elevate and bring it towards the midline. The colon

is retracted inferiorly and the stomach is retracted

plane to open the lesser sac and expose the splenic

of the gastrosplenic ligament and short gastric

vessels, which mobilises the stomach medially

spleen is rotated medially and the lateral peritoneal

A major long-term risk of total splenectomy is overwhelming infection, particularly in children younger than 5 years. Consequently, partial splenectomy has gained popularity, initially in the paediatric population, but increasingly in adult patients. Partial splenectomy may be done open or laparoscopically, although a minimally invasive technique is usually the preferred method. The indications for partial splenectomy include benign tumours (hamartoma, epidermoidal cyst, or localised lymphangioma or haemangioma) and haematologic conditions leading to hypersplenism. Partial splenectomy may not be performed for tumours that are centrally located due to the terminal blood supply of the spleen. The operating room set-up, patient positioning, trocar placements and initial dissection are the same as for laparoscopy. However, careful control of the individual vessels that supply the different pedicles of the spleen is the most critical difference. The hilar vessels, leading to an anterior artery and posterior vein, terminating in the splenic parenchyma, are meticulously dissected. Depending on the location of the tumour, the vessels terminating in the pole or region containing the abnormality are isolated. Placing a temporary clamp will create an area of demarcation to confirm the appropriate selection. The artery and vein are then divided in sequence (if the upper pole is selected, the short gastrics will be divided as well). The line of demarcation is then used to guide the transection along the surface of the parenchyma. The parenchyma is then cauterised and divided. The omentum can be placed in contact with the cut section of the spleen. The remainder of the procedure is similar to the laparoscopic approach.

Because the spleen is particularly important in the immune response to encapsulated bacteria, vaccinations against Haemophilus influenza B, Streptococcus pneumoniae and Neisseria meningitidis should be administered perioperatively. For all elective cases, vaccinations should be administered at least 2 weeks preoperatively. For emergency cases, vaccinations should be administered 2–4 weeks postoperatively, although for trauma patients, just prior to discharge is acceptable due to a high incidence of loss to follow-up. The purpose of perioperative vaccination is to avert overwhelming postsplenectomy infection (OPSI). OPSI is the development of a fulminant, rapidly fatal bacterial infection following splenectomy. OPSI is the most feared complication after removal of the spleen, and the incidence in the first 2years postsplenectomy is estimated at 0.9% for adults and 5% for children.

( of the adrenal gland and is derived from neural crest cells (

left renal vein. Lymphatic drainage from the adrenal glands flows directly into adjacent periaortic and paracaval nodes.

synthesis and circulates in both bound and free

unbound state. The free form passes into target Two separate endocrine organs, namely the cortex and medulla, comprise the adrenal gland. The adrenal cortex metabolises cholesterol to produce different steroid hormones in each zone

ACTH levels are suppressed, an ACTH-independent process originating from the adrenal glands is the likely cause of the syndrome. If serum ACTH levels are elevated, a high-dose dexamethasone suppression test is required. If ACTH levels are suppressed with high-dose dexamethasone, the likely aetiology is a pituitary tumour. However, if ACTH levels are unaffected by high-dose dexamethasone, an ectopic source of ACTH is the likely cause. If an adrenal cause is suspected, an abdominal CT should be performed to localise the tumour. Cortisol-secreting adrenal tumours, particularly those with overt Cushing’s syndrome and high cortisol levels, have been associated with somatic activating mutations in protein kinase A (PKA) catalytic subunit (PRKACA) and the Gs alpha subunit (GNAS).

Patients with pheochromocytoma have chronic hypersecretion of catecholamines that causes volume-contraction as well as haemodynamic and glycaemic instability. Thus, they must be pre-medicated with a selective alpha-adrenergic receptor-blocker (phenoxybenzamine) for several weeks before proceeding to adrenalectomy.

Postoperatively, patients are susceptible to vasoplegia and hypoglycaemia, and should be monitored closely.

4 cm that produce a clinical syndrome of hormone excess. A significant number have distant metastases at presentation, usually to liver, lungs, lymph nodes and bone.

5 cm

The work-up of adrenal incidentalomas must address functionality and malignant potential of the mass that will guide treatment or observational approaches. A thorough history and physical examination must be performed to evaluate for potential subtle clues about functionality or malignancy that may have been overlooked during prior assessments. Biochemical evaluations as described above should be performed to rule out aldosterone, cortisol or catecholamine-producing adrenal masses. Although most adrenal incidentalomas are non­functional, approximately 10–15% secrete excess adrenal hormones.

Adrenalectomy is recommended for

4 cm, or tumours with imaging characteristics concerning for malignancy. For masses with benign appearances (<10 HU, washout >50%), small (<

4 cm), and completely non-functional, imaging and biochemical surveillance between 3 and 12months is reasonable.

The patient is placed in a left lateral decubitus position flexed at the hip. The left arm is extended and the right arm suspended. The surgeon faces the patient and the assistant is behind the patient. Video monitors are positioned at the head of the bed. Four trocars are generally placed along a linear curve situated below the right costal margin once pneumoperitoneum is achieved using a Hassan technique. The right adrenal gland is situated behind the liver, necessitating its medial mobilisation by dividing the triangular ligament. An atraumatic liver retractor is introduced through the lateral port to hold the liver out of the way. Mobilisation of the liver allows for identification of the vena cava, which is the main anatomical landmark for identifying and dissecting the right adrenal gland. The right border of the vena cava is dissected caudally to expose the renal vein, which constitutes the inferior landmark of the operating field. The vena cava is then dissected cephalad to the diaphragm, to expose the main adrenal vein and, if present, the accessory adrenal vein. Both are ligated and divided. The arterial blood supply is then identified, ligated and divided. The gland is then freed from its fatty and inferior ligamentous attachments along the superior pole of the kidney. The gland is then placed in a plastic bag and removed.