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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
Fig. 2 Large left adrenal
tumor (T) displacing the
left kidney (K) inferiorly.
Note the left renal vein
(RV) stretched across the
inferomedial aspect of the
tumor capsule
A. Papachristos and S. B. Sidhu
• Large tumors displace normal anatomical structures as they enlarge. The kidney
is pushed inferiorly and therefore the renal vessels are usually stretched along the
medial aspect of the tumor capsule (Fig.2). These may easily be mistaken for
adrenal vessels and care must be taken to correctly identify and preserve them
during dissection of the tumor. If the tumor involves the renal vessels or the
upper pole of the kidney, an en-bloc nephrectomy should be performed.
4.1 Right Sided Open Adrenalectomy
A generous subcostal incision two ngerbreadths below the costal margin is performed from the midline to the mid-axillary line. It is important that this incision
line is marked prior to exing the operating table.
The external oblique, internal oblique and transverse abdominal muscles laterally and rectus abdominus medially are divided using cautery. The peritoneum is
then incised sharply, entering the peritoneal cavity. A thorough laparotomy is performed, systematically examining all four quadrants of the peritoneal cavity to
assess for metastatic disease.
While small adrenal tumors can usually be accessed without right colonic or
duodenal mobilization, in the setting of open adrenalectomy the tumor is large or
locally invasive, and requires mobilization of overlying structures to ensure adequate exposure.
Open Adrenalectomy
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The liver is mobilized by dividing the right triangular ligament to the diaphragm
(Fig.3), allowing medialization of the right lobe. The falciform ligament is divided
between clips and dissected cranially to the diaphragm, taking care to avoid the
hepatic veins.
• Occasionally this will not afford adequate exposure and a right hemi- hepatectomy
may be required for access (Fig.4).
Fig. 3 A subcostal
incision is made, the
muscle layer is divided and
the peritoneal cavity
entered. The triangular
ligament is divided, the
liver retracted superiorly
and the peritoneum of the
hepatorenal pouch is
divided to gain access to
the upper border of the
adrenal tumor (M). GB
gallbladder
Fig. 4 A right a hemihepatectomy has been
performed to facilitate
resection of a large right
ACC.The duodenum (D)
has been Kocherized until
the left renal vein is
identied, providing access
to the IVC
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A. Papachristos and S. B. Sidhu
• It is important to remember that medial retraction of the liver may cause IVC
compression and hypotension, and so a close ongoing dialogue with the anesthe-
tist is important.
The hepatic exure of the colon is mobilized and retracted inferiorly.
The duodenum is then Kocherized to expose the IVC (Fig.4).
The peritoneum of the posterior abdominal wall and Gerota’s fascia is incised at
the lateral, inferior and superior margins of the tumor if initially accessible. This
step denes the eld of dissection (Fig.5), and will allow greater mobility in lateral
retraction of the tumor to exposure the lateral border of the IVC.
Once Gerota’s fascia has been incised at the upper pole of the kidney, the upper
pole is dened and the perinephric fat is swept up to be included with the specimen.
If the tumor is involving the kidney or renal hilum, this incision into Gerota’s
fascia is continued lateral to the kidney, to enter a posterior plane on the on the quadratus lumborum muscle, preparing for en-bloc resection.
The plane between the IVC and the tumor is identied in the inferior aspect of the
eld and dissected to expose the lateral border of the IVC along a broad front, working from inferior to superior. The IVC is dissected from the adrenal tumor (Fig.6).
Small tributaries of the caudate lobe that drain directly to the IVC must be
secured, taking care not to avulse them during liver retraction.
We aim to triangulate the dissection onto the adrenal vein from below and above.
With the patient in the lateral position, the adrenal vein is encountered as the IVC is
passing under the liver (Fig.7).
Fig. 5 Open
adrenalectomy for a right
sided adrenal
pheochromocytoma.
Dissection is carried out
along the lateral margin of
the IVC, triangulating from
above and below to
encounter the adrenal vein
(not shown). PHEO
pheochromocytoma, K
kidney, IVC inferior
vena cava
Open Adrenalectomy
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Fig. 6 The lateral border
of the IVC is dissected on
a broad front. Here it has
been slung with the blue
vascular loop. The right
adrenal tumor (T) can be
seen in the angle between
the IVC and right renal
vein (RV)
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The adrenal vein is identied, ligated and divided.
• The retrocaval component of the adrenal requires gentle retraction of the IVC
• Once the adrenal vein is secured, the tumor is lifted off from the retroperitoneum
and the feeding arteries, which arise from the inferior phrenic, the aorta and the
renal arteries are ligated and divided with a thermal sealing device.
• In the situation of vascular invasion or tumor thrombus, it is crucial to involve an
experienced vascular surgeon. Extension of tumor thrombus into the left atrium
may necessitate cardiopulmonary bypass to achieve resection (Fig.8).
Supra and infra-hepatic control of the IVC should be secured prior to approaching
the adrenal vein if the extent of vascular involvement is unclear.
Occasionally invasive disease necessitates IVC resection and reconstruction to
achieve an R0 resection margin (Fig.9). Similarly, in the case of renal involvement,
early proximal control of the renal vessels should be achieved (Fig.10).
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A. Papachristos and S. B. Sidhu
Fig. 7 Open
adrenalectomy for a large
ACC invading the right
kidney. (a) Right renal vein
is identied below the
inferior margin of the
tumor. (b) The renal vein
has been divided. The
arrow shows the putative
position of the right
adrenal vein. ACC adrenal
tumor, RV renal vein, IVC
inferior vena cava, K
kidney, GB gallbladder
a
b
4.2 Left Sided Adrenalectomy
The patient is positioned supine with a wedge under the left side and the operating
table exed to accentuate the space between the iliac crest and costal margin.
