contents
29.1 Positions/Incisions . . . 299
29.1.1 Approaches to the Left Adrenal Gland . . . 299 29.2 Step I: Entering the Lesser Sac/Exposure
of the Pancreas . . . 299
29.3 Step II: Mobilization of the Inferior Border of the Pancreas . . . 300
29.4 Step III: Exposure of the Adrenal;
Ligation of the Left Adrenal Vein;
Mobilization of the Left Adrenal Tumor . . . 300
29.1 Positions/Incisions (Fig. 1)
The patient lies in the supine position. The preferred incision for open anterior left adrenalectomy is as for right adrenalectomy an extended left subcostal incision. The midline incision may be used if the pa- tient has a narrow costal angle or in the rare case of multiple adrenal paragangliomas/pheochromocyto- mas.
29.1.1 Approaches to the Left Adrenal Gland The left adrenal gland can be approached via four dif- ferent routes:
1. Through the gastrocolic ligament 2. Through the lienorenal ligament 3. Through the transverse mesocolon 4. Through the lesser omentum
The best approach is through the gastrocolic ligament into the lesser sac.
29.2 Step I: Entering the Lesser
Sac/Exposure of the Pancreas (Fig. 2) The lesser sac is entered through the gastrocolic liga- ment.Gentle traction with two hands on the transverse colon and countertraction of the greater omentum will demonstrate the avascular plane that can be easily in- cised by diathermy. The lesser sac needs to be widely opened so that the anterior surface of the pancreas is well visualized. Occasionally if exposure is inadequate the splenic flexure of the colon can be mobilized.
Adhesions from the posterior wall of the stomach to the pancreas are cauterized.
29 Open Left Anterior Adrenalectomy
Dimitrios A. Linos
Fig. 1
29.3 Step II: Mobilization of the Inferior Border of the Pancreas (Fig. 3)
The peritoneum along the inferior border of the pan- creas is incised using cautery. The incision continues all the way from the body to the tail of the pancreas.
29.4 Step III: Exposure of the Adrenal;
Ligation of the Left Adrenal Vein;
Mobilization of the Left Adrenal Tumor (Fig. 4)
The left adrenal is exposed by lifting the inferior sur- face of the pancreas upwards. Gerota’s fascia is opened and the upper pole of the kidney is retracted inferi- orly. With blunt dissection the left renal vein is seen.
Following this large vein 3–4 cm from the kidney’s hilum a smaller, good size though long vertical vein will appear that leads into the adrenal tumor. This is the left adrenal vein. With a right angle clamp it is dissected and securely divided and ligated. When the
tumor is large or highly vascular more large veins can be encountered requiring similar ligation while pro- tecting the integrity of the left renal vein. Once the two to three large veins are ligated the remaining adrenal tumors can be easily mobilized. The smooth collabo- ration between the surgeon, who exposes each en- countered small vessel with a long right-angle instru- ment (“disecteur”), and his first assistant, who coagu- lates them using his long “bovie”, is the secret of the bloodless removal of the adrenal gland and tumor in toto.
Dimitrios A. Linos 300
Fig. 28-02 Transverse colon
Gastrocolic ligament
Pancreas Stomach
Fig. 2
29 Open Left Anterior Adrenalectomy 301
Transverse colon Pancreas
Stomach
Peritoneum
Left adrenal vein Pancreas
Adrenal tumor Fig. 3
Fig. 4
