Scott M. Wilhelm

Introduction

The adrenal glands reside in the retroperitoneum just above the kidneys (Fig. 4-1). Histologically, the adrenal glands are divided into an outer cortex comprising three layers—zona glomerulosa, zona fasciculata, and zona reticularis—and an inner medulla (Fig. 4-2). These histologic layers correspond to various hormones produced by the adrenal glands.

When considering which adrenal tumors may require surgical resection and which can be monitored, physicians can determine the need for surgical intervention using the following three general categories:

Surgical Principles

The “gold standard” for adrenalectomy has become the transabdominal laparoscopic adrenalectomy. The only current contraindication to the laparoscopic approach is malignancy in the form of adrenocortical carcinoma, which should be approached by an open technique to ensure adequate en bloc tumor resection.

To begin the transabdominal laparoscopic approach, the patient is positioned in the lateral decubitus position to allow gravity to assist with the dissection. A patient requiring right adrenalectomy is placed into a left lateral decubitus position in a jackknife position. Four laparoscopic ports are used, with a 10- to 12-mm port along the lateral border of the right rectus muscle at approximately the level of the umbilicus for the camera and three 5-mm ports along the costal margin. The port closest to the xiphoid process is used for a liver retractor, and two working ports are used for the operative dissection. For left adrenalectomy, the patient is reversed into the right lateral decubitus position, and because there is no need for retraction of the liver, three ports can be triangulated for the operative procedure (Fig. 4-3).

Stay updated, free articles. Join our Telegram channel

Join