Laparoscopic Adrenalectomy

ANATOMY
Blood supply from 6-8 branches of inferior phrenic, middle adrenal from aorta near SMA origin, inferior from renal artery
Left drains into renal vein, right directly into IVC
PROCEDURE
If phaeochromocytoma, ligate veins first, be careful handling gland.

Lap left adrenalectomy
1.Position patient in right lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possibly one additional for retracting the spleen and 2 working ports, in order – working, hasson, working, retractor from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the splenic flexure of colon.
4.Divide lienorenal ligament from lower pole of spleen to diaphragm. This will help the spleen and tail of pancreas fall medially.
5.Retract the spleen if required via the most posterior port. Start to mobilize the left adrenal starting laterally (leave the glands attachment to the kidney intact till last as it can be used to retract the gland inferiorly).
6.Follow the capsule of the gland infero-medially to identify the adrenal vein emanating from the postero-medial aspect and clip once defined.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.

Lap right adrenal
1.Position patient in left lateral with table broken.
2.One Hasson, one 10mm port for clip applicator and one 5mm, (possible one additional 10mm for retracting the liver and 2 working ports, in order – retractor, working, hasson, working from anterior to posterior) are inserted along the costal margin and pneumoperitoneum achieved.
3.Begin mobilization of the hepatic flexure of colon and divide any other sub-hepatic adhesions as necessary. The right triangular ligament may also have to be divided.
4.Retract the lower edge of the liver (via the most anterior port) and incise the posterior peritoneum just below the liver so as to open a curved space between the adrenal (located partly adjacent to the bare area of liver) and the liver superiorly (i.e. the inferior leaf of the coronary ligament).
5.Start to mobilize the right adrenal by deepening the incision medially to identify the right adrenal vein emanating from the antero-medial surface, entering the posterior aspect of the IVC (as the gland is in a plane posterior to the IVC). Beware of an adrenal artery coming from behind the IVC. Leave the attachment to the kidney intact till last as it can be used to retract the gland inferiorly.
6.Clip the adrenal vein using two ligaclips on the staying side.
7.Once freed, the gland is placed in an endocatch bag and removed through an enlarged port site.