormones, it is referred to as adrenal insufficiency, or Addison’s disease. Patients with Addison’s require synthetic hormones in the form of medication to prevent potentially fatal complications.

If the adrenal glands produce too much of a hormone – most commonly caused by an adrenal tumor or bilateral adrenal hyperplasia (enlargement and overproduction of both adrenal glands) – it can result in one of the following conditions:

  • Cushing's syndrome (too much cortisol)
  • Primary hyperaldosteronism (too much aldosterone)
  • Virilizing syndrome (too much androgen)
  • Pheochromocytoma (too much adrenaline produced by an adrenal tumor)
  • Paraganglioma (too much adrenaline produced by a tumor outside of the adrenal glands)

Surgical removal of the tumor or diseased adrenal gland is almost always the preferred treatment for conditions where the adrenal glands are overproducing hormones.

Conditions treated by Endocrine Surgeons

Thyroid Cancer

What is Thyroid Cancer?

Thyroid cancer (or carcinoma) is a malignant lump or growth originating in the thyroid gland. Thyroid cancer is the most rapidly increasing cancer in the United States, and primarily affects women. There are three basic types of thyroid cancer: Differentiated Thyroid Cancer (Papillary, Follicular, and Hurthle Cell Cancers); Medullary Thyroid Cancer; and Anaplastic (or Undifferentiated) Thyroid Cancer.

Symptoms

  • Enlarging lump or mass on the thyroid gland (lower neck).
  • A lump or mass on the side of the neck (lymph gland).
  • Hoarseness or change in voice.
  • Pressure or tightness in the lower neck.
  • Difficulty swallowing.
  • Many early thyroid cancers do not cause symptoms and are found during exams or studies performed for other reasons.

Causes

As with many other cancers, doctors do not know all of the reasons why cancer develops. There are several known risk factors for thyroid cancer:

  • Radiation to the head or neck (especially during childhood).
  • Family history of thyroid or other endocrine tumors.
  • History of “goiter” (enlarged thyroid).
  • Gender - more than 75% of thyroid cancers affect women; however, men with a thyroid lump are at higher risk of their lump being a cancer.
  • History of iodine deficiency (rare in the United States).

Diagnosis

After a thyroid nodule is discovered, your doctor may recommend a needle biopsy (FNA) if the nodule has any concerning features. Sometimes, gene expression testing or molecular tests are used for additional information about a nodule and its risk of cancer. Your doctor will discuss the results with you and determine if and when to recommend surgery for definitive diagnosis and/or treatment.

Surgical Treatment

Fortunately, most thyroid cancers are very treatable and have an excellent prognosis. Treatment is dependent on the type of thyroid cancer, and usually involves surgical removal of all or part of the thyroid (and sometimes lymph glands). After surgery, thyroid hormone replacement pills are required. Additional treatment with radioactive iodine or other medications may be recommended depending on the tumor type and stage of disease. Long-term monitoring and treatment by an endocrinologist or other thyroid cancer specialist is generally recommended, as thyroid cancer can recur in the neck or other places.

What are the different types of thyroid cancer?

There are three basic types of thyroid cancer, and treatment depends on the tumor type:

  • Differentiated thyroid cancer (Papillary, Follicular, or Hurthle Cell types) account for more than 90% of thyroid cancers and arises from the follicular cells of the thyroid that help produce and store thyroid hormones. These tumors tend to grow slowly, and when detected early, are usually very treatable. Surgery is the main treatment (removal of part or all of the thyroid, and possibly lymph glands). Because differentiated thyroid cancer cells tend to uptake and process iodine, radioactive iodine treatments are sometimes given after surgery. These tumors also make a protein called Thyroglobulin, which can be measured in the blood stream and used to follow patients after surgery.
  • Medullary thyroid cancer accounts for 5-7% of thyroid cancers, and arises from the C cells of the thyroid. Up to 20% of medullary cancers are associated with familial cancer syndromes and other endocrine tumors, so genetic testing is often recommended. Surgery is the main treatment (removal of part or all of the thyroid, and possibly lymph glands). Medullary cancers do not process iodine, so iodine scans and treatments are not helpful.
  • Anaplastic thyroid cancer is a rare form of thyroid cancer that grows very quickly and can be difficult to treat. Because it tends to be aggressive and spread to other parts of the body, chemotherapy and radiation treatments (rather than surgery) are the main forms of treatment.

Hyperthyroidism

What is hyperthyroidism?

The term hyperthyroidism ("overactive thyroid gland") refers to any condition in which too much thyroid hormone is produced in your body. Hyperthyroidism is quite common and affects more women than men. If hyperthyroidism is very mild, you may not have any symptoms; however most often patients are very symptomatic. Sometimes hyperthyroidism is confused with "HYPOthyroidism" — a condition in which not enough thyroid hormone is being produced.

