Identify the posterior peritoneum as it lays over the adrenal glands and kidneys. Incise the peritoneum and identify the left adrenal gland. In the operating room, the adrenal glands are easily identifiable by a very bright yellow appearance. The surrounding fat is a dull yellow in comparison. In a cadaveric specimen, the adrenal and the surrounding fat do not have the same degree of color contrast.

Identify the adrenal by its anteromedial location to the kidney and firm consistency. Its color is a dull gray and is rather unremarkable in a cadaver. The adrenal glands are a retroperitoneal structure and lie inside a slip of Gerota’s fascia separate from the kidney (Fig. 8.2). Dissect the gland off of the kidney. Arterial supply is varied and is very rich. The adrenal glands and the thyroid gland have the greatest blood supply per gram of human tissue. Note that the lymphatic drainage of the left adrenal gland is superiorly to the posterior mediastinal nodes, medially to lateral periaortic nodes, and inferiorly to renal hilar nodes (see Fig. 8.1).

Note from the diagram (Fig. 8.3) that the arterial supply to the left adrenal comes as follows:

1. Superiorly from inferior phrenic vessels

2. Medially from the aorta

3. Inferiorly from the renal artery

The adrenal arteriolar vessels are drawn large in the diagram to make identification easy; however, in situ, these arterioles are filamentous and may be difficult to identify.

Identify the adrenal vein that drains into the left renal vein (see Fig. 8.1). This is typically a single vein but minor accessory veins to the inferior phrenic vein may occur. After identification of the left adrenal vein, transect the vein as well as its filamentous arterial blood supply and remove the adrenal using blunt and sharp dissection with downward traction on the kidney.

Note the medial location of the left adrenal and that it extends inferiorly into the renal hilum within Gerota’s fascia (Fig. 8.2). Exposure is essential to successful adrenal surgery. Control of any bleeding is difficult without stable and excellent exposure with identification of surrounding structures.

Identify the peritoneum as it covers the adrenal and kidney on the right side (see Fig. 8.2). Proceed as on the left side with incision of the peritoneum to gain access to the retroperitoneal space. Notice proximity of the duodenum.

Identify the right adrenal gland. As on the left, it will appear a dark gray unremarkable color; however, on palpation, it will have a different consistency than the surrounding retroperitoneal fat. The right adrenal lies in a medial location and is generally hidden behind the inferior vena cava (IVC) (see Fig. 8.3). Retract the IVC to the left gently. Note that the lymphatic drainage of the right adrenal gland travels superiorly toward the liver (see Fig. 8.1).

The arterial supply to the adrenal glands is very rich and on the right comes:

1. From the inferior phrenic artery

2. From the aorta coursing behind the IVC

3. From the renal artery inferiorly (Fig. 8.3)

Retract the right adrenal gland laterally using thumb and forefinger. Gentle medial retraction of the IVC and careful medial dissection of the gland will identify a short, large right adrenal vein draining into the
lateral-posterior IVC (see Fig. 8.1). Identification of this vein is essential and often difficult due to its posterior position. Control of the right adrenal vein should be done with care to avoid injury to the IVC. Note that the arterial supply has many branches. Divide the small arterial branches and the large right adrenal vein. The gland may now be removed.