Special Surgical Procedures II
LESSON 3: Procedures in Genitourinary Surgery
Section Iii: operations on the kidney, ureter, and adrenal glands
3-21
3-21. ADRENALECTOMY
a. General. This operation involves the partial or total excision of one or both adrenal glands. This procedure may be done to treat hyperfunction of the adrenals, remove tumors of the glands themselves, or treat tumors elsewhere in the body that are affected by adrenal hormonal secretions, such as carcinoma of the prostate or breast.
b. Patient Preparation. For unilateral adrenalectomy, the patient may be placed in the lateral kidney or supine position. More often, however, both glands are explored, and the supine position is selected.
c. Operative Procedure--Lateral Approach.
(1) An incision curving from the midline and extending from the rib cage to the iliac crest is made with the scalpel through the skin, fat, and muscle. The lumbodorsal fascia is cut to reveal the sacrospinal muscle. This muscle is detached from the ribs, using forceps and dissecting scissors.
(2) The rib is resected.
(3) An opening is made through the transverse fascia with scissors. The pleura and diaphragm are protected with wet pads, and Gerota's capsule is incised to expose the kidney and adrenal gland.
(4) The gland is dissected free, using scissors and Babcock forceps. The blood supply of the gland is identified, clamped or clipped, and divided. Bleeding vessels are ligated. To release the glands, the left adrenal vein, a branch of the left renal vein, is separated by clamping and cutting. The right adrenal vein, a tributary of the vena cava, is also divided. Fine vascular sutures may be required to repair inadvertent injury to the vena cava.
(5) When hemostasis has been assured, the wound is closed in layers--muscle, fascia, subcutaneous tissue, and skin.
d. Operative Procedure--Abdominal Approach.
(1) The abdominal wall is incised, and the peritoneal cavity is opened and explored. Bleeding vessels are clamped and ligated.
(2) The abdominal wound is retracted, and the surrounding organs protected with laparotomy pads, using instruments and sutures as for routine laparotomy.
(3) The retroperitoneal area near the diaphragm is opened on the left side, exposing the renal fascia.
(4) The renal fascia is opened to reveal the left kidney and adrenal gland.
(5) The adrenal gland is freed from the kidney by sharp and blunt dissection, clamping and ligating all bleeding vessels with silk sutures number 3-0 or vascular clips.
(6) After all bleeding is controlled, the kidney is gently replaced in the renal fascia, and closed with interrupted chromic sutures number O.
(7) The peritoneum is closed over the left kidney and renal fascia.
(8) The abdominal retractors are rearranged to give access to the peritoneum over the right kidney and adrenal gland. Care must be taken here to avoid trauma to the liver.
(9) The right retroperitoneal space is opened to reveal the renal fascia.
(10) The renal fascia is opened, exposing the right kidney and adrenal gland.
(11) The adrenal gland is freed in the same manner as the left one and excised.
(12) The right kidney is replaced in the renal fascia, which is sutured closed.
(13) The right retroperitoneal area is closed with chromic sutures #0.
(14) The abdomen is inspected for bleeding vessels, which are ligated.
(15) The wound is closed in the routine laparotomy fashion.
