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.

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.

Divide the gastrocolic omentum widely by taking the omentum off the greater curvature of the stomach. Serially control and divide 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 (Fig. 105.3A). 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 or superiorly located 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 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. The harmonic scalpel facilitates divison of these branches, which are often embedded in retroperitoneal fat. It should then be possible to slip a finger behind the adrenal and elevate it. This posterior plane is generally avascular. Downward mobilization of the adrenal gland is facilitated by keeping the attachments to the kidney intact until the vein is approached.

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 (Fig. 105.3B). 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 hemostatically (Fig. 105.3C). Because these contain only multiple, small arterial twigs, no major structures are at risk for injury.