The adrenal glands are located in the retroperitoneum, and each gland weighs approximately 4g. The glands have their own capsule; they are surrounded by peri­renal fat and enclosed in the Gerota’s fascia [6]. The right adrenal gland is in contact with the posterolateral aspect of the retro-hepatic vena cava, and it is surrounded by the right kidney inferolaterally, the bare area of the liver anterosuperiorly, and the diaphragm posteriorly. The left adrenal gland is located between the left kidney and the aorta and it is surrounded by the spleen and the tail of the pancreas anteriorly and the diaphragm posteriorly [6]. The adrenal gland arterial supply is similar and consistent for both sides. It arises from 3 main sources: The inferior phrenic artery gives rise to the superior adrenal artery, the middle adrenal artery branches off the aorta, and the inferior adrenal artery arises from the renal artery. The typical venous drainage of the adrenal glands is through a single vein. The right adrenal vein is quite short and drains directly into the inferior vena cava (IVC) posterolaterally. The left adrenal vein runs inferomedially to empty in the left renal vein after joining the inferior phrenic vein [7]. A large retrospective study of over 500 adrenalectomies revealed the intraoperative variations to the standard anatomy to be as high as 13% [8]. The variations included no main adrenal vein identiable, additional small veins, two adrenal veins, more than two adrenal veins, and variant drainage to the IVC or to the right hepatic vein or to the inferior phrenic vein. Solid understanding of these anatomical landmarks and possible anatomical variations helps with the surgical dissection along the avascular planes around the adrenal gland, avoiding inadvertent injuries or intraoperative bleeding.

Along with the patient’s positioning, the port placement is one of the most critical portion of the operation. The peritoneal cavity is entered using a 5mm optic view trocar on the right midclavicular line in the lower quadrant (Fig.29.3a). This 5mm trocar is left as an assistant port for suction or to be quickly upsized to a 12mm trocar for placement of baby lap pads and compression, in case of a signicant IVC bleeding requiring conversion to open. Once pneumoperitoneum of 15mmHg is established, the most lateral 8mm robotic trocar is introduced under direct visual­ization between the right posterior and midaxillary lines, approximately 1–2cm from the costal ridge. After that, three other 8mm robotic trocars are placed from lateral to medial, with at least 6cm distance between each other, along the costal ridge toward the xyphoid process (Fig.29.3a). The robotic instrument conguration from lateral to medial is as follows: forced bipolar, camera, scissors, and tip-up grasper (by the xyphoid process for liver retraction).

We follow the open book technique, which was previously described for laparo­scopic adrenalectomy [6]. The rst step is to divide the coronal ligament of the right lobe of the liver, allowing the mobilization of the liver anteromedially. This maneu­ver opens the book that is comprised of the bare surface of the liver on the right­hand page and the kidney and adrenal gland/tumor on the left-hand page. The tip-up grasper is utilized to retract the right lobe of the liver, exposing the IVC.Given how cephalad the right adrenal gland is located, rarely mobilization of the hepatic exure of the colon or duodenum is required. Different than the laparoscopic technique, we develop the space between the IVC and adrenal gland from inferior to superior (Video 29.1). We perform this dissection layer by layer along the posterolateral

Patients are admitted for overnight observation with anticipated discharge home postoperative day 1. Diet is resumed the same day of the operation and early mobi­lization is resumed as for other minimally invasive operations. For pheochromocy­toma patients, decision regarding admission to the intensive care unit is determined at the end of the case depending on the need of vasopressor support. Hemodynamically stable patients are admitted to the regular ward. Cushing’s syndrome/disease patients receive perioperative steroids and steroid tapering the weeks following their surgery. For patients with preoperative diagnosis of hyperaldosteronism, the potassium supplement is stopped after surgery and serum potassium levels are checked on postoperative day 1 and a week after surgery. Antihypertensive medica­tions are stopped or have their dose reduced depending on their blood pressure after the adrenalectomy.