Right adrenalectomy, open

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  • Adrenal anatomy – glandulae suprarenales

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    (1) Adrenal gland, (2) Left kidney, (3) Abdominal aorta (4) Inferior phrenic arteries, (5) Superior suprarenal arteries, (6) Middle suprarenal arteries, (7) Inferior suprarenal arteries, (8) Aberrant accessory renal artery, (9) Renal arteries, (10) Testicular arteries

    The paired adrenals are located superior to the superior poles of the kidneys, separated only by a thin layer of fatty tissue. Since they are flattened along the posteroanterior axis, they have clearly distinct anterior and posterior aspects. The left adrenal resembles a crescent, while the right gland is mitral shaped. The anterior aspect of the left adrenal is completely covered with peritoneum, while the latter covers only the inferior aspect of the right adrenal. The posterior aspect of both adrenals abuts the lumbar aspect of the diaphragm.

    The topography of the right adrenal relates to the liver and inferior vena cava, while the left adrenal reaches the spleen and is separated from the posterior gastric wall by the lesser peritoneal sac. Both adrenals are located at about the level of the 11th/12th thoracic vertebra and enclosed by a vascularized capsule of connective tissue made up of collagen fibers and smooth muscle cells. Adult adrenal glands weigh about five to seven grams.

    Blood supply

    1. Arteries

    Inferior phrenic artery → Superior suprarenal artery

    Aorta → Medial suprarenal artery
    Renal artery → Inferior suprarenal artery

    There are numerous variants!

    2. Veins

    In each adrenal the venous blood is collected in the central vein which exits the gland through the suprarenal hilum and becomes the left (or right) suprarenal vein.

    Right suprarenal vein → Inferior vena cava
    Left suprarenal vein → Renal vein

    3. Lymphatics

    The lymphatics exiting the adrenals primarily parallel the arteries. The primary lymph nodes of the adrenals are the para-aortic and lumbar lymph nodes. Some lymphatics traverse the diaphragm and drain into the posterior mediastinal lymph nodes.

  • Pathophysiology

    Tumors of the adrenal glands are either primary neoplasias or metastases.

    Primary adrenal tumors arise from the adrenal cortex or medulla. Some but not all of them produce hormones.

    Adrenal neoplasias actively producing hormones correlate with the corresponding zones in the adrenal cortex or medulla. Tumors of the glomerular zone result in primary aldosteronism (Conn syndrome) and those of the fascicular zone in hyperadrenocortisolism (Cushing syndrome), while neoplasias of the reticular zone produce an overabundance of sexual hormones. Tumors of the adrenal medulla are called pheochromocytomas.

    Cortical and medullary tumors of the adrenal gland may be benign or malignant, with the former by far predominant. In cortical tumors the probability of malignancy correlates with the size. In pheochromocytomas there is no such direct relationship between the tumor size and rate of malignancy.

    Histological differentiation between benign and malignant adrenal tumors is hampered by their cellular polymorphism and becomes impossible in pheochromocytomas. Here, only the presence of distant metastasis suggests the malignant nature of the tumor.

    The gross anatomy of adrenal tumors presents with a homogeneously yellow-brownish cut surface, while pheochromocytomas appear as greyish-red, often also cystic, neoplasias.

    Primary tumors of the adrenal glands include myelolipomas, adrenal cysts and ganglioneuromas. Almost without exception these are benign.

    Adrenal metastasis is primarily seen in cancer of the lungs and kidneys and in malignant melanoma.

    Primary lymphomas are extremely rare.

    While the etiology of most primary tumors of the adrenal cortex remains unclear, more than 20% of pheochromocytomas arise from genetic causes (e.g., multiple endocrine neoplasia type 2).

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 16.08.2013

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  • Laparotomy and exploration

    148-4

    Transverse right laparotomy at the level of the umbilicus. After transecting the right rectus muscle with bipolar scissors and opening the peritoneum extend the incision in the midline to the xyphoid process. Explore the intestinal organs to rule out other metastases and confirm resectability.

  • Kocher maneuver mobilizing the duodenum

    148-5

    Depending on the conditions in the field the right colic flexure may have to be freed. Follow this by mobilizing the descending duodenum until the inferior vena cava is exposed along its full length.

  • Exposing the right retroperitoneum and mobilizing the liver

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    The posterior aspect the right adrenal abuts the diaphragm. The inferior aspect contacts the right kidney and the anteriosuperior aspect borders on the nude area of the liver. The anteromedial aspect of the right adrenal is posterior to the inferior vena cava. Paralleling the inferior vena cava open up the parietal peritoneum covering the anteroinferior aspect of the right adrenal.

    Transect the right triangular ligament before retracting the liver craniad. Now transect the adhesions between the inferior aspect of the liver and the adrenal. The perineoplastic inflammatory reaction will have resulted in intimate contact.

    Note: Surgical procedures on the right retroperitoneum are more difficult than on the left side because enlargement of the liver, obesity and barrel chest may make visualization and control of the surgical field quite difficult.

  • Exposing the inferior vena cava

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    Also expose the posterohepatic segment of the inferior vena cava when mobilizing the liver from caudad as well; in doing so, individual veins draining into liver segment 1 must be transected before the right hepatic lobe can be retracted far enough to the left.

  • Separating right adrenal and kidney

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    Now dissect the adrenal tumor off the superior renal pole and its perirenal fatty tissue.

  • Transecting the adrenal vein

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    The most important landmarks are the inferior aspect of the liver and lateral margin of the inferior vena cava. Dissection along the lateral margin of the inferior vena cava will lead to the right adrenal vein.

    Usually, only via a single vein drains the blood from the right adrenal into the suprarenal vein. This vein exits the adrenal at the anterior aspect of the gland. The right adrenal vein courses just a small distance before it drains directly into the inferior vena cava.

  • Posterocaval dissection of the adrenal tumor

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    Now carry the dissection posterior to the inferior vena cava. Here, the arterial blood supply is encountered which is transected between clips.

    Note: The numerous small arterial feeders from the aorta and renal artery are of minor importance.

  • Specimen removal

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    Orientation in the presence of large tumors is facilitated by encircling the renal vein with a vessel loop. Follow this by gradually dissecting the adrenal tumor off the retroperitoneum posterior to the inferior vena cava. As final step remove the specimen in toto from the surgical field.

  • Closing the diaphragm and sealing the liver

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    If tumor resection required partial removal of the diaphragm, close this defect with a running suture. In large adrenal tumors check the decapsulated surface of the liver for leakage of blood and bile; sealing such defects with a TachoSIl® patch is recommended.

  • Drainage and closing the abdominal wall

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    After draining the right adrenal compartment close the abdominal wall with two-layered suture of the fascia and the skin with a subcuticular suture.

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Ingolstadt

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  • Literature summary

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  • Current trials

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com