Anterior Approach

At times, either for intra-abdominal procedures that cannot be accomplished laparoscopically or for other reasons, an anterior open approach may be chosen. A surgical headlight may be helpful in the dissection of these tumors, which can be situated very high and deep in the retroperitoneum.

Right Adrenal

We prefer the exposure of a right adrenal pheochromocytoma through a long right subcostal incision with the patient positioned supine, sometimes with elevation of the right side of about 15 degrees. After standard exploration, the liver is retracted superiorly and its attachments are freed from the retroperitoneum. A mechanical retractor is helpful to elevate the right costal margin, and the assistant retracts medially and inferiorly on the duodenum and porta hepatis.

Occasionally, mobilization of the hepatic flexure of the colon and kocherization of the duodenum may be helpful to gain wider exposure. Because the most critical zone of dissection is the superomedial aspect of the right adrenal, the adrenal vein, the safest method involves dissecting toward it from both above and below.

Initially, the retroperitoneal attachments to the liver are incised, allowing some elevation of the liver. The retroperitoneum is incised over the superolateral aspect of the tumor and then carried medially until curving slightly over its superomedial aspect. Similarly, the retroperitoneal layer overlying the inferior vena cava (IVC) above the duodenum is incised, the lateral edge of the IVC is defined, and dissection proceeds superiorly. As the IVC is dissected toward the tumor, transection of one or two small branches from the anterior surface of the IVC to the caudate lobe of the liver further opens the dissection space. At least one fourth of the tumor may reside behind the IVC, and a vein retractor should be positioned to retract the vein medially and slightly anteriorly. Gentle lateral and inferior traction by the surgeon on the tumor helps exaggerate the angle between the adrenal vein and vena cava to facilitate visualization of the short, broad adrenal vein as it enters the posterior aspect of the vena cava. This is preferably controlled by large clips or suture ligated and the vein is transected. Typically, a significant drop in blood pressure occurs with this step, but other small venous connections are not rare, usually emptying into the renal vein inferiorly. Sometimes identified only by palpation as a tethering band at the superomedial "corner" of the tumor is the arterial branch from the inferior phrenic artery. This should be controlled, because failure to attend to this vessel probably accounts for significant bleeding that may be falsely attributed to adrenal venous bleeding. Other important arterial blood supply and less constant veins are located inferomedially, connecting to the aorta, renal arteries, and the renal vein. Control of these vessels completes the dissection.

Left Adrenal

A left adrenal tumor is exposed through a long left subcostal incision, with rib retraction similar to that for the right adrenal. Exposure can be achieved either by gaining access through the lesser sac and approaching the tumor directly under the pancreas or by mobilizing the spleen and pancreas out of their bed to the patient's right, thereby widely exposing the adrenal area. Usually, we mobilize the omentum from the midtransverse colon to the splenic flexure. Adhesions from the posterior wall of the stomach to the pancreas are lysed, and the pancreas is elevated by incising along its inferior border and mobilized by gentle blunt dissection. A retractor under the stomach and pancreas exposes the adrenal gland and tumor. The spleen can often be left in its bed but, if necessary, can be fully mobilized from its lateral attachments and short gastric vessels. Particularly when the tumor is quite large, the spleen and the body and tail of the pancreas are retracted out of the operative field to the patient's right upper quadrant. The critical zone of the left adrenal—the adrenal vein—is located inferomedially. If the renal vein can be visualized easily, early in the dissection, it should be ligated. Often, however, the tumor is large enough to overlap the renal vessels, and initial dissection to gain more mobility of the tumor should be directed to free the superior border of the gland. As with the right side, the arterial branch of inferior phrenic artery must be controlled. As the renal vein is dissected, a branch of the renal artery commonly courses immediately adjacent to the posterior and lateral aspect of the tumor, in jeopardy of inadvertent injury. Care must be exercised to protect this vessel by dissecting it away from the tumor. Once the adrenal vein is transected, the inferomedially located arterial branches must be controlled.

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