CHAPTER 119: ADRENALECTOMY, RIGHT LAPAROSCOPIC

INDICATIONS

The indications are as previously described for laparoscopic left adrenalectomy.

PREOPERATIVE PREPARATION

The same steps in preparation are taken as described for the laparoscopic left adrenalectomy.

ANESTHESIA

The anesthetic considerations as described for the left adrenalectomy are followed.

ANATOMY

See Chapter 117, figure 2.

POSITION

A vacuum-assisted beanbag should be placed on the operating table prior to bringing the patient into the room. The patient is positioned with the bag being at the level of their flank below the ribs and above the iliac crest over the break position of the table so as to allow a “jack knife” extension that may be useful in obese patients.

For a right adrenalectomy the patient is placed in the right lateral position with the right arm crossing the chest and supported on an arm board (figure 1a). The left arm is placed on an arm board and an axillary roll used. In general the left and right positions are mirror images of each other. After the patient is positioned, the air is suctioned from the beanbag in order to secure the position. In addition, the patient is secured across the chest and hips to the table with wide adhesive tape, as the operating room table will be tilted. Some surgeons may prefer to improve tape adhesion with a skin preparation.

INCISION AND EXPOSURE

For a right adrenalectomy the surgeon stands on the patient’s left side (figure 1a). The camera operator stands to the surgeon’s left or right and the assistant on the patient’s right. A 10-mm 30-degree laparoscope is inserted using the aforementioned technique either in a supraumbilical position or the right lateral subcostal position in the midclavicular line just above the level of the umbilicus. A 5-mm port is placed in the right lateral subcostal area in the anterior axillary line and another 5-mm port is placed just to the right of the midline and the right of the round ligament. A third 5-mm port is placed on the right side in the anterior axillary line midway between the costal margin and the iliac crest (figure 1b). Additional ports or larger ports may be placed depending on the preference of the surgeon, the size of the tumor, and the shape and size of the patient. The patient is then placed in a reverse Trendelenburg (head-up) position.

DETAILS OF THE PROCEDURE

On the right side, the hepatic flexure of the colon is mobilized from the lateral gutter using the ultrasonic device. Any adhesions about the lateral liver or even the gallbladder may need to be incised with sharp dissection (figure 2). A ...