Retroperitoneal Approach

Comparing the lateral and posterior retroperitoneal approaches for total adrenalectomy, Baba et al. (37) found that the retroperitoneal posterior approach allowed direct access to the main vascular supply prior to gland manipulation. Sasagawa et al. (26) reported their experience of partial adrenalectomy using a posterior retroperitoneoscopic approach. The patient is positioned in low jackknife position with the trunk-thigh hinge of the table used as a flexion point to open the relevant posterior lumbar area between the 12th rib and iliac crest. A 20-mm transverse muscle splitting incision is made below the tip of 12th rib for the primary port. The retroperitoneal space is accessed by digital dissection. The use of a commercially available balloon dilator is optional. After creating the space, two 10-mm trocars are placed 2 to 3 cm medial and lateral to the first port by finger guidance. Ablunt-tip trocar is inserted as the primary port and fixed with sutures to avoid gas leak. CO2 is insufflated into the retroperitoneum. Dissection begins by incising the Gerota's fascia from just below the diaphragm to the level of renal pedicle along the medial crus of the diaphragm. On the left side, adrenal arteries including middle adrenal artery need to be clipped before isolating the main adrenal vein and inferior phrenic vein cranial to

the renal pedicle. On the right side, multiple adrenal arteries are encountered before reaching the inferior vena cava and main adrenal vein. Further steps of dissection depend on the location of the tumor and are akin to the transperitoneal approach (Fig. 5).

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