contents
30.1 Positions/Incisions . . . 303 30.2 Step I: Kocher Maneuver . . . 304 30.3 Step II: Exposure of the IVC . . . 305 30.4 Step III: Exposure of the Tumor/Initial
Mobilization . . . 306
30.5 Step IV: Identification and Control of Right Adrenal Vein . . . 307
30.6 Step V: Mobilization of the Tumor . . . 308
30.1 Positions/Incisions (Fig. 1)
The position of the patient is supine.A pillow between his right flank and lower chest turns the torso about 20° to the left. Hyperextension of the operating table will allow more working space in the subcostal and lateral area. The preferred incision is an extended (both laterally and medially) generous right subcostal incision.
The alternative incision is an upper vertical midline incision with adequate infraumbilical extension espe- cially in patients with narrow costal angle.This type of incision may also facilitate exploration of extra-adre- nal pheochromocytomas/paragangliomas. Rarely, es- pecially in very large adrenal carcinomas, a thora- coabdominal incision may be necessary for better ex- posure and control.
Dimitrios A. Linos
Thoracoabdominal incision Subcostal incision Vertical midline incision
Fig. 1
Fig. 30-02
Pancreas
Duodenum
Liver
Transverse colon Fig. 2
After initial hand evaluation of the abdomen is done to assess possible unknown preoperatively pathology, the hepatic flexure of the colon is mobilized inferiorly
The aim in the first step is to expose and mobilize the second portion of the duodenum (Kocher maneuver).
Scissors or monopolar diathermy is used to divide the
lateral attachments of the duodenal loop.
30.3 Step II: Exposure of the IVC (Fig. 3) The next and very important step is to expose the inferior vena cava from behind the duodenal loop to as high as possible. This exposure will lead to the adrenal tumor that is usually located higher than
initially expected. On the other hand, this (at least 8–10 cm) exposure of the IVC will allow vascular con- trol of the dangerous excessive bleeding that may occur inadvertently during the removal of the tumor, especially while trying to divide the right adrenal vein.
Fig. 30-03
Pancreas Right adrenal vein
Duodenum Inferior vena cava Liver
Gallbladder
Transverse colon Fig. 3
of the Tumor/Initial Mobilization (Fig. 4)
With the inferior vena cava safely exposed, the left hand of the operating surgeon pulls the upper pole of the right kidney downwards to better expose the adre- nal tumor. Gerota’s fascia is widely opened and the tumor is clearly seen. A vein retractor is necessary to
border of the adrenal tumor, which usually continues behind the IVC.
Mobilization of the tumor starts by freeing its me- dial attachments along the inferior vena cava, starting from the lower end and moving upwards toward the main “dangerous” right adrenal vein. Rather small ar- teries and veins will be encountered that can be cauter- ized and occasionally ligated depending on their size.
Fig. 30-04
Pancreas
Right adrenal vein
Duodenal loop
Inferior vena cava Liver
Gallbladder
Gerota‘s fascia
Adrenal tumor Fig. 4
30.5 Step IV: Identification and Control of Right Adrenal Vein (Fig. 5)
The main right adrenal vein is wide and short, drain- ing directly into the inferior vena cava usually coming from the most superior and medial “corner” of the ad- renal. A good and bloodless exposure of the area is necessary; the tip of a suction keeps the field dry to
allow dissection of the main adrenal vein, allowing the placement of two clips on the caval site and one on the gland site. Fine long scissors or a knife blade can be used to safely divide the vein. In case of inadvertent avulsion or slippage of the caval clips serious hemor- rhage can start. A Satinsky vascular clamp should im- mediately be placed along the previously exposed IVC for bleeding control and vascular repair.
Fig 30 05
Right adrenal vein Suction instrument
Fig. 5
(Fig. 6)
With the right main adrenal vein clipped and divided, the rest of the mobilization can be more easily and quickly done using monopolar diathermy and occa- sional ligation or clipping of larger vessels. The mobi- lization starts from the superior edge of the adrenal tumor that can be more easily seen with continuous downwards retraction of the right kidney. Special at-
sionally a large accessory subhepatic adrenal vein draining into the right hepatic vein can be encoun- tered, requiring early recognition and safe division.
The mobilization continues from the superior aspect of the tumor laterally along the essentially avascular plane requiring cautery use only. At the same time the posterior aspect of the tumor is mobilized from its loose connection to the diaphragm.
Pancreas
Right adrenal vein
Duodenal loop
Inferior vena cava Liver
Gallbladder
Gerota‘s fascia
Adrenal tumor Occational accessory
subhepatic adrenal vein
Fig. 6
