Cortical-sparing adrenalectomy can be performed in an open or laparoscopic fashion. Small pheochromo- cytomas can be approached in an open fashion by either a dorsal lumbotomy or an open anterior ap- proach. In patients with VHL lacking extensive intra- abdominal adhesions, in those not requiring con- comitant major pancreatic and renal procedures, and in patients with small unilateral or bilateral pheochro- mocytomas, the adrenal glands can be approached la- paroscopically. Our preferred method is through a lat- eral transperitoneal approach. The principles for cor- tical-sparing surgery are the same as for open and laparoscopic techniques.The adrenal gland is exposed but not mobilized. In open cases, careful palpation is performed along with intraoperative ultrasonography to identify the location of the tumor. In laparoscopic cases, more emphasis is placed on visual inspection and laparoscopic ultrasonography, although subtle
differences in texture of the gland can be noted with la- paroscopic instrumentation. Once the location of the tumor is identified, only that part of the gland is mobilized. This is performed carefully with clips, electrocautery, and harmonic scalpel. Only arterial tributaries to the involved segment(s) (aortic,renal,or phrenic) are divided. If the main adrenal vein is in this region,it too is divided.Provided the remainder of the gland is left in situ, without mobilization, there are sufficient emissary veins running with the remaining arterial tributaries to maintain adequate venous drainage.When an adequate amount of gland has been mobilized, it can be separated from the segments to be spared by means of a stapling device or harmonic scalpel. Once the specimen is removed, it must be ex- amined by the surgeon and pathologist to ensure an adequate margin around the pheochromocytoma (Figs. 1–5).
36 Laparoscopic Partial Adrenalectomy
Geoffrey B. Thompson
Adrenal tumor Inferior phrenic vein
Left renal vein Renal arterial branch Harmonic scalpel
Inferior vena cava
Inferior phrenic artery
Central vein
Aortic arterial branch Fig. 1. Cortical-sparing left adrenalectomy (CSA) with cen- tral resection. Central vein and aortic branches have been di- vided. No mobilization is performed of remaining upper and lower poles to protect emissary veins and arterial branches (inferior phrenic and renal). Transection is performed la- paroscopically using a harmonic scalpel
Geoffrey B. Thompson 342
Renal arterial branch Aortic arterial branch
Central vein
Adrenal tumor
Fig. 2. CSA (left) with resection of superior pole tumor. Only inferior phrenic branches are divided
Fig. 3. Upper and lower pole tumors resected. Midportion of gland preserved on aortic arterial branch and emissary veins
Adrenal tumor
Right renal vein
Renal arterial branch
Harmonic scalpel Central vein
Aortic branch
Fig. 4. Right CSA resecting upper pole tumor. Only inferior phrenic branches are divided. Central vein is preserved
36 Laparoscopic Partial Adrenalectomy 343
Fig. 19-05 Renal arterial branch
Inferior phrenic network
Adrenal tumor
Aortic branch Harmonic
scalpel
Lap us
Fig.5.Lower pole is resected by dividing aortic and renal arterial branches with their emissary veins. Central vein is preserved.
The intraoperative ultrasound rules out other intraparenchymal nodularity
