The indications are as described for laparoscopic left adrenalectomy (see Chapter 122).
The same steps in preparation are taken as described for the laparoscopic left adrenalectomy (see Chapter 122).
The anesthetic considerations as described for the laparoscopic left adrenalectomy are followed (see Chapter 122).
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 at the level of the flank below the ribs and above the iliac crest over the break position of the table so as to allow a jackknife 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 is 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 because the operating room table will be tilted. Some surgeons may prefer to improve tape adhesion with a skin preparation or to tape across towels to decrease skin damage.
The patient’s hair should be removed with electric hair clippers with minimal trauma to the skin. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
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 a 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 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, the shape and size of the patient, and the need for liver retraction. The patient is then ...