Description of the Operative Technique
Video Clip: Right Adrenalectomy
Patient position. For right adrenalectomy, the patient is placed in a left lateral decubitus and reverse Trendelenburg position, supporting the extended right arm. The surgeon stands on the patient's left, and the assistant just caudally to the surgeon. Two monitors are placed over the shoulders of the patient. The costal margin is marked before insufflation.
Ports. The following ports are placed:
11-mm port in the anterior axillary line 2-3 cm below the costal margin. A 30-mm scope is introduced, and evaluation for injuries or adhesions is performed.
5-mm port anterior and medial at the lateral border of the rectus muscle.
5-mm port lateral and inferior to the costal margin.
5-mm or 11-mm port in the epigastrium, close to the xiphoid, to introduce a liver retractor.
Technique. The patient is placed in a left lateral decubitus and reverse Trendelenburg position. A line is drawn 2 cm below the right costal margin before insufflation, to avoid a difficult closure if an open procedure is required. After the ports are placed, the right lobe of the liver is lifted.The dissection starts releasing the retroperitoneum from the lateral liver edge, taking care to avoid injuries to the inferior vena cava or to its branches, and then advancing and cutting the right triangularligament, dissecting toward the diaphragm.
The lateral border of the inferior vena cava is found, and the adrenal gland is identified. Be careful when palpating the gland if the diagnosis is pheochromocytoma. The adrenal vein is identified and divided, using clips or an energy device.
Continue the dissection using a cautery device, watching for additional venous drainage into the right renal vein. Hemostasis is confirmed, and the specimen is placed in a bag and extracted.
Video Clip: Left Adrenalectomy
Patient position. For left adrenalectomy, the patient is placed in a right lateral decubitus position and reverse Trendelenburg position, supporting the extended left arm. The surgeon stands on the patient's right, and the assistant just caudally to the surgeon. Two monitors are placed over the shoulders of the patient.
Ports. The following ports are placed:
11-mm port in the anterior axillary line 2-3 cm below the costal margin. A 30-mm scope is introduced, and evaluation for injuries or adhesions is performed.
5-mm port anterior and medial at the lateral border of the rectus muscle.
5-mm port lateral and inferior to the costal margin.
5-mm port is placed at a convenient location to help with retraction or dissection.
Technique. The patient is placed in a right lateral decubitus and reverse Trendelenburg position. A line is drawn 2 cm below the left costal margin before insufflation, to avoid a difficult closure if an open procedure is required.
After the ports are placed, the splenocolic ligament is cut, mobilizing the colon caudally and medially. The lienocolic and posterior splenic attachments are freed, allowing the spleen and tail of the pancreas to be displaced medially. An S-shaped plane between the kidney, the spleen, and the tail of the pancreas is found; the top of the S is behind the spleen and tail of the pancreas. The spleen and tail of pancreas are kept together.
The adrenal gland is identified. The adrenal vein and the inferior phrenic vein are identified. These veins can be divided using clips or an energy device.
The dissection continued using a cautery device. Hemostasis is confirmed, and the specimen is placed in a bag and extracted.
Medscape Gastroenterology © 2013
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Cite this: Edgar J. Figueredo, Oscar M. Crespin, Peter C. Wu, et. al. Laparoscopic Adrenalectomy: A Step-by-Step Guide - Medscape - Jul 11, 2013.
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