Place a Foley catheter and an orogastric tube and apply pneumatic compression stockings. Access to the adrenals by the transperitoneal approach requires four ports, and if these ports are placed too close to one another, instruments from one port are likely to interfere with those from another. For this reason, place ports 9 to 12 cm apart, depending on the size of the patient. This requires that the most lateral port be inserted through the flank. To make this possible, place the patient on a beanbag in the lateral decubitus position, with the area between the iliac crest and eleventh rib lying over the kidney rest. Raise the kidney rest to its highest position to open up this space, and then flex the table. Tilt the patient slightly backward to about 15 degrees, and then inflate the beanbag. Support the ipsilateral arm on a mobile upper arm rest and place a roll under the dependent axilla and a pillow between the legs. Lay towels over the nondependent hip and shoulder, and use adhesive tape over the towels to secure the patient to the table.

Mark a line two fingerbreadths caudad to the costal margin before insufflation. The lateral ports will be positioned in this line (Fig. 88.1A). The most medial port will be placed in the linea alba, 10 to 15 cm caudad to the xiphoid (port 1), with a supraumbilical incision being used in smaller patients. The next port (port 2) will be placed about 10 cm further laterally, in the midclavicular line. The third (port 3) will be placed 10 cm lateral to port 2, in the anterior axillary line.

Begin with an open insertion through the second port, then place ports 1 and 3 under direct vision after insufflation. The most lateral port (port 4) is placed through the flank between the iliac crest and the eleventh rib after the splenic flexure of the colon has been mobilized for left adrenalectomy or the hepatic flexure of the colon taken down for right adrenalectomy.