Control of the Main Adrenal Vein

Gerota's fascia is incised transversely at the level of the upper pole of the kidney. The upper renal pole is mobilized and allowed to fall posteriorly away from the adrenal.

On the left side, dissection continues between the upper pole of the kidney and the adrenal to the renal hilar vessels. The dissection continues medially along the renal artery or vein until the adrenal vein is identified and then clipped and divided. If the adrenal vein cannot be identified, the dissection is recommenced laterally and superiorly to free the adrenal from the diaphragm. The dissection then continues around the inferomedial aspect of the gland where adrenal vein will be identified.

On the right side, the dissection is carried superiorly along the lateral aspect of the vena cava until the adrenal vein is seen. The vein is divided, and the gland mobilized.

Instead of incising Gerota's fascia to enter the plane between the upper pole of the kidney and the adrenal, an alternative strategy is to lift the kidney medially and anteriorly and incise Gerota's fascia just anterior to the psoas muscle and then identify the renal hilum. The dissection then continues along the lateral aspect of the vena cava on the right or aorta on the left superior to the renal hilum. On the right, the adrenal vein is encountered during this medial dissection but on the left, it may not be seen and may require circumferential mobilization of the gland before it is identified.

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