An incision two nger-breadths below the costal margin from the mid-axillary
line to the midline, and dissection and entry to the peritoneal cavity is performed in
a similar way to the right side.
We adopt a similar approach to open dissection as is performed during left anterior laparoscopic adrenalectomy, and have included some representative gures to
illustrate the anatomical teaching points.
The splenic exure and descending colon are mobilized by incising the white
line of Toldt and developing the embryological fusion plane (Fig.11).
The peritoneal incision line lateral to the colon is also continued superiorly to
divide the lienophrenic (splenophrenic) ligament. This allows medial retraction of
the spleen and visualization of the lienorenal (splenorenal) ligament (Fig.12).
Although the left adrenal can be approached through the lesser sac by opening
the gastrohepatic (1) or gastrosplenic ligaments (2), and incising the posterior peritoneum, the exposure afforded by this approach is limited, and is not well-suited to
Open Adrenalectomy
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Fig. 8 Transesophageal
echocardiogram
demonstrating tumor
thrombus (T) in the IVC
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large or invasive tumors for which open adrenalectomy is typically required. Instead,
we prefer the approach through the lienorenal (splenorenal) ligament (3) (Fig.13).
The lienorenal (splenorenal) ligament is incised to enter the plane between the
spleen/tail of pancreas and the kidney (Fig.14). It is important that this incision in
the lienorenal (splenorenal) ligament is not made too close to the splenic capsule,
and the correct plane is identied, otherwise troublesome bleeding from small hilar
branches may be encountered.
Once the plane between the kidney and spleen/tail of pancreas has been developed, “opening the book”, a left medial visceral rotation allows wide exposure of
the retroperitoneum and adrenal tumor.
Gerota’s fascia is incised at the lateral aspect of the upper pole of the kidney/
inferior margin of the tumor and continued superiorly to the diaphragm to mark the
lateral extent of the resection eld (Fig.15).
Dissection is also continued medially to identify and dene the renal vessels.
They may be stretched along the inferomedial aspect of the tumor and may be of a
similar size to the vessels entering the tumor. Care must be taken not to inadvertently divide them as capsular dissection proceeds.
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Fig. 9 IVC resection and
reconstruction may be
required to achieve a R0
resection. L liver, G graft
replacing IVC
A. Papachristos and S. B. Sidhu
As the inferomedial corner of the tumor is approached, the adrenal vein is identied and ligated. The inferior phrenic vein usually joins the left adrenal vein before
the junction with the left renal vein (Fig.16).
If local invasion necessitates en-bloc resection of the spleen and tail of pancreas,
the gastrocolic and gastrosplenic ligaments are divided to enter the lesser sac and
dene the proximal resection margin on the pancreas and splenic vessels (Fig.13).
Occasionally en-bloc resection of a cuff of diaphragm or posterior abdominal wall
musculature is necessary to ensure an R0 resection margin (Fig.17).
The tumor is then lifted off from the retroperitoneum and any feeding vessels are
ligated and divided.
We do not routinely leave a drain tube, however in the setting of multivisceral
resection involving liver or pancreas, a 15F drain is placed.
The abdominal wall is closed in two layers with two running 1-0 polydioxanone
sutures. The subcutaneous tissue is approximated with interrupted 3-0 vicryl and the
skin is sutured using an absorbable 3-0 monolament suture.
Open Adrenalectomy
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Fig. 10 Resected specimen of ACC with en-bloc right liver and preoperative CT scan. The CT
scan demonstrates loss of tissue planes between the adrenal gland and the liver, predicting the need
for en-bloc resection
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Fig. 11 Open
adrenalectomy for a left
4cm ACC.The splenic
exure of the colon is
mobilized to expose the
spleen, which is then
medialized by dividing the
lienorenal ligament. S
spleen, SF splenic exure
66
Lesser
Falciform
va
ligament
Gastr
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Fig. 12 Laparoscopic
view of the left upper
quadrant after division of
the lateral splenic
attachments, allowing
medialization of the spleen
(S) over the anterior
surface of the tumor (T)
A. Papachristos and S. B. Sidhu
omentum
1
Stomach
Aorta
2
olienal
ligament
Spleen
3
KidneyLienorenal
ligament of liver
Hepatic artery
bile duct, and
portal vein
Epiploic foramen
Inferior vena ca
Fig. 13 Plane of mobilization to expose the adrenal. We opt to mobilize the spleen and tail of
pancreas by incising the lienorenal ligament (3)
Fig. 14 The spleen and
the tail of the pancreas
have been medialized to
expose the adrenal tumor
(T). S spleen, SV splenic
vein, adrenal tumor (T),
tail of pancreas (P). The
plane of dissection (arrow)
allows “opening of the
book” to expose the medial
aspect of the adrenal tumor
Open Adrenalectomy
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Fig. 15 Gerota’s fascia
(G) is incised to enter the
plane on the capsule of the
tumor (T). The stretched
adrenal vein (AV) and
tented left renal vein (RV)
can also be seen
Fig. 16 The left adrenal
vein (AV) is encountered
on the inferomedial aspect
of the gland. The left renal
vein is identied; the
adrenal vein is shown here
draining into the left renal
vein. AV adrenal vein,
adrenal tumor (T), RV
renal vein
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Fig. 17 Resected
specimen of a large left
ACC.Two samples of
tumor tissue (*) have been
removed from the anterior
aspect after excision for
research purposes
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