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General Surgery
Adrenalectomy
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 119 slides
Overview
- Adrenalectomy in one slide
- Scope of this topic
Adrenal anatomy and physiology
Where the glands sit, what they make, and the vessels that decide how the operation is done
- Position of the adrenal glands
- Layers of the adrenal gland
- Adrenal cortex
- Adrenal medulla
- Arterial supply of the adrenal glands
- Venous drainage of the adrenal glands
- Right versus left adrenal vein
- Periadrenal fat and neighbouring organs
Indications for adrenalectomy
Which adrenal tumours earn an operation, and what must be done before the patient reaches theatre
- Aldosteronoma
- Preoperative control of hyperaldosteronism
- Biochemical confirmation before adrenalectomy
- Which forms of hyperaldosteronism need surgery
- Adrenal venous sampling to confirm laterality
- Outcomes after resection of an aldosteronoma
- Pheochromocytoma
- Genetic syndromes and bilateral disease
- Symptoms of catecholamine excess
- Preoperative preparation for pheochromocytoma
- Alpha-blockade and salt loading
- Early history of pheochromocytoma surgery
- Intraoperative handling of a pheochromocytoma
- Timing of adrenal vein ligation
- Choice of approach for pheochromocytoma
- Cortisol-producing adrenal adenoma
- Clinical features of Cushing's syndrome
- Excluding malignancy before resection
- Tumour size and the choice of open resection
- Steroid cover after removing a cortisol-producing adenoma
- Technical challenges of laparoscopy in Cushing's syndrome
- Adrenal cyst
- Myelolipoma
- Adrenal cortical carcinoma
- Surgical approach to adrenal cortical carcinoma
- Intraoperative signs of malignancy
- Incidentaloma
- Size thresholds in incidentaloma management
- Decision analysis for incidentaloma
- Paraganglioma
- Adrenal metastasis
- Limits of laparoscopic metastasectomy
- Choosing between endoscopic and open resection
Endoscopic adrenalectomy
Why keyhole surgery became the default, and the patients in whom it should not be used
- Development of endoscopic adrenalectomy
- Retroperitoneoscopic adrenalectomy
- Recovery advantages of the laparoscopic approach
- Morbidity of open incisions
- Laparoscopy in Cushing's and Conn's syndrome
- Single-incision laparoscopic adrenalectomy
- Contraindications to laparoscopy
- Radical adrenalectomy with an intact capsule
- Bilateral adrenalectomy for ACTH-dependent Cushing's syndrome
- Morbid obesity as a limiting factor
- Hand-assisted ports
- Conversion rate and variability of patient response
Exposures and operative technique
Positioning, ports, and the step-by-step dissection on each side
- General principles: bleeding and visualisation
- General principles: blood removal and energy devices
- Port spacing and instrument crowding
- Retraction of the adrenal gland
- Positioning for the lateral transperitoneal approach
- Patient flexed over the break in the table
- Theatre layout for the lateral decubitus position
- Instrumentation
- Right laparoscopic adrenalectomy: position and ports
- Port sites for right laparoscopic adrenalectomy
- Right side: the first view and freeing the hepatic flexure
- Right upper quadrant at the start of the operation
- Right side: mobilising the liver from the diaphragm
- Liver retracted from the epigastric port
- Peritoneal incision that exposes the right adrenal
- Right side: dissecting the superior border
- Right adrenal gland exposed within perinephric fat
- Right side: finding and dividing the adrenal vein
- Right adrenal vein entering the vena cava
- Right adrenal vein divided between clips
- Right side: completing the dissection
- Right side: specimen removal
- Sequence of right laparoscopic adrenalectomy
- Left laparoscopic adrenalectomy: position and ports
- Port sites for left laparoscopic adrenalectomy
- Left side: taking down the splenic flexure
- Gerota's fascia and the splenic flexure on the left
- Left side: sequence of dissection
- Left renal vein and the takeoff of the adrenal vein
- Left side: vein ligation and completion
- Left adrenal gland after division of the adrenal vein
- Sequence of left laparoscopic adrenalectomy
- Retroperitoneoscopic adrenalectomy: advantages
- Retroperitoneoscopic adrenalectomy: prone positioning
- Retroperitoneoscopic adrenalectomy: first incision
- Retroperitoneoscopic adrenalectomy: the other two ports
- Retroperitoneoscopic adrenalectomy: creating the working space
- Retroperitoneoscopic adrenalectomy: landmarks
- Retroperitoneoscopic adrenalectomy: vein and attachments
- Retroperitoneoscopic adrenalectomy: closure
- Retroperitoneoscopic access, step by step
Complications
What goes wrong after endoscopic adrenalectomy, how often, and the mistakes that cause the worst of them
- 5.9%
- Frequency and pattern of complications
- Anatomic risks of adrenal surgery
- Risks of pneumoperitoneum
- Impaired venous return under pressure
- Vascular injury during laparoscopic adrenalectomy
- Distinguishing adrenal vein from renal vein on the right
- Distinguishing adrenal gland from pancreas on the left
- Adrenal arteries during dissection
- Problems specific to the retroperitoneoscopic route
- Complications of endoscopic adrenalectomy
Open adrenalectomy
The three classic exposures, and the situations that still demand them
- Indications for open adrenalectomy
- Anterior approach: right adrenal gland
- Anterior approach: left adrenal gland
- Posterior approach
- Thoracoabdominal approach
Summary and references
What to carry away, and the sources behind it
- Key points: anatomy and patient selection
- Key points: technique and safety
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition