Endocrine

Adrenalectomy (Laparoscopic)

OPERATION: Laparoscopic Adrenalectomy — [Right / Left] — [Transabdominal Lateral Approach]
ANAESTHETIC: General anaesthesia
POSITION: Lateral decubitus, [right / left] side up. Table flexed at waist to maximise costiliac space. Urinary catheter. VTE prophylaxis.

INDICATION:
[Phaeochromocytoma / Cushing's adenoma / Conn's adenoma (aldosteronoma) / non-functioning incidentaloma >4 cm / adrenal metastasis]. Preoperative biochemical confirmation and appropriate endocrine review completed. [For phaeochromocytoma: alpha-blockade established pre-operatively]. Imaging: CT/MRI [size, laterality, characteristics].

PROCEDURE:
WHO Checklist performed. Patient prepared and draped widely (nipple to ASIS, midline anteriorly, spine posteriorly).

PORT PLACEMENT:
Pneumoperitoneum via open or closed technique at the anterior axillary line 2 cm below the costal margin. 5 or 10 mm camera port at this site. 30° laparoscope. Two additional 5 mm ports placed 2 cm below the costal margin in the epigastrium and anterior axillary line. [Fourth port at posterior axillary line if additional retraction required]. Abdomen inspected.

LEFT ADRENALECTOMY:
Splenorenal ligament incised. Spleen and pancreatic tail allowed to fall medially by gravity, revealing the left kidney and adrenal. Avascular plane developed along anterior surface of kidney. Superior and medial dissection carried to the diaphragm. Inferior and medial borders of the adrenal gland exposed. Left adrenal vein identified at the inferior pole of the gland and divided between clips / vessel sealing device. Inferior phrenic artery identified and ligated. Dissection continued supero-laterally with successive small vessel control using diathermy or energy device. Adrenal gland completely mobilised.

RIGHT ADRENALECTOMY:
Liver retractor placed via epigastric port, retracting liver superiorly. Retroperitoneal attachments of right lobe of liver and triangular ligament incised to expose anterior surface of adrenal gland. IVC exposed at medial border. Right adrenal vein identified — typically short and broad, entering IVC posteriorly at right angle. Vein secured and divided between clips / vessel sealing device / vascular stapler. [Variant: vein draining to right hepatic or renal vein — managed accordingly]. Arterial branch of inferior phrenic artery at superomedial aspect controlled. Dissection proceeded medial to lateral, inferior to superior, dividing small attachments until gland fully mobilised.

SPECIMEN RETRIEVAL:
Adrenal gland placed in endoscopic retrieval bag and removed through the medial 10 mm cannula [or via slightly extended port site]. Haemostasis of adrenal bed confirmed.

Ports removed under direct vision. Port fascia closed. Skin subcuticular suture.

FINDINGS:
[Right / left] adrenal gland. [Size]. [Macroscopic appearance — well-encapsulated adenoma / haemorrhagic lesion]. Gland excised intact. Adrenal vein ligated. Pancreatic tail [not injured / proximity noted and protected].

SPECIMEN: [Right / left] adrenal gland to histopathology.
EBL: [Volume] ml. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
[Steroid replacement commenced if bilateral adrenalectomy or Cushing's / monitoring for adrenal insufficiency]. [Antihypertensive adjustments for phaeochromocytoma and aldosteronoma]. Endocrine review at 4–6 weeks. Biochemical assessment at follow-up.