Symptoms

  • Enlargement of your thyroid gland
  • Weight loss despite unchanged eating or exercise habits
  • Fast heart rate
  • Increased nervousness or irritability
  • Heat intolerance or increased sweating
  • Hair loss and rapid growth of nails
  • Changes in your menstrual periods
  • Increased appetite or more frequent bowel movements
  • Visual changes (redness, dryness, and/or blurry vision)
  • Protrusion of the eyes (in some patients with graves' disease)

Causes

  • Graves' disease (named after Irish doctor: Robert Graves) is an autoimmune disorder where the body makes antibodies that attack the thyroid gland. This usually results in an enlarged thyroid gland and hyperthyroidism.
  • Toxic nodule or toxic multi-nodular goiter- a disorder where a single nodule ("lump" or "mass") or multiple nodules in the thyroid gland produce excess (“toxic”) amounts of thyroid hormone.
  • Thyroiditis - an inflammatory process in the thyroid gland leading to release of excess amounts of thyroid hormone into the blood stream. This condition can be caused by a disorder of the immune system, a viral infection, or can occur within several months of giving birth.
  • Excessive iodine ingestion or overmedication with thyroid hormone. Taking excessive amounts of iodine (in the form of sea kelp, "thyroid helper" tablets, or certain heart medications) or taking excessive amounts of thyroid medication can also lead to high thyroid hormone levels in the bloodstream.

Diagnosis

Your physician will look for characteristic symptoms and signs of an "overactive" thyroid gland. Tests can be used to confirm the diagnosis and determine the cause. Blood tests measure the amount of thyroid hormones (thyroxine-T4, triiodothyronine-T3, and thyroid hormone stimulating hormone-TSH) in the blood stream. Sometimes a "radioactive iodine uptake and scan" of your thyroid (a measurement and image of how much iodine is taken up into your thyroid gland and how the iodine is distributed) is needed to determine the cause of hyperthyroidism.

Surgical Treatment

If your hyperthyroidism isn’t adequately managed with medication, you may be a candidate for surgical removal of your thyroid. Total thyroidectomy (surgical removal of the entire thyroid) or subtotal thyroidectomy (surgical removal of part of the thyroid) is performed by an endocrine surgeon. Because symptoms of hyperthyroidism often return after a subtotal thyroidectomy, most surgeons perform total thyroidectomies to prevent future complications or additional surgeries. The absence of a thyroid leads to hypothyroidism, and thyroid hormone replacement medication is needed for the rest of your life.

Hyperparathyroidism

What is Hyperparathyroidism?

Maintaining a normal calcium level is important for various functions of the human body. Our bones serve as the main reservoir of calcium in the body. Our parathyroid glands act as the major overseer of calcium balance to keep its level in a very specific range for bone and general health. Hyperparathyroidism is an excess production of parathyroid hormone (PTH) from these glands. Over-production of parathyroid hormone can be from a benign parathyroid growth, or from overgrowth of all four glands. This results in bone loss, and disrupts the balance of many organ systems.

Symptoms

Symptoms of hyperparathyroidism usually reflect the effects of excess parathyroid hormone (PTH) leeching too much calcium from bone and raising the levels of calcium in the bloodstream, disrupting a delicate equilibrium. The higher calcium serum level can then:

  • Drive acid production in the stomach and cause irritation of the stomach and GI tract
  • Cause excess calcium to be filtered by the kidneys - increased urine calcium can lead to kidney stone formation
  • Deplete calcium from bone leading to osteoporosis and fractures
  • Lead to fatigue and joint complaints
  • Interfere with brain processes, leading to mental sluggishness, memory problems, and mood and sleep disturbances

In most patients, the diagnosis is made on routine blood tests, when calcium and parathyroid levels are only slightly affected, and symptoms are mild or even non-existent.

Causes

Primary hyperparathyroidism occurs because of some problem with one or more of the four parathyroid glands:

  • A benign growth (adenoma) on a gland
  • Enlargement (hyperplasia) of two or more parathyroid glands
  • A cancerous (malignant) tumor (rare)

Diagnosis

The average person with this disease is more likely to be a woman just past middle age. Men are 2-3 times less likely than women to be affected. There is redundancy in the body’s ability to produce this hormone, in that we have 4 small glands located around (para) the thyroid and that’s how they got their name. Usually, only 1 of these 4 small glands is the overproducer and it is the doctor’s job to find the small culprit.

Since symptoms are usually mild or nonexistent, most patients are diagnosed by screening tests we commonly use. Many people are found to have a high calcium level by health fair lab tests or routine blood work at a primary care doctor’s office. These days, many women have a bone density test coinciding with their routine mammogram. A loss of bone density may prompt additional testing and lead to the diagnosis of hyperparathyroidism.

Verification of the diagnosis comes from other supportive lab tests, including a measure of parathyroid hormone (PTH). It is also important to ensure that there are not other causes of a high calcium level, such as cancer or autoimmune diseases. Once the diagnosis is confirmed by lab tests, finding the small culprit parathyroid gland may require certain sensitive imaging tests, for which The Medical Center of Aurora has the capabilities to perform.

Risks for having hyperparathyroidism include head/neck radiation exposure and some inherited family conditions. Low vitamin D levels can also disrupt the calcium/parathyroid balance and must also be checked and corrected. Most patients with hyperparathyroidism do not have any risk factors.

