Open Anterior Left Adrenalectomy
Christopher R. McHenry, MD and Michael S. Wolfe, MD
here are many different surgical approaches for re-
T moving the adrenal gland, each with its own advan-
tages and disadvantages.1 The choice of the surgical ap-
proach is primarily dependent on the nature of the disease
affecting the adrenal gland and the size of the adrenal
tumor. The conventional open, anterior approach is uti-
lized for treatment of adrenocortical carcinoma, the soli-
tary adrenal metastasis when it is large and there is con-
cern for tumor spillage, suspected malignancy, and very
large tumors (greater than 10 cm) in which mobilization
is more difficult and the risk of malignancy is higher.
Complete surgical excision, performed by an open, en
bloc resection, is the only chance for cure of an adrenal
malignancy, and this is best accomplished by an open
anterior adrenalectomy. The open anterior approach to
the adrenal gland facilitates exploration of the entire ab-
domen, and it is the only approach where both adrenal
glands can be exposed through a single incision. In this
chapter, the open anterior transperitoneal left adrenalec-
tomy is illustrated. The preoperative preparation of pa-
tients for adrenalectomy, the surgical anatomy, the steps
for intraoperative exposure and resection of the left adre-
nal gland, the postoperative care, and the potential com-
plications of left adrenalectomy are outlined.
PREOPERATIVE PREPARATION
Before adrenalectomy, intravascular volume depletion
and electrolyte abnormalities are corrected. All patients
are typed and screened for possible blood transfusion.
Prophylaxis against thromboembolism is used in the form
of a sequential compression device or subcutaneous hep-
arin. This is particularly important in patients with hy-
percortisolism who have a four-fold increase in thrombo-
embolic complications compared with the general
population.2 The presence of subclinical hypercorti-
solism is excluded in all patients with a 1 mg overnight
dexamethasone suppression test.3 Patients with hyper-
cortisolism must be treated with perioperative gluco-
corticoids to prevent acute adrenal insufficiency post-
From the Department of Surgery, MetroHealth Medical Center, Case Western
Reserve University, Cleveland, OH.
Address reprint requests to Christopher R. McHenry, MD, Department of Sur-
gery, MetroHealth Medical Center, 2500 MetroHealth Drive, H918, Cleveland,
OH 44109-1998.
Copyright 2002, Elsevier Science (USA). All rights reserved.
1524-153X/02/0404-0107$35.00/0
doi:10.1053/otgn.2002.35346
288 Operative Techniques in General Surgery, Vol 4, No 4 (December), 2002: pp 288-295
operatively. Glucocorticoid replacement is continued
postoperatively until the suppressed adrenal gland re-
gains function. A mechanical bowel preparation is neces-
sary when there is suspicion of tumor invasion of the
colon.
Preoperative preparation in patients with a pheochro-
mocytoma consists of treatment of hypertension as well
as expansion of intravascular volume. Multiple agents are
often required for control of blood pressure. A selective
alpha-1 adrenergic receptor antagonist is usually a part of
the therapeutic regimen and is started one to three weeks
before operation. Terazosin, doxazosin, and prazosin are
the most frequently used agents. These agents, in our
practice, have replaced the use of phenoxybenzamine.
Calcium channel blockers and angiotensin-converting
enzyme inhibitors are also used to control blood pressure
in patients with a pheochromocytoma. A beta-receptor
antagonist is used for treatment of persistent tachycardia
or arrhythmias. It should not be started until adequate
alpha blockade has been achieved to prevent precipitation
of hypertensive crisis from unopposed alpha receptor
stimulation.
Intravascular volume depletion in patients with a pheo-
chromocytoma occurs as a result of persistent vasocon-
striction. Preoperative volume expansion is necessary to
help avoid profound hypotension after adrenalectomy.
During operation for removal of a pheochromocytoma,
the patient should have an arterial line for continuous
blood pressure monitoring and a central venous catheter
for monitoring of volume status. Nitroglycerin and/or
sodium nitroprusside are used for control of intraopera-
tive hypertension, and esmolol, a short-acting beta
blocker, is used for treatment of intraoperative tachyar-
rhythmias.
Over 50% of adrenocortical carcinomas are functioning
tumors, producing one or more hormones. Functioning
adrenocortical carcinomas most commonly cause hyper-
cortisolism but may also cause virilization, feminization,
and/or hyperaldosteronism. Metapyrone, mitotane, or ke-
toconazole may be used preoperatively to help control the
adverse effects of hypercortisolism. Oral potassium chlo-
ride is used to correct the hypokalemia commonly seen in
patients with hyperaldosteronism. Spironolactone may
be used to control hypertension in patients with hyperal-
dosteronism and will also facilitate correction of hypoka-
lemia.
Adrenocortical carcinomas are locally invasive tumors
Open Anterior Left Adrenalectomy 289

Fig 1. Anatomy of the adrenal glands.

that require an en bloc resection for cure. This may in- ‘Y’ or ‘witch hat’ (Fig 2). It is slightly larger and thicker
clude removal of a kidney. As a result, if an adrenocortical and