Advances in minimally invasive surgery have made it possible to remove solid organs such as the adrenal gland laparoscopically. Several studies have shown that when applied to appropriate operative candidates, laparoscopic adrenalectomy is a safe alternative to conventional open surgery with real advantages in terms of decreasing postoperative pain and length of hospital stay and allowing earlier return to normal activity. The indications for laparoscopic adrenalectomy are essentially the same as those described for open adrenalectomy. We do not recommend laparoscopic adrenalectomy for known primary or metastatic malignant tumors of the adrenal glands, because of the risk of tumor implantation that might compromise the patient's chance for cure, nor do we recommend it for lesions larger than 6 to 8 cm where the chance of malignancy is high. The preoperative preparation, laparoscopic instruments, operative techniques, and potential complications and their treatments are described in this review. Laparoscopic adrenalectomy is becoming the preferred method of surgically treating many adrenal problems. Although conventional surgical approaches will undoubtedly be required to treat certain adrenal lesions, surgeons with an interest in treating patients with adrenal disorders must become proficient in the technique of laparoscopic adrenalectomy. This will allow them to select the most appropriate operative approach for their patients' individual problems.
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The operating room setup for laparoscopic left adrenalectomy is depicted.
The patient is placed in a lateral decubitus position for laparoscopic left adrenalectomy. Trocars (10/11 mm) are placed in the subcostal region in the midclavicular line and in the anterior, mid, and posterior axillary lines. Trocar incisions are placed along a line, allowing them to be connected by a single incision in the event that conversion to an open procedure becomes necessary.
Laparoscopic left adrenalectomy requires mobilization of several structures. Seen here are the spleen (S), its lateral attachments (LA), and the splenic flexure of the colon (SF). Entrance into the left retroperitoneum is achieved by dividing the splenocolic ligament (indicated by arrowheads). Division of the lateral attachments allows adequate splenic displacement.
Once the retroperitoneum is entered, the tip of the pancreas (P), kidney (K), and periadrenal adipose tissue (PAT) are seen. Note the superomedial displacement of the spleen (S).
The adrenal gland (AG) is identified within its periadrenal adipose tissue. The adrenal vein (AV) is well visualized as it enters the left renal vein (arrow). Caution must be exercised to avoid injury to the renal vessels at this point in the operation.
The adrenal gland (AG) and adrenal vein (asterisk) have been mobilized. Note the placement of the titanium clips (arrows)—3 on the side that enters the renal vein, 2 on the side of the specimen. The vein is then divided between clips with laparoscopic scissors (LS).
The diaphragm (D), liver (L), and gallbladder (GB) are readily identified prior to dissection of the right adrenal gland.
The liver (L) is retracted medially, and the adrenal gland (AG) is well visualized. Note that the adrenal vein is seen here (arrow) as it courses toward the inferior vena cava.
The right adrenal gland (AG), containing a neoplasm in this case, is carefully dissected while maintaining medial retraction on the liver (L). The gray arrow identifies the right central adrenal vein as it courses toward the inferior vena cava.
The right adrenal vein has been safely mobilized between the adrenal gland (AG) and the inferior vena cava (IVC). The liver (L) is retracted medially. Note the titanium clips (arrow) that have been placed on the right adrenal vein prior to its division.
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