Right adrenalectomy, open

The laparotomy begins with a right-sided transverse incision at the level of the navel and is then extended in the midline supraumbilically to the xiphoid. Examination of the abdominal organs to exclude further metastases, confirmation of resectability.

The liver is elevated and the duodenum is mobilized and retracted medially to such an extent that the inferior vena cava is accessible in its full length.

Note: Detachment of the right colonic flexure may additionally be necessary depending on the operating field (not required in this example).

To achieve a sufficiently good depiction of the right adrenal gland, which is retroperitoneal and located directly under the liver next to the inferior vena cava, it is necessary to displace the liver cranially and medially. First, the parietal peritoneum covering the front of the lower part of the adrenal gland is opened parallel to the inferior vena cava. 

Note: Surgical procedures on the right retroperitoneum are more challenging than on the left side, as liver enlargement, obesity, or a barrel chest can significantly complicate the positioning of the surgical site.