Operative approaches for the endoscopie adrenalectomy

PROCEDURES Three different techniques are described in this video: the lateral transperitoneal approach to the right gland, the lateral transperitoneal approach to the left gland and the retroperitoneoscopic approach to the left gland. Current methods of endoscopie adrenalectomy entail early ligation of the main adrenal vein using extracorporeal slip knots. These manoeuvres and the necessary endoscopie dissection is made easier by the adoption of distally curved instruments and 30° angled telescope. Placing the patient in the full lateral position, particularly for the right adrenalectomy, enables the weight of the liver anterior to the adrenal to aid in its own retraction. The retroperitoneoscopic surgery of the adrenals can be difficult because movements of instruments are often impaired by the closeness of the costal margin. Ultrasound guidance is used to position the access needle well within the perirenal fat, above the adrenal gland. The retroperitoneal space is then widened by blunt, balloon dissection. The restricted working space of this access and its rapid loss while using suction devices, demand a very meticulous dissection. This approach obviates the need for timeconsuming laparoscopic mobilization of overlying organs, but is only indicated for small lesions on the left side, since the short main right adrenal vein is approached and safely ligated through the anterior transperitoneal way. CONCLUSIONS Over the years a number of open surgical approaches to the adrenal glands have been devised, but endoscopie surgery seems now to offer obvious benefits. The post-operative course is similar to that of laparoscopic cholecystectomy, except that some endocrine disorders will necessitate hormonal support, which may delay hospital discharge.