Plate 147
###### Figure 12

Usually, the principal adrenal vein is first identified and then doubly ligated with 00 silk (Figure 6). The surgeon then cautiously works about the medial and inferior edges of the gland and ligates the principal artery or accessory arteries in a similar manner. The many minor vessels encountered must also be either carefully ligated or secured with clips.

The approach to the left adrenal via the transabdominal route may take either of two courses, as demonstrated in Figures 7, 8, 9, and 10. The usual approach is shown in cross section in Figures 7 and 8. The abdominal contents are carefully packed toward the surgeon and then, carefully grasping the spleen, the surgeon divides the avascular splenorenal ligament so that the spleen is mobilized somewhat toward himself or herself. With blunt dissection, it is then possible to dissect above Gerota's fascia but beneath the pancreas and primary splenic artery and vein. This dissection may be carried medially as far as the superior mesenteric vein, which will give a degree of mobilization as shown in Figure 11. The surgeon then incises the Gerota's fascia over the left kidney (Figure 8) and, with blunt dissection, clears the superior pole of the left kidney and comes upon the adrenal, which is shown here in a somewhat medial and inferior location. The left lobe of the liver is also identifiable, but it is usually not necessary to mobilize or retract it. The same general principles of exposure apply to the left adrenal gland except that the prominent adrenal vein (Figure 11) is shown being secured first. The surgeon then works about the periphery of the gland, ligating all prominent vessels. This is often slow, meticulous work, but—if in doubt—it is safer to ligate or clip each suspicious vascular area.

Many surgeons have found it useful to approach the left adrenal through the transverse mesocolon, after mobilizing the inferior border of the body and tail of the pancreas (Figure 9). This is accomplished by first removing most of the greater omentum from its attachment along the transverse mesocolon and carefully securing any bleeding points in this ...

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