Published on 09/04/2015 by admin

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Last modified 09/04/2015

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CHAPTER 14 Adrenalectomy

Step 1. Surgical anatomy

A thorough knowledge of normal adrenal anatomy and the relationship of the adrenals to surrounding structures is essential for surgeons who undertake adrenalectomy.

The adrenal glands are located at the superior-medial aspect of each kidney and are composed of a cortex and medulla with distinct endocrine functions. The steroid hormones (cortisol, aldosterone, and the adrenal androgens) are synthesized and secreted in the adrenal cortex, and the adrenal medulla synthesizes the catecholamines, norepinephrine and epinephrine. Catecholamines may also be synthesized in extra-adrenal chromaffin tissue in the paraganglia.

Each adrenal gland is embedded in Gerota’s fascia and is surrounded by retroperitoneal fat. The adrenal gland has a golden yellow appearance because of the high lipid content of the cortex.

The right adrenal gland is pyramidal in shape and lies superior to the right kidney, whereas the left adrenal is more flattened and is in intimate contact with the medial aspect of the superior pole of the left kidney.

Bordering structures for the right adrenal are the inferior vena cava medially, the liver anteriorly, and the kidney inferiorly. A portion of the anteromedial border of the gland usually extends posterior to the vena cava. The right triangular ligament of the liver crosses the anterior surface of the adrenal gland superiorly, which means that the upper portion of the gland has no peritoneum covering its surface. Structures that border the posterior aspect of the right adrenal are the diaphragm superiorly and the anteromedial portion of the superior pole of the right kidney inferiorly.

Structures neighboring the left adrenal gland are the spleen and fundus of the stomach superiorly, the splenic flexure of the colon, the tail of pancreas, and splenic vessels inferiorly, and the left crus of the diaphragm posteromedially and the medial aspect of the left kidney posterolaterally. The renal vessels lie just below the inferior border of the adrenal, and in the setting of a large tumor, they may overlie the renal artery and vein.

The adrenal blood supply is derived from numerous branches of the inferior phrenic, aortic, and renal arteries. A single central vein drains each adrenal.

Step 2. Preoperative considerations

Preoperative preparation for adrenalectomy should entail the following: