Organ Injury

Direct injury to the adrenal gland may cause troublesome bleeding and may also compromise the oncological safety of the procedure. This is best avoided by dissecting the periadrenal fat and the adrenal gland within the superior packet of Gerota's fascia as a whole rather than dissecting the gland itself.

On the left side, the tail of the pancreas may also be confused with the adrenal, but it lacks the characteristic color of the adrenal. If it does not look like the adrenal, it is probably not the adrenal!

Similarly, the spleen is at risk during left-sided procedures. Attachments to the spleen should be divided sharply to avoid avulsion of part of the splenic capsule. Incising the leinorenal ligament allows the spleen to be retracted superiorly and medially away from the operative site.

The diaphragm and colon are at risk on both sides, whereas the duodenum and liver are at risk on the right. Dividing the inferior coronary ligament to allow gentle superior retraction of the liver away from the adrenal minimizes hepatic injury.

By applying the general principles of careful hemostasis, and careful, deliberate dissection to positively identify the relevant anatomy, the risk to adjacent organs is minimized.

At times, the operative view may be compromised by camera fogging, poor lighting, or poor image quality. A detailed discussion of these issues is beyond the scope of this chapter; however, in such instances, it is imperative to stop and correct the problem rather than continue in suboptimal circumstances.

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