|
|
| The initial position is supine for induction of endotracheal anesthesia and the placement of a foley catheter. If needed, monitoring lines are placed. Next, the patient is turned right side up at 30 to 45 degrees. The kidney rest is positioned just above the iliac crests, and a roll, wedge or bean bag is used to maintain this position. The dependent axilla is padded, and the right arm is placed on an elevated arm board, or taped across the chest. The table is broken slightly, and the kidney rest raised, extending the available lateral abdomen between the costal margin and the iliac crest. The patient is prepped to the right posterior axillary line, as the operating field will extend to the right midaxillary line. The table is then rotated to the right, flattening the patient. This facilitates the cut down for the camera insertion. |
|
|
| The camera is placed in the midline approximately half way between the umbilicus to the xiphoid. A 30 degree scope is inserted, and the abdomen explored. A midline port is placed on the assistant's side (left) near the xiphoid for a liver retractor. A second 5mm (or smaller) port is placed for the assistant that is positioned halfway between the camera and the sub-xiphoid port. The assistant elevates the liver with his/her right hand, and the anatomy is surveyed. The surgeon then places two ports in the right mid-abdomen. The sizes of these ports depend on which hand the surgeon uses to operate the ultrasonic dissector, and suturing instruments. One port is placed in the proximity of the anterior axillary line. The 5th port splits the difference between this lateral most port and the camera. |
|
Click for enlarged view |
The liver and gall bladder are elevated by the assistant with the right hand via the 10mm sub-xiphoid port. The hepatic flexure of the colon may overly the adrenal, but not in all cases. If needed the superior most aspect of the lateral reflection of the right colon is taken off the abdominal side wall. The assistant uses his left hand to apply medial and caudal tension, while the surgeon provides counter tension to the abdominal side wall. The dissection device (scissors or ultrasonic dissector)is in the surgeons right hand . This set up places the dissecting tool between the forces of tension and countertension. Note that this same dissection set up scheme is employed through out advanced laparoscopy. This dissection is continued on to the gastrocolic ligament and the colon is reflected toward the left lower quadrant. The completed retroperitoneal exposure should include the superior pole of the kidney, the duodenum and IVC. The adrenal gland should be visible at this point if not earlier. In the case of a small gland, or fatty retroperitoneum, the characteristic color of adrenal tissue distinguishes it from retroperitoneal fat. The adrenal gland is a deeper more amber shade of yellow than adipose. |
Click for enlarged view |
The dissection is commenced on the inferior pole of the adrenal gland and directed in the superior and lateral direction. An inferior pole vessel may be present and require ligation. The assistant elevates the cleared lateral edge of the gland with the body of his/her lefthanded grasper while the surgeon develops the plane under the adrenal gland, working in a medial direction. |
Click for enlarged view |
The attention is then directed toward
the medial boarder of the organ. Here it abuts and may extend behind the
IVC. This is where the ultrasonic dissector has its greatest advantage.
Adequate lateral and posterior mobilization facilitates the retraction
needed to separate the adrenal from the lateral wall of the IVC. As usual,
the dissection commences from superficial to deep, and from inferior to
superior pole.
Located on the medial aspect of the right adrenal is the main adrenal vein. This vein is large, short, and empties directly into the IVC. Dissection around the vein is accomplished with a right angle clamp. The vein is controlled with silk ligatures passed around the vein with the right angle clamp and tied extra corporeally. As in open cases, an ample vein cuff is left on the side of the vena cava. |
Click for enlarged view |
Once the main vein is taken, the dissection is continued up the medial border.There is the possibility of another venous branch from the superior pole of the adrenal to the vena cava. Once the medial dissection is completed, gland is retracted toward the diaphragm to facilitate dissection of the upper pole. A plastic retrieval bag is used to keep the specimen intact and protect against the dispersal of cellular material. |
All images, Text and descriptions are property of the Online Atlas of Surgery. Reproduction by written permission only. Copies of the origional artwork are available as either slides or prints. For information please contact the ATLAS.
