Plate 149

The indications are as previously described for laparoscopic left adrenalectomy.

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

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

See Plate 146.

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.

For a right adrenalectomy the surgeon stands on the patient's left side (Figure 1A). The camera operator stands to the surgeon's left 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.

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 Kocher maneuver is done to expose the inferior vena cava in its position directly posterior to the second portion of the duodenum and possibly the right renal vein as it is essential to know the location of these structures before entering Gerota's fascia (Figure 3). The right lobe of the liver should be mobilized by dividing posterior and lateral attachments until the diaphragm is exposed so as to gain a better exposure of the right adrenal (Figures 2 and 3). A retractor is placed to hold the liver superomedially (Figures 2 and 3). This may require an additional port—either a 5-mm or a 10-mm one depending upon which retractor device is used. The peritoneum lateral to the duodenum is then incised, and it is mobilized in the usual Kocher maneuver manner by using a blunt tip dissector or the ultrasonic device (Figure 3). This area is then cleared to show the right renal vein. Gerota's fascia is incised and the superior pole of the right kidney is located (Figure 3). The adrenal is identified by its characteristic yellowish color, lobulated appearance, and its clearly definable blunt lateral edge.

The surgeon should bear in mind that the vascular attachments are usually on or near the medial and superior edges of the gland rather than on its broad surfaces. (See Plate 146). After initial lateral and inferior mobilization, the adrenal gland may be retracted laterally. It is helpful to identify the retrohepatic inferior vena cava (Figure 4) and then the right adrenal vein. The right adrenal vein is identified and doubly clipped proximally and distally using a 5-mm clip applier and divided (Figures 4 and 5). The superior attachments of the adrenal gland are then divided and the superior arterial supply clipped or coagulated freeing the gland. Next the inferior portion of the gland is further dissected exposing the adrenal artery arising from the right renal artery. This is doubly clipped (Figure 6). The generally avascular lateral area is then incised and additional exposure and mobility of the adrenal gland may be obtained by gentle blunt dissection directly posterior and lateral to the gland (Figure 7). The suction tip is an excellent tool for this blunt dissection. The gland should be free at this point for extraction (Figure 8). The tumor bed is inspected for bleeding and any additional hemostasis obtained.

The same technique is used to remove either the right or the left gland from the peritoneal cavity. The 10-mm laparoscope is removed, and the videocamera is mounted on a 5-mm laparoscope. This is inserted through the most inferior 5-mm trocar. A clear plastic specimen retrieval bag device is inserted into the peritoneal cavity through the 10-mm Hasson port. The bag is opened and the adrenal gland is grasped by some peri-adrenal fat or connective tissue. The gland is delivered into the bag (Figure 8). The bag is closed and separated from its insertion device. Using gentle traction, the bag with the adrenal gland is pulled from the abdominal cavity through the Hasson insertion site. The incision may need to be enlarged for larger tumors. It is not necessary to fragment the adrenal gland into pieces as it is soft and pliable, permitting it to be removed through a relatively small opening. The camera is then placed back on the 10-mm laparoscope and the bed of the adrenal gland is irrigated and inspected for bleeding, which may be controlled by electrocautery, the harmonic scalpel, or clips.

The Hasson trocar site is closed with interrupted absorbable sutures. In the patient with hypercortisolism, nonabsorbable sutures may be necessary. For Hasson incisions in the lateral abdomen or flank, the use of a Thompson closure device may be helpful. The skin is closed with subcuticular absorbable sutures or staples.

The general principles are the same as those for open adrenalectomy and those specific to laparoscopic adrenalectomy are described in the section on laparoscopic left adrenalectomy (see Plate 148).