Posterior Approach

The posterior approach provides the most direct route to the adrenal glands. Compared to the other approaches, no major muscles are transected and little dissection is required to expose the adrenal glands. A large transabdominal wound is avoided. It has the purported advantage of decreased postoperative ileus, since the peritoneal cavity is not entered. Patients are able to ambulate and take a normal diet early after operation, and their hospital stay is often shortened. The posterior approach is effective for the exposure and removal of glands up to 5 cm in diameter. Glands larger than this may be difficult to resect with this approach. It has the disadvantage of exposing only one individual gland with each incision, so two incisions are necessary if this approach is used for bilateral adrenal pathology. In addition, exposure of the adrenal veins can prove difficult, mandating close attention to prevent venous avulsion and uncontrolled hemorrhage. This approach should not be used for large adrenal masses that mandate wide exposure and early vascular control; if used, it should be reserved for bilateral hyperplasia (Cushing's disease) or small, benign adenomas.

Proper positioning is crucial in facilitating this approach. After the patient is intubated, he or she is placed prone, with the break of the table at the level of the 12th rib (Fig. 73-5). Pillows are placed under the patient's abdomen and lower legs, and the operating table is jackknifed to hyperflex the patient's back. Flexion of the knees, along with placement of sequential compression devices on the lower legs, reduces the likelihood of deep venous thrombosis. A hockey stick incision starting approximately 5 cm lateral to the midline of the vertebral column, progressing downward and outward in curvilinear fashion at the level of the 10th rib, over the 12th rib, and extending toward the iliac crest is typically described. We usually use a straight incision that follows the oblique course of the 12th rib and have found that it provides sufficient exposure. Division of subcutaneous fat exposes the latissimus dorsi. This is transected with cautery, revealing the sacrospinalis muscle, which in turn is divided to expose the 12th rib. The sacrospinalis is retracted toward

12th Rib

12th Rib

FIGURE 73-5. The patient is placed in the prone position for a posterior adrenalectomy. The break in the table should be beneath the 12th rib. Padding is placed to allow chest expansion for respiration and to avoid any pressure points.

midline, and its attachment to the 12th rib is severed. The middle lamella of the lumbodorsal fascia underlying the sacrospinalis is incised to expose the quadratus lumborum and the transversalis fascia. Insertion of the index finger under the incised middle layer of the lumbodorsal fascia and sharp division of the posterior subcostal ligament releases the pleura from the 12th rib. The periosteum of the 12th rib is then incised and stripped before the rib is resected. The 12th intercostal nerve should be identified and preserved throughout these steps. Once the 12th rib is removed, the retroperitoneum is entered. Proper retraction is critical at this point. Typically, upward retraction of the 11th rib reveals the reflection of the parietal pleura and the lateral arcuate ligament of the diaphragm. The pleura is retracted upward. If the pleura is inadvertently opened, it can be repaired over suction catheters that are withdrawn as the incision in the pleura is closed under positive-pressure ventilation. Postoperatively, a chest tube is usually not necessary.

With retraction of the 11th rib, a layer of perinephric fat becomes visible. Dissection through this layer reveals Gerota's fascia, which is entered to reveal the kidney. This is then manually depressed to expose the adrenal gland. Rotating the superior pole of the kidney caudally and posteriorly facilitates exposure of the adrenal gland, which can be readily identified from the surrounding perinephric fat by its characteristic gold-brown color. The gland can then be dissected out starting superiorly and progressing caudally. Care must be taken in handling the gland, which can be friable. To reduce the risk of breakage, spillage of cells, and autotransplantation, the gland should be handled by its surrounding adventitia. The multiple tributary blood vessels should be clipped, ligated, or cauterized, although the actual arterial branches to the gland are not typically identified during the procedure. Care must be taken to avoid avulsing the adrenal vein, which itself is doubly ligated or stick-tied with a silk suture and divided. The relative shortness of the right adrenal vein predisposes it to an avulsion or tear with resulting major hemorrhage from the IVC. If this occurs, stick sponges should be applied to the cava proximally and distally to the tear, which is subsequently repaired with a 4-0 Prolene in running or interrupted fashion.

Once the gland is dissected out from the perinephric fat and all blood vessels have been appropriately divided, the gland may be removed. The perinephric fat should be carefully inspected for bleeding as well as for ectopic adrenal rests that may be present. When hemostasis is achieved, and all satellite adrenal tissue removed, the wound may be closed in appropriate layers.

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