Surgical Treatment

Based on lab results, symptoms and severity, and other health conditions, surgical removal of the diseased parathyroid(s) may be recommended. Because there is currently no medical blocker of parathyroid hormone and its effects, surgery is the only cure for hyperparathyroidism.

The Medical Center of Aurora’s endocrine surgery department is experienced in minimally invasive parathyroid surgery, as well as traditional open bilateral neck exploration. Because most patients with parathyroid disease have only one gland that is abnormal, the minimally invasive surgery, known as focused parathyroidectomy, is often preferred. During a focused parathyroidectomy, a small incision is made in the lower neck to locate and remove the diseased parathyroid, which is identified on pre-operative localizing tests.

In a traditional open bilateral neck exploration, surgery is performed to allow the surgeon to view all 4 parathyroid glands, identify which ones are diseased, and remove the abnormal glands. This can be performed with an incision as small as 1 ½ inches.

Long-term care and monitoring after surgery is also recommended since the disease can re-present later in the remaining parathyroid glands that were not removed.

Cushing’s Syndrome

What is Cushing’s Syndrome

Patients diagnosed with Cushing’s syndrome have too much cortisol steroid, a hormone produced by the adrenal glands, in their blood. While normal levels of cortisol are essential to the body’s stress response and contribute to normal sleep-wake cycles, elevated levels over a prolonged period can cause damage to many organ systems.

Symptoms

While other symptoms exist, some of the hallmarks of Cushing’s syndrome include:

  • A fatty hump between your shoulders (buffalo hump)
  • A rounded “moon face”
  • Pink or purple stretch marks on your skin
  • Frequent and easy bruising
  • High blood pressure
  • Bone loss
  • Type 2 diabetes

Causes

Cushing’s syndrome can result from a pituitary or adrenal gland tumor. The Medical Center of Aurora’s endocrine surgeon can treat adrenal gland sources of the disease. Prolonged use of prescription steroid medications similar to cortisol (like those used to control inflammatory diseases such as rheumatoid arthritis, asthma, and inflammatory bowel disease) can put patients at a higher risk of developing Cushing’s syndrome.

Diagnosis

Diagnosing Cushing’s syndrome can be a difficult, long process because the symptoms can be similar to other conditions. Common diagnostics for Cushing’s syndrome include:

  • Urine test: 24 hour urine cortisol level
  • Saliva test: midnight salivary cortisol level
  • Blood test: low dose dexamethasone suppression test
  • Advanced imaging of the adrenal glands
  • Petrosal sinus sampling

Treatment

For patients Cushing’s syndrome caused by an adrenal tumor, the endocrine surgeon can remove the diseased adrenal gland(s). This is usually accomplished through minimally invasive techniques like laparoscopy, though large or complex tumors may require open surgery. One complication of adrenalectomy for those with Cushing’s syndrome is the need for extra steroids to be given intravenously during the operation. Patients may need to continue to receive steroids after surgery until the remaining adrenal gland can produce adequate amounts of cortisol on its own.

Hyperaldosteronism

What is hyperaldosteronism?

One of the hormones produced by the adrenal glands is aldosterone. Aldosterone regulates the body’s blood pressure by adjusting the sodium and potassium in the blood. An overproduction of aldosterone can cause the body to retain sodium and discard potassium in dangerous amounts, thereby causing high blood pressure. Primary hyperaldosteronism is a disease in which one or both adrenal glands produce too much aldosterone.

Symptoms

The most common indication of hyperaldosteronism is elevated blood pressure that does not respond to traditional blood pressure medications. Symptoms of high blood pressure include headaches and blurred vision. Low levels of potassium can also signal an overproduction of aldosterone, and may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis.

Causes

  • An benign aldosterone-producing tumor or "aldosteronoma" in one of the adrenal
  • Bilateral hyperplasia, where both adrenal glands are hyperactive and make too much aldosterone
  • Unilateral adrenal hyperplasia (a rare condition where one of the adrenal glands is hyperactive but there is no clear tumor)
  • Malignant aldosterone-producing tumor (a rare type of adrenocortical cancer that makes too much aldosterone)
  • Rare genetic syndromes such as familial hyperaldosteronism types I and II in which both adrenal glands make too much aldosterone

Diagnosis

A blood test is the first screening done to diagnose hyperaldosteronism, which measures the plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio (PAC:PRA ratio test). To confirm the diagnosis or to identify if one or both glands is deseased, additional tests will be performed:

  • Captopril Suppression Test
  • 24-Hour Urinary Excretion of Aldosterone Test
  • Saline Suppression Test
  • Adrenal Venous Sampling

Surgical Treatment

Treatment for primary hyperaldosteronism depends on whether one (unilateral) or both (bilateral) glands are overproducing aldosterone. Patients with bilateral disease are treated with medication. In patients with unilateral disease, an adrenalectomy (removal of the adrenal gland) is recommended. This surgery is typically performed using a minimally invasive technique called laparoscopy, where the surgeon accesses the glands with the help of a camera and several small incisions in the abdomen. In cases where a large or cancerous tumor is present, an open surgery may be necessary.