Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 8 |
• Adrenals—Anterior, Posterior (Open and Laparoscopic) |
89 |
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Right middle |
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adrenal artery |
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Right and left inferior phrenic artery |
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Left middle adrenal artery |
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Right superior |
Left superior |
|
adrenal artery |
adrenal artery |
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Right
adrenal vein Left inferior phrenic vein
Left adrenal vein
Right inferior adrenal artery
Left inferior adrenal artery
MC
A
Left inferior phrenic artery |
Right inferior |
Enlarged left |
phrenic artery |
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adrenal gland |
Right middle |
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adrenal artery |
Left adrenal |
Right inferior |
artery and vein |
adrenal artery |
B
FIGURE 8–1
9 0 |
S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
Unilateral adrenalectomy is perfectly suited for the laparoscopic approach because of the small size of most adrenal masses and the large incision necessary for open excision.
Resection of an adrenal cancer should include en bloc resection of involved organs. Such an extensive resection is best performed with an open approach.
Patients with pheochromocytomas must be medicated preoperatively with phenoxybenzamine (alpha blocker) for 7 days or longer to control hypertension. If tachycardia is present once the blood pressure is controlled, a beta blocker is added for another 5 days before operation.
A stress dose of glucocorticoids should be given preoperatively to all patients with hypercortisolism.
Routine prophylaxis against deep venous thrombosis and pulmonary thromboembolism is standard of care.
Preoperative intercostal nerve blocks or placement of an epidural catheter should be considered for the open approaches to help with postoperative pain control.
STEP 3: OPERATIVE STEPS
1.INCISION
Unilateral adrenalectomy is approached laparoscopically in most cases. The patient is placed in the lateral decubitus position with the table flexed. The open flank incision in the lateral decubitus position or the posterior approach in the prone position is favored for larger masses ( 10 cm), which have a higher malignant potential.
Bilateral adrenalectomy is often approached through a midline or bilateral subcostal incision with the patient in the supine position. The laparoscopic approach can be used, but the patient usually must be repositioned into the contralateral decubitus position after the first side is complete.
Four ports are usually sufficient for the laparoscopic approach. The size of the trocars will depend on the size of the available instrumentation (scopes, clipping device, right-angle dissector, liver retractor, retrieval bag) and the size of the lesion.
The incision for the posterior approach is along the ipsilateral 12th rib with the patient appropriately padded in the prone, jackknife position (Figure 8-2).
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
91 |
Thoracoabdominal
incision
Subcostal
incision
A
B
Incision over 12th rib
C
FIGURE 8–2
9 2 |
S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
2. DISSECTION
Laparoscopic Adrenalectomy
The first port (12 mm) is placed using a trocar with internal visualization or by open technique just below the ipsilateral costal margin in the anterior axillary line.
A 12-mm port is placed higher along the costal margin at least a handbreadth from the first. Two 5-mm ports are placed lower along the costal margin down to the posterior axillary line. The left colon will need to be mobilized before the most posterior port can be placed for left-sided operations.
Left-Sided Laparoscopic Operation
The splenic flexure and some of the descending colon need to be mobilized using a combination of sharp and blunt dissection with care used to stay anterior to the kidney. The hook cautery or ultrasonic dissector is used to accomplish this. The spleen and tail of the pancreas are then mobilized by dividing the splenorenal ligament. Gravity will help these organs fall medially and out of the dissection field (Figure 8-3).
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
93 |
Spleen hangs toward midline in left lateral decubitus position
A
Spleen hanging
toward midline
Incising through splenorenal ligament
B
FIGURE 8–3
Incision to mobilize splenic flexure
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S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
Dissection medially between the adrenal gland and the superior pole of the kidney will reveal the adrenal vein, which should be clipped and divided early in the operation
(Figure 8-4).
The remainder of the gland’s blood supply and attachments can be effectively divided with the ultrasonic dissector. Occasionally a larger blood vessel may be encountered that warrants more secure ligation with clips. The inferior phrenic vein enters the left adrenal vein medially and can be a source of troublesome bleeding if not identified and controlled.
The entire gland is then placed in a retrieval bag and removed after slightly enlarging one of the port sites.
Tumor in left adrenal gland
Left adrenal artery and vein
FIGURE 8–4
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
95 |
Right-Sided Laparoscopic Operation
The triangular ligament of the right hepatic lobe is divided, and gravity retracts it medially usually without the need for a specific liver retractor. At this time the adrenal gland is usually easily identified above the kidney and lateral to the vena cava (Figure 8-5).
Patient in right lateral decubitus position
A
Incising through right triangular ligament
B
FIGURE 8–5
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S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
Identification of the adrenal vein is then pursued at the lateral aspect of the vena cava with lateral displacement of the adrenal gland. A right-angle dissector is very useful here. Once identified, the vein is clipped and divided (Figure 8-6).
The remainder of the blood vessels and attachments are easily controlled and divided with the ultrasonic dissector (Figure 8-7). This dissection progresses medial to lateral, so the lateral attachments provide lateral retraction until the completion of the mobilization.
Once liberated from its attachments, the gland is placed in a retrieval bag and removed.
Right adrenal vein
FIGURE 8–6
Removing adrenal gland
Clip on
right adrenal vein
FIGURE 8–7
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
97 |
Left-Sided Anterior Open Approach
One approach to left adrenalectomy is full mobilization of the splenic flexure and splenorenal ligament as described in the laparoscopy section.
Another approach is through the lesser sac. After the abdominal incision of choice is made, the lesser sac is opened by incision of the greater omentum at the insertion onto the left side of the transverse mesocolon (Figure 8-8).
Subcostal incision
A
FIGURE 8–8 |
B |
Incision to mobilize splenic flexure
9 8 |
S E C T I O N I • H E A D A N D N E C K A N D E N D O C R I N E P R O C E D U R E S |
The peritoneum below the tail of the pancreas is incised so that the tail of the pancreas can be retracted superiorly (Figure 8-9).
The peritoneum covering the left renal vein is opened, and the left adrenal vein is identified on the superior aspect of the left renal vein lateral to the aorta. The left renal vein is ligated and divided (Figure 8-10).
The blood vessels and tissues around the perimeter of the adrenal gland are divided using a combination of blunt and sharp dissection and suture ligation when needed. This dissection proceeds from medial to superior, then lateral, and finally inferior.
FIGURE 8–9
FIGURE 8–10