Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
.pdf
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
99 |
Right-Sided Anterior Open Approach
The right lobe of the liver is retracted superiorly, or the triangular ligament is incised to retract the liver medially. The kidney, vena cava, and adrenal mass should be visualized behind the peritoneal covering. Occasionally, a Kocher maneuver may be performed to provide better exposure.
The peritoneum just lateral to the vena cava is incised. Dissection in the plane between the vena cava and the adrenal gland will expose the right adrenal vein, which should be ligated and divided at this time (Figure 8-11).
Subcostal incision 
A
B
FIGURE 8–11
1 0 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
The remaining attachments of the adrenal gland should be divided around its perimeter (Figure 8-12). Occasionally, for larger tumors, a large feeding vessel may be encountered, which may require ligation, but most of this mobilization can be done with the ultrasonic dissector.
Right adrenal vein
A
Clip on
right adrenal vein
Right kidney
|
Clip on accessory |
B |
right adrenal vessel |
|
FIGURE 8–12 |
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
101 |
Posterior Open Approach
The posterior approach requires appropriate positioning and padding of the patient in the prone position.
The incision over the 12th rib is deepened to the level of the periosteum, which is then incised. The 12th rib is resected as far medially as reachable. A self-retaining retractor is placed to provide exposure (Figure 8-13).
Enlarged left adrenal gland 
Incision over 12th rib
A
Stripping 12th rib superiorly |
Resect rib |
medial to lateral |
|
Intercostal muscles |
|
Stripping 12th rib inferiorly lateral to medial
B
FIGURE 8–13
1 0 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
The intact pleural membrane is carefully dissected from its attachments to the diaphragm, and the diaphragm may need to be incised radially along the line of its fibers. Care is taken to avoid injury to the intercostal nerve, especially during subsequent retraction
(Figure 8-14).
Incision through diaphragm
Incise through pleura
A
Perirenal fat |
Left adrenal gland |
|
|
Renal capsule |
Resected 12th rib |
|
|
|
Left adrenal |
|
artery and vein |
Perirenal fat
Left kidney
B
FIGURE 8–14
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
103 |
The fascia enveloping the kidney and adrenal gland (Gerota’s fascia) is incised. A retractor placed medially and beneath Gerota’s fascia and the diaphragm provides exposure while the fat and adrenal gland are swept inferiorly (Figure 8-15).
As with the other adrenalectomy techniques, the dissection should be aimed at careful identification, ligation, and division of the adrenal vein early. However, the small adrenal arteries should be ligated as they are encountered on the way to the vein. For a left adrenalectomy, the left adrenal vein may not be visible until the gland is mobilized circumferentially.
The remaining attachments are divided and the entire gland is removed.
Adrenal gland
Placing a clip on left adrenal vein
FIGURE 8–15
1 0 4 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
3. CLOSING
Port sites up to and including 12 mm do not need fascial closure if dilating tip trocars are used in place of cutting trocars. For cutting trocars, all port sites larger than 5 mm should be closed using a laparoscopic suture passer.
Standard closure of the incision after the open approaches should be tailored to the surgeon’s preference.
For the posterior approach, the diaphragm is closed with interrupted, horizontal mattress polypropylene sutures. The pleural membrane should then be inspected for holes, and if present, a small caliber drainage tube should be placed before the hole is sutured closed. The remaining layers are closed with absorbable suture.
STEP 4: POSTOPERATIVE CARE
Pain management for laparoscopic adrenalectomy is with oral analgesics, whereas the open approaches typically require intravenous narcotics.
The diet should be advanced as tolerated, with the expectation that the anterior open approaches may result in some degree of postoperative ileus.
The most common complications are the result of injury to adjacent structures. Adrenal vein, vena cava, liver, and kidney injuries result in life-threatening bleeding during the operation or more subtle bleeding with the development of a hematoma postoperatively. A missed thermal or retractor injury to the intestines will cause sepsis in the first week after the operation.
Acute adrenal insufficiency should be suspected in patients developing hemodynamic instability postoperatively. Prompt recognition and treatment with steroids are critical to avoid a potentially fatal outcome.
Glucocorticoid stress doses are tapered postoperatively for patients with cortisol-secreting tumors but should be administered until the function of the hypothalamic-pituitary- adrenal axis is confirmed with an adrenocorticotropic hormone (ACTH) suppression test.
Patients having bilateral adrenalectomy should have life-long replacement of glucocorticoids and mineralocorticoids.
C H A P T E R 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) |
105 |
STEP 5: PEARLS AND PITFALLS
The appropriate preoperative preparation of the patient with a pheochromocytoma cannot be overstated. Failure to follow the sequence of alpha blockade followed by beta blockade can lead to hemodynamic catastrophe.
Even with the appropriate preparation, patients with pheochromocytomas may have wide fluctuations in blood pressure as the adrenal gland is manipulated intraoperatively. Early control of the adrenal vein and appropriate hemodynamic monitoring and intervention are keys to minimizing this complication. Careful attention to fluid management should continue into the postoperative period.
Manipulation should be by grasping the tissue around the adrenal glands or pushing it to the side, and dissection of the adrenal glands should be extracapsular. Lacerations of the gland will cause bleeding, which compromises adequate visualization and/or causes spillage of potentially malignant cells.
SELECTED REFERENCES
1.Bravo EL: Pheochromocytoma: Diagnosis, localization and management. N Engl J Med 1984;311: 1298-1303.
2.Gagner M: Laparoscopic adrenalectomy. Surg Clin North Am 1996;76:523-537.
3.Prinz A: A comparison of laparoscopic and open adrenalectomies. Arch Surg 1995;130:489-492.
C H A P T E R 9
WIDE LOCAL EXCISION
Baiba J. Grube
STEP 1: SURGICAL ANATOMY
The breast is an organ that is composed of lobes, ducts, fibrous stroma, ligaments, adipose tissue, nerves, blood vessels, and lymphatics. The nipple-areolar complex is a specialized structure containing elements of skin epithelium, sweat and sebaceous appendages, and ductal epithelium with a nerve supply from branches of the second to sixth intercostal nerves.
The breast parenchyma is organized into lobes that have a central duct, peripheral branching ducts, and glandular tissue.
The lobes are variable in size, shape, and extent of branching.
Ducts from different lobes are not constructed in wedge-like radial fashion but may lie over or under one another in an overlapping manner like intertwining roots.
Most experts believe that ducts from one lobe do not anastomose with ducts of another lobe, but this is still an area of investigation.
The nonuniform distribution of lobe anatomy influences the ability to map the breast parenchyma and has implications for surgical resection. Most tumors are localized and limited in extent, with a smaller percentage distributed segmentally and a minor number coursing in an irregular intertwined pattern.
The peripheral ducts terminate in five to nine central ductal orifices in the nipple.
Breast cancer is primarily a disease that begins in the terminal duct lobular units.
Definition of terms for breast conservation:
Lumpectomy, tylectomy, wide local excision, partial mastectomy, or segmental mastectomy are roughly synonymous terms referring to the removal of a cancer through a small incision on the breast with a rim of normal healthy breast tissue, leaving the majority of normal breast tissue undisturbed. In most cases the nipple-areolar complex is left intact.
108