Adrenalectomy

Surgical options

• Considerations
  • Tumour size
  • Indication for surgery
    • Open for cancer
  • Patient size (BMI)
• Options
  • Posterior retroscopic
    • If >4cm difficult
    • If less then 3 fingers between rib and iliac spine
    • If high BMI
  • Anterior laparoscopic
  • Open

Laparoscopic transperitoneal adrenalectomy (lateral approach)

Operative steps

• Place in lateral decubitus position
• Stabilise the patient using a beanbag or alternative
• “Break” the table - to maximise the distance between iliac crest and costal margin.
• First the first port in mid-clavicular line, then futher ports in anterior, mid and posterior axillary lines.

Left side

• Right lateral decubitus position
• 4x left subcostal ports including 1x 12mm camera port and 3x 5mm port
• Mobilise the splenic flexure
• Mobilise the spleen and tail of the pancreas by dividing the spleno-colic and splenorenal ligaments
  • Flip them medially exposing the adrenal
• Start dissection at the upper pole - carrying the dissection downwards along both medial and lateral borders.
• Divide small arterial branches with ligasure.
• The lower aspect of the gland frequently goes down as far as the renal hilum.
• Do not grasp the adrenal as it bleeds easily.
• Identify the left adrenal vein on the infero-medial aspect of the gland as it empties into the renal vein.
• Once this is secured, dissect the posterior aspect of the adrenal gland and take it off the kidney - there may be further arterial branches which require clipping.
• The tumour is placed in a bag and then removed by enlarging one of the incision (or if the tumour is large, performing a Pfannensteil incision).

https://www.youtube.com/watch?v=KAvQxAkzCBs&ab_channel=DrDeeprajBhandarkar

Right side

• Divide the right triangular ligament of the liver and retract the liver medially with a Nathenson retractor
• Keep mobilisation the liver until the IVC is identified
• Incise the posterior peritoneum along the lateral edge of the IVC and identify the adrenal gland.
• Continue dissection superiorly along the lateral edge of the IVC until the right adrenal vein is identifed
  • It is short and wide
  • Divide it between double clips or use a vascular stapler.
• Continue mobilisation along the lateral aspect of the IVC until the superior pole
• Continue medial to lateral dissection rolling the adrenal laterally
• Mobilise the remaining gland off the kidney, liver, and posterior muscles.
• Divide small vessels with a ligasure.
• Remove through a retrieval bag.

https://www.youtube.com/watch?v=hUGZ_7D932E&ab_channel=Cirug%C3%ADaLaparosc%C3%B3picaSevilla-MISS

Laparoscopic retroperitoneal adrenalectomy (posterior approach)

Operative steps

• The operative steps are similar regardless of size.
• Position the patient prone
• Place the arms alongside the head
• Break the table to tense the lumbar fascia.
• Make an incision between the tips of the 11th and 12th ribs and dissect bluntly through the muscles until you can feel the kidney.
• Insert a port and create a space using 20mmHg of C02 pressure
• Introduce 2 further ports on either side of the camera port.
• Identify the kidney and dissect it downwards until you see the edge of the adrenal.
• Dissect the ventral and lateral aspect of the adrenal gland until the renal vein is encountered
• This leaves the adrenal to “hang” by its superior attachment
• Divide it with a vascular stapler or between double clips.
• Complete the dissection of the adrenal gland.
• Check for haemostasis while lowering the insufflation pressures.

[Posterior retroperitoneoscopic adrenalectomy](https://www.youtube.com/watch?v=_uWvESs59sI

Relative Anatomy

• Relationships of adrenal glands
  • R) – IVC, liver, hepatic flexure, duodenum, kidney
  • L) – Pancreas, spleen, splenic flexure, kidney
• Vascular specifics
  • Both drained yia single adrenal vein
  • R) vein is very short and fat and drains directly into the IVC
  • 3 arteries
    • Inferior (from Renal A) is often the most prominent and often requires direct ligation
    • Others may be taken with diathermy or other device
• Intraoperative complications & challenges
  • Bleeding
    • From IVC is the most feared and problematic
  • Principles of management
    • Immediate pressure to stop bleeding and avoid air embolism
    • Compression with swabs above and below defect
    • Primary suture closure
    • Low threshold for conversion to open
    • Call for help early
• Post-operative complications
  • Immediate
    • Intra-op
    • Bleeding
    • Visceral injury
    • Phaeo crisis
    • Anaesthetic complications
  • Early
    • Infection
    • Haematoma/collection
    • Wound complications
    • Pancreatic fistula (unidentified injury)
    • Hypoglycaemia/BP control (phaeo)