contents
31.1 Position . . . 309 31.2 Incisions . . . 309
31.3 Step I: Resection of the 12th Rib . . . 309 31.4 Step II: Reflection of the Pleura . . . 310 31.5 Step III: Recognition of the Left Adrenal . . . 311 31.6 Step IV: Recognition of the Right Adrenal . . . 312
31.1 Position
The patient is turned to the prone position after intu- bation. Pillows or blankets are placed underneath the chest and pelvis allowing the peritoneal organs to fall away from the retroperitoneum.The table is flexed into the jackknife position to eliminate lumbar lordosis.
The knees are flexed and the lower legs supported with soft pillows.
31 Open Posterior Adrenalectomy
Dimitrios A. Linos
Aorta Costa XII
Inferior vena cava Left kidney
Spleen
Right kidney
31.3 Step I: Resection of the 12th Rib
The first step of the posterior approach is resection of the 12th rib (or the 11th rib in the rare case that the 12th is rudimentary). To get there the latissimus dorsi and the lumbodorsal fascia are cut with diathermy and the sacrospinalis muscle is retracted medially. Using the diathermy and the periosteal elevator the rib is re- moved subperiosteally all the way up to its junction with the vertebral body. Care is taken to avoid injuring the underlying pleura and the subcostal nerve.
31.2 Incisions
The classical Young curvilinear incision extending from the 10th rib (4–5 cm from the midvertebral line) to the iliac crest (8–10 cm from the midverterbral line) is usually used. Nevertheless, since the adrenal gland lies beneath the origin of the 12th rib from the verte- bral body, a single straight incision over the 12th rib with a small vertical upward extension, if needed, is adequate in most cases.
Fig. 1 Fig. 2
Dimitrios A. Linos 310
Sacrospinal muscle
Thoracolumbal fascia Latissimus dorsi muscle
Twelfth rib
Fig 31 04
Gerota‘s fascia Pleura & periostium of the twelfth rib
Sacrospinal muscle Latissimus dorsi muscle
31.4 Step II: Reflection of the Pleura
The second step is to reflect upward the pleura that lie immediately beneath the resected rib. This is done carefully with blunt or sharp dissection, but occasion-
ally holes are made in the pleura. They should be rec- ognized and repaired at this point. The underlying pleura diaphragm can be either divided using dia- thermy or retracted upward to expose the underlying adrenal and upper pole of the kidney.
Fig. 4 Fig. 3
31.5 Step III: Recognition of the Left Adrenal
Gerota’s fascia is incised and the posterior surface of the kidney is visualized. Downward retraction is nec- essary to better expose the adrenal. On the left side it is found medial to the upper pole of the kidney. The left adrenal vein is recognised coming off the left renal
vein. As with all adrenal approaches the remaining veins and arteries are usually small requiring cauteri- zation and rarely ligation. The adrenal tumor along with the healthy adrenal tissue, intact, should be mo- bilized from the surrounding tissues, leaving last its connections with the kidney, which act as retractors until then.
31 Open Posterior Adrenalectomy 311
Gerota‘s fascia
Aorta
Left adrenal vein Diaphragma
Adrenal tumor
Kidney Fig. 5
Fig. 29-06 a,b
Fig. 29-06 c
Adrenal Incision
Vena cava
Aorta Adrenal
Kidney
Posterior approach
Kidney Inferior vena cava
Right adrenal vein Dimitrios A. Linos 312
a
b
c
Fig. 6
31.6 Step IV:
Recognition of the Right Adrenal
Be careful when making the initial incision remembering that the right adrenal in the prone position lies on the “left” side of the patient (a). The advantage of the posteri- or approach is the almost immedi- ate reach of the adrenal following the resection of the 12th rib (b).
The recognition and careful pre- paration before ligation of the short right adrenal vein as it comes off the inferior vena cava is of paramount importance for the safe and smooth progress of the adrenalectomy (c).
