Adrenalectomy
Most adrenalectomies are performed transabdominally. In this chapter, the transabdominal approach to the adrenal glands will be described first because it is the one that is appropriate for tumors, such as pheochromocytomas, that may well be bilateral. A complete examination of the abdominal cavity, as well as removal of the adrenal (suprarenal) glands, is possible only through this approach.
The posterior approach to the adrenals is used only when adrenalectomy is performed for endocrine ablation or for resection of a small, isolated aldosteronoma. It is described at the end of this chapter.
A lateral or flank approach provides excellent exposure, especially for the right adrenal gland. However, it is rarely used. References at the end of this chapter provide details of exposure using this method. Occasionally, large adrenal tumors require a thoracoabdominal incision for adequate exposure. Again, this is rare.
Laparoscopic adrenalectomy is described in Chapter 88.
Steps in Procedure
Transabdominal Adrenalectomy
Supine position, roll under lower costal margin
Bilateral subcostal or midline incision
Thorough abdominal exploration
Left adrenalectomy
Divide gastrocolic omentum and retract stomach cephalad
Incise peritoneum along inferior border of pancreas and gently retract cephalad
Reflect transverse colon inferiorly
Palpate kidney and incise Gerota’s fascia just medial to superior aspect of kidney
Identify adrenal gland and left renal vein
Expose anterior surface of left renal vein
Identify left adrenal vein; divide now or later
Identify and divide small branches from inferior phrenic artery and vein
Divide adrenal vein if not already taken
Right adrenalectomy
Reflect hepatic flexure downward and fully mobilize duodenum
Retract liver cephalad
Palpate right kidney and identify adrenal gland just medial to inferior vena cava at superior pole of kidney
Expose adrenal gland
Identify and secure adrenal vein
Secure small vessels along medial aspect of gland and remove it
Posterior Adrenalectomy
Patient is positioned prone with slight break to straighten the curvature of the spine
Incision straight from tenth rib downward, then curving laterally toward iliac crest
Divide attachments of erector spinae muscle to twelfth rib and resect rib (subperiosteally)
Expose Gerota’s fascia and elevate diaphragm and pleura
Pull downward on kidney to expose adrenal gland
Divide attachments of adrenal gland, leaving vein for last step (both sides)
Ligate adrenal vein and divide it
Obtain hemostasis and close without drains
Hallmark Anatomic Complications
Injury to inferior vena cava (right)
Entry into pleural space (posterior adrenalectomy)
List of Structures
Adrenal (Suprarenal) Glands
Left and right suprarenal veins
Inferior phrenic vein
Inferior phrenic artery
Superior suprarenal arteries
Middle suprarenal artery
Inferior suprarenal artery
Kidneys
Left renal vein
Left gonadal vein
Gerota’s fascia
Inferior vena cava
Organ of Zuckerkandl
Trapezius muscle
Latissimus dorsi muscle
Erector spinae muscles
Internal oblique muscle
Transversus abdominis muscle
Quadratus lumborum muscle
Lumbodorsal fascia
Eleventh and twelfth ribs
Transabdominal Adrenalectomy Incision (Fig. 87.1)
Technical Points
Position the patient supine on the operating table with a roll under the lower costal margin, or break the operating table slightly to elevate the upper abdomen. Plan a bilateral subcostal or midline incision, depending on the physical habitus of the patient. For most patients, a subcostal approach is best. It may be necessary to make this incision quite long to obtain adequate exposure, especially in obese patients. Thoroughly explore the abdomen in the usual fashion.
Anatomic Points
The right adrenal lies slightly lower than the left and is conveniently approached through a right subcostal incision. Access to the left adrenal is more difficult because the gland occupies a more cephalad position. Although both adrenal glands are covered by overlying structures of the gastrointestinal tract, mobilization of these structures is easier on the right than on the left.
Left Adrenalectomy (Fig. 87.2)
Technical Points
Divide the gastrocolic omentum widely by taking the omentum off the greater curvature of the stomach. Serially clamp and tie the multiple branches of the gastroepiploic artery and vein that extend from the omentum to the greater curvature. Elevate the stomach cephalad with a retractor. Incise the peritoneum lying along the inferior border of the pancreas and gently elevate the pancreas by blunt dissection. Place a Harrington retractor on a moist laparotomy pad to elevate the pancreas. Reflect the transverse colon downward to improve exposure. Rarely, it may be necessary to mobilize the splenic flexure to achieve adequate exposure. Generally, the adrenal gland lies far enough medially that simple downward traction on the colon suffices.
Exposure obtained through the lesser sac is limited and is appropriate only for small tumors. If wider exposure is required, fully mobilize the spleen and tail of the pancreas up into the midline to expose the underlying retroperitoneal structures.
Palpate the kidney and use this as a guide to the left adrenal, which lies just cephalad and medial. Incise Gerota’s fascia just medial to the superior aspect of the left kidney. The adrenal gland should be palpable and visible in this region. Identify the left renal vein and open the tissues overlying it to expose its anterior surface. The left gonadal vein is a useful landmark. The left adrenal vein generally lies just medial to it, on the superior aspect of the left renal vein. Begin to mobilize the adrenal gland by clipping small branches from the inferior phrenic artery and vein, which may enter the superior and medial borders of the adrenal. Secure these with hemoclips and divide them. It should then be possible to slip a finger behind the adrenal and elevate it. This posterior plane is generally avascular.
The adrenal vein passes inferiorly. Trace the superior aspect of the left renal vein to identify the relatively long adrenal vein passing off the superior surface just medial to the entrance of the gonadal vein. Ligate it in continuity and divide it. Leave the tie on the adrenal side long and use it to further elevate the adrenal into the field. Divide any remaining connections at the superior aspect of the gland (more or less blindly) with hemoclips. Because these contain only multiple, small arterial twigs, no major structures are at risk for injury.
Anatomic Points
The middle colic artery may be at risk for injury when the peritoneum along the caudal border of the pancreas is divided, or when the transverse colon is retracted inferiorly. This artery, an early branch of the superior mesenteric artery, usually arises posterior or just inferior to the neck of the pancreas and passes to the right. However, it can divide into left and right branches shortly after its origin, with the left branch then being in potential danger; alternatively, an accessory middle colic artery passing toward the splenic flexure can be present (occurring about 10% of the time). The inferior or transverse pancreatic artery runs along, or in, the caudal border of the pancreas, giving off posterior epiploic arteries that run in the anterior leaf of the transverse mesocolon, or sometimes giving off a fairly significant colic branch to the left colic flexure.
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