A Foley catheter and orogastric tube are placed. Pneumatic compression stockings are applied. Access to the adrenals by the transperitoneal approach generally 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, ports should be placed 8 to 10 cm apart, depending upon the size of the patient. This requires that the most lateral port be inserted in the posterior axillary line. To make this possible, the patient is placed on a beanbag in the lateral decubitus position, with the area between the iliac crest and the 11th rib lying over the kidney rest (Fig. 106.1A). The kidney rest is then raised to its highest position in order to open up this space, then the table is flexed. The patient is tilted slightly backward to approximately 15 degrees, then the beanbag inflated. The ipsilateral arm is supported on a mobile upper arm rest, a roll is placed under the dependent axilla, and two pillows between the legs. Towels are laid over the nondependent hip and shoulder, then adhesive tape used over the towels to secure the patient to the table.

The lateral ports are positioned in a line two finger breadths caudad to the costal margin, which is marked upon the patient prior to insufflation as shown in Figure 106.1B. The most medial port is 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) is placed approximately 10 cm further laterally, in the midclavicular line. The third (port 3) is placed 10 cm lateral to port 2, in the anterior axillary line. We begin with an open insertion through the second port, and then place ports 1 and 3 under direct vision after insufflation. The most lateral port (port 4) is placed through the posterior axillary line between the iliac crest and the 11th rib; sometimes this requires taking down the splenic flexure of the colon for left adrenalectomy, and more rarely, the hepatic flexure for right adrenalectomy.

The adrenal glands are retroperitoneal organs so transperitoneal access to these organs requires reflecting intraperitoneal structures medially. This includes mobilization of the splenic flexure of the colon, the spleen, and pancreas on the left. On the right, the right lobe of the liver must be mobilized and retracted. The right adrenal gland is slightly more caudad than the left, and is bordered by the kidney inferiorly, the diaphragm posteriorly, the liver superiorly, and the vena cava medially. The left adrenal rests on the superior pole of the left kidney, is adjacent to the aorta medially, lies posterior to the tail of the pancreas and spleen, and the diaphragm is located superiorly and posteriorly (see Chapter 105, Figure 105.1). Accessory adrenal tissue may be present near the gland or may even migrate in the vicinity of the testes or ovaries (see Chapter 105, Figure 105.6).