Open Adrenalectomy Technique

Updated: Mar 24, 2017
  • Author: Peter P Stuhldreher, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

The approach chosen should maximize exposure to the important structures during surgery. Posterior/flank approaches offer the least efficient access to the vasculature, whereas abdominal approaches portend greater morbidity. It is critical to be mindful of the named vascular structures associated with the adrenal glands, as well as the potential for there to be numerous unnamed collateral vessels associated with large adrenocortical carcinomas.

The main arterial supply to the right adrenal gland is the inferior adrenal artery, a branch of the right renal artery, and venous drainage is directly into the inferior vena cava (IVC). On the left, the main arterial supply comes from the middle adrenal artery, a direct branch from the aorta, and the venous drainage is mainly to the left renal vein via the adrenal vein. Care should be taken with medial dissection of the adrenal gland because there are many anastomotic networks of veins and arteries in addition to the major vascular structures.

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Open Excision of Adrenal Gland

Posterior approach

Also referred to as the lumbodorsal approach, this approach has the advantage of allowing the surgeon to remain in an extraperitoneal dissection plane and offers access to both adrenal glands (though this requires two incisions).

Although this approach has several modifications, the standard approach has the patient in the prone position with arms extended over the head. The incision is made over the 11th or 12th rib, with or without a “hockey stick” extension cephalad. [4, 25]

The diaphragm is then dissected cephalad; incision through the diaphragm may be made if necessary. The peritoneum is swept inferiorly, and adjacent retroperitoneal organs are identified and mobilized if necessary.

The vessels of the adrenal can then be ligated and the specimen removed after mobilization.

Although the morbidity of this procedure is reported to be low, previously mentioned rates of nerve or musculosketetal pain may be underreported. Access to vasculature is also limited.

Flank approach

The flank approach will be familiar to the urologist because it can also be used for extraperitoneal access to the kidney. The patient for this approach is positioned in the lateral decubitus position with the pathologic side up. Adequate padding of the patient in this position is imperative to avoid hyperextension of nerves and to protect against the risk of rhabdomyolysis (especially in the obese patient).

The lower leg is flexed and padded at the hip; pillows are used in between the legs, and the upper leg is extended and padded with the lower leg flexed. The lower arm is placed in roughly 90º of extension with an axillary roll and the upper arm is placed in a flexed, extended posture in the appropriate arm board.

Incision is made over the 11th rib and carried down through the muscle and fascial layers over the 11th rib. The rib is mobilized posteriorly taking care to avoid injuring the neurovascular bundle. The rib is then resected and entry is made into the retroperitoneal space through the lumbodorsal fascia.

The peritoneum is reflected anteriomedially, and often the vena cava or aorta may be identified when one is operating in the correct anatomic plane, depending on the side. The kidney may be mobilized as well for inferior traction to help expose the adrenal.

Dissection usually begins along the medial side of the gland with ligation of vascular structures. With sharp dissection, the adrenal can be mobilized off the psoas muscle and separated from the ipsilateral kidney.

This approach offers excellent exposure in obese patients, in that their pannus will move anteriomedially and make dissection to the adrenal gland easier than it would be with an anterior approach. As with the posterior approach, vascular access is not as expedient as with anterior approaches. In addition, there is a risk of injury to the pleural reflection at the level of the 11th rib in the midaxillary line and inadvertent entry into the pleural cavity or lung injury. Accordingly, the authors advocate routine postoperative chest radiography to evaluate for pneumothorax and rule out unidentified injuries. This approach also limits the surgeon to evaluation of the ipsilateral gland only.

Anterior subcostal and midline approaches

These two approaches are very familiar to both urologists and general surgeons; exposure to many other organs can be obtained through these approaches.

The subcostal approach is initiated with the patient supine and the incision is made two fingerbreadths below the costal margin. This may be extended across the midline if necessary or extended to a full chevron if access to both adrenals is warranted.

The rectus muscle and fascia are divided medially, and the external oblique, internal oblique, and transversus abdominis are divided with their fascia laterally. The falciform ligament is identified in the right hemiabdomen and ligated after sharp incision of the peritoneum. The colon is then identified and reflected medially by sharp dissection.

