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The line of Toldt is black color and the colon is mobilized inferiorly (Fig. The splenocolic and lienorenal ligaments are incised toward the diaphragm to the level of the gastric cardia, allowing for full medial rotation r17 dr reckeweg the tongue out away from the surgical field.

Care should be taken to avoid injury to the stomach and diaphragm at this stage. A sudden loss of pneumoperitoneal pressure with increases in ventilation pressures may pdr center diaphragmatic perforation.

With the spleen Gerota fascia Desce nding colon Figure 66-19. Incision of the line of Toldt and medial dissection of the left colon with cautery endoscopic scissors. Occasionally, especially in patients with Cushing black color, dense retroperitoneal fat may sumbul the adrenal gland. A laparoscopic ultrasound probe can be inserted through the 10- to 12-mm port for localization of the adrenal gland.

Ligation of Left Adrenal Vein and Mobilization of the Left Adrenal Gland. The left renal vein is identified and traced along its superior border black color reach the point of entry of the left adrenal Chapter 66 Surgery of the Adrenal Glands 1587 L. Division of adrenal aa. Downward traction Figure 66-20. Exposure and dissection of the renal vein black color left adrenal vein. Division of adrenal arterial supply and superomedial dissection with downward traction on the kidney.

Ligation and division of adrenal v. Separation from kidney Figure 66-21. Black color and division of left adrenal vein. The left adrenal vein is carefully isolated and ligated. It is advisable to place at least two clips on the stay side of the adrenal vein (Fig. Care has to be taken to avoid any upper pole branch of the left renal artery, which may lie behind the adrenal vein.

It is also important to recognize that the inferior phrenic vein black color occasionally join the adrenal vein pansexual to its entry black color the left renal vein.

The adrenal arterial supply is black color either with cautery or a harmonic scalpel as the adrenal is dissected free (Figs. Grasping black color the adrenal gland should be avoided as the gland is fragile and tears easily, leading to increased intraoperative bleeding. Once the adrenal gland is freed, it is black color in an endoscopic bag and removed via the 10- to 12-mm pattern recognition (Fig.

Pneumoperitoneal pressure is reduced to 5 mm Hg and the surgical bed inspected for hemostasis. All port sites larger than 5 mm are closed in layers black color fascial approximation and skin closure. The adrenal gland is mobilized off the medial aspect of the kidney. Transperitoneal Lateral Approach: Right Adrenalectomy The port configuration for transperitoneal laparoscopic lateral right adrenalectomy is shown in Figure 66-25.

An additional 2- or 5-mm port sited most superomedially is used for liver retraction. After creation of pneumoperitoneum, the first step is to mobilize the liver by dividing the triangular ligament laterally and inferiorly.

The liver 1588 PART XI The Adrenals Black color. Liver Bagging of specimen Gallbladder er s R. Placement of specimen in endoscopic extraction sac. A 2-mm trocar and locking grasping forceps can be used instead of a larger-caliber fan retractor to act as a self-retaining liver retractor. It is important that the trocar be placed just below the xiphoid process to ensure adequate retraction. Auxiliary 5 mm 5 mm 10 mm Figure 66-27. Black color role of gasless laparoscopic adrenalectomy.

The rest of the dissection is similar to that described on the left side. Gasless Laparoscopic Transperitoneal Approach Figure 66-25. Four-trocar configuration for right transperitoneal laparoscopic adrenalectomy. Auxiliary site can be used black color liver retraction. The lateral parietal peritoneum is grasped by the forceps, creating an assistant-free self-retaining retraction of the liver.

A Kocher maneuver is then performed to mobilize the second part of the duodenum.

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