Plate 147

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 generally avascular area. Care must be taken to preserve the middle colic vessels, since the omentum is sometimes closely blended with the mesocolon, and these vessels therefore are liable to damage during the procedure. An incision is then made along the distal or inferior margin of the pancreas from the tip of its tail back along the body to the region of the inferior mesenteric vein [danger point (central arrow), Figure 9]. This allows the surgeon to mobilize the distal pancreas with blunt finger dissection so that it may be elevated in a cephalad manner and to expose the Gerota's fascia directly over the left kidney, whose midportion is usually directly exposed by this approach. This fascia is then incised and the dissection carried about the superior pole of the kidney, where the adrenal can be identified (Figure 12). Its lateral edge is then approached and its removal performed as in the procedure described above.

The incision is closed in the routine manner. However, retention sutures are recommended in hypercortisolism, as poor wound healing is a known complication.

Blood losses must be replaced carefully, and patient observation and blood pressure monitoring must be unfailingly frequent, preferably by an intra-arterial line. Should blood pressure continue to fall in the recovery area or during closure despite adequate endocrine replacement, retroperitoneal hemorrhage from an unsecured vessel must be strongly suspected. In patients who have had a pheochromocytoma removed and for whom adequate fluid and blood replacement has been accomplished, a postoperative vasopressor in the form of norepinephrine is usually necessary for 24 to 36 hours, after which time it is gradually tapered as tolerated. Propranolol hydrochloride (Inderal) and lidocaine hydrochloride (Xylocaine) may be needed to control tachycardia and cardiac arrhythmias.

Patients will experience a drop in the level of circulating corticosteroids after removal of a hyperfunctioning tumor or after subtotal or total adrenalectomy. Therefore they must have cortisone support before, during, and after surgery. Cortisone acetate in the dose of 100 mg is given intravenously the evening before and on the morning of surgery. Supplemental intravenous hydrocortisone is given during the operation as needed. A final dose of 100 mg cortisone acetate is given intravenously in the evening after surgery, with a total dose of approximately 300 mg being given the day of surgery. This is gradually tapered down over the next 7 to 10 days to approximately 50 mg per day, which may be given in divided doses. It is felt that 30 to 50 mg per day of oral cortisone represents reasonable maintenance therapy. However, it may be necessary to add an active mineralocorticoid to this if maintaining sodium and potassium balance is difficult. In the immediate postoperative period, however, the major problem is to ensure adequate cortisone replacement, as it is easy to undertreat but almost impossible to overtreat with cortisone.

The postoperative ileus and return to alimentation should be handled the same as for any laparotomy. Wound healing, however, will be impaired in patients with hypercortisolism, and infection is a possibility, as many of these patients also have extensive furunculosis. Last, it is important that the patient's long-term medical management and follow-up and endocrine replacement be clearly defined.