The spleen may be mobilized off the colon and kidney on the left by incising the ligamentous attachments, and the liver can be retracted superolaterally after ligamentous attachments are divided on the right. Care must be taken on the right to identify and protect the duodenum and on the left to identify and protect the tail of the pancreas. Both of these structures can be reflected medially with appropriate mobilization when necessary.

The adrenal gland can then be mobilized from medial to lateral, with care taken to ligate vascular branches when encountered and to mobilize the kidney for inferior traction when necessary. The wound is then closed in the standard fashion.

Access with a midline approach is very similar, except that the incision is made from the xiphoid inferiorly, circumscribing the umbilicus. Entry into the peritoneum is obtained after identification of the midline raphe of the rectus sheath and sharp dissection. This approach will obligatorily limit the lateral extent of exposure, in that the adrenal gland on the right is located almost behind the vena cava and on the left in a very deep position when approached in this manner.

This approach offers the advantages of being well known to all surgeons and allowing for bilateral exploration. However, it does lend itself to longer convalescence and a higher rate of ileus, and it may be difficult with obese patients.

Thoracoabdominal approach

For this approach, the patient is placed in the supine position with the upper torso rotated at a 45º angle with a body roll. The incision is then made through the eighth or ninth intercostal space through the muscle layers and carried medially through the costal cartilage.

The incision is carried through the anterior and posterior rectus sheaths, and the pleura is entered and the lung packed out of the field. During division of the diaphragm, care is taken not to proceed too centrall; the phrenic nerve can be damaged with careless division.

Control of the diaphragm during division with traction sutures is recommended. Entry into the peritoneal cavity and exposure to the adrenal gland is then carried out as described for the anterior approaches.

Closure of the diaphragm in this approach should be done with interrupted figure-eight nonabsorbable suture. The ribs muse be reapproximated. Before complete anterior closure, a chest tube is placed to suction and water seal.

This approach offers excellent exposure to the retroperitoneum and the great vessels while also offering excellent exposure if IVC thrombus is present. However, it has the highest morbidity of all the approaches, carrying the risks of prolonged ileus, pulmonary complications, and need for chest tube placement. Consequently, most authors reserve this approach for large tumors and adrenocortical carcinoma. [4, 25]

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Complications

Inadvertent injury to the surrounding structures can occur during adrenalectomy. Vascular injuries can be associated with hemorrhage or ligation of vessels not associated with the adrenal gland. Given the adrenal gland’s close approximation to the IVC, renal vessels, hepatic vessels, splenic vessels, and lumber vessels, injury to these structures is possible. Ligation of an upper-pole renal artery branch, the IVC, or mesenteric vessels is also possible.

Damage to adjacent organs is also a concern depending on the approach chosen with the anterior/thoracoabdominal approaches having more reported bowel injuries, but the flank and posterior approaches are associated with inadvertent pleural injuries. Expert knowledge of the anatomy of the peritoneum and retroperitoneum is of utmost importance to prevent injury and to facilitate intraoperative recognition of such injury to decrease morbidity. Additionally, patients are at risk for wound complications such as breakdown, soft-tissue infection, and dehiscence.

Also with hormonally active tumors, several complications may arise that require careful monitoring and management for successful avoidance. With aldosterone-secreting tumors, hyperkalemia may be seen postoperatively as the contralateral adrenal gland’s aldosterone secretion has been inhibited by oversecretion from the removed gland preoperatively. Hypokalemia may also be seen immediately postoperatively. Hypotension can be seen after resection of pheochromocytoma as a consequence of the preoperative alpha-adrenergic blockade.

More significantly, adrenal insufficiency (from downregulation of the hypothalamic-pituitary axis secretion of ACTH from excess cortisol) is a devastating complication of resection for Cushing syndrome if not recognized, aggressively treated, and prophylactically guarded against with steroid replacement. Hypoglycemia and hyperglycemia also may be seen postoperatively.

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