Step 3 Intraoperative Ultrasound

After securing three secondary ports (Fig. 4B), real-time ultrasound is performed using a flexible, steerable color Doppler ultrasound probe inserted through a lateral port and positioned directly on the pleural surface of the hemidiaphragm. Intraoperative ultrasound allows the precise localization of the adrenal mass on the abdominal side of the diaphragm (Fig. 4C) and its location relative to the adjacent anatomical structures, including the edge of the liver and inferior vena cava on the right side (Fig. 5A), or the edge of the spleen and aorta on the left side. The proposed incision site is radially scored on the thoracic surface of the diaphragm with electrocautery (Fig. 5B). Confirmation of accuracy of the location of the proposed line of diaphragmatic incision directly over the adrenal mass is obtained by repeat ultrasonography (Fig. 5C).

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