In comparison the left adrenal gland is more difficult to expose,
but less precarious due to it's distance from the vena cava.
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| Patient positioning is a mirror image of the right side. The surgeon, camera and assistant do not change sides of the table. |
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| The port placement is similar to the right side. As stated before the surgeon's dominant hand is best served with a larger (10 /12mm.) port. |
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The splenic flexure invariably
overlies the left adrenal. The lateral upper reflection of the descending
colon is incised and the flexure is displaced inferior and medial. Here
the surgeon can use the scissors with the left hand to keep optimal tension,
and avoid crossing his/her own instruments. As the dissection progresses onto the splenocolic ligament the assistant uses the body of a grasper in the left hand to elevate the spleen. The assistant's right hand applies inferior and medial traction to the colon, as the surgeon uses both hands to develop the plane between the colon and spleen. The retroperitoneal exposure should include the superior pole of the left kidney, and have access to the lesser sac. |
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The gland is located by following Gerota's
fascia in a superior and medial direction. Some dissection in the retroperitoneal
fat may be necessary, again guidance is obtained from the characteristic
color of adrenal tissue. The assistant continues to elevate the spleen
with the body of a blunt grasper . Dissection of the inferior edge of the
pancreas and developing an operating space in the lesser sac may be required.
As with the right side, the dissection is commenced on the lateral border and carried in a superior direction. Either scissors/cautery or ultrasonic dissection is employed. Once the lateral aspect of the gland is mobilized attention is directed towards the inferior pole. A large vein is located here and courses in the cranial-caudal direction to drain into to the left renal vein. This structure will require dissection and ligation as described for the right side. After this vessel is divided the inferior pole is completely mobilized. The assistant elevates the gland with the body of his/her right hand grasper while the surgeon divides the adherent retroperitoneum posterior to the gland. The medial aspect of the gland is freed next .There are segmental arterial feeders from the aorta which require opposing tension forces, dissection and ligation as previously described. The adrenal arteries are usually small enough to use clips alone. |
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The remaining vasculature is cauterized or clipped as needed. The gland is elevated by the assistant while the surgeon completes the dissection of the superior pole. The specimen is placed in a retrieval bag and removed from the operative field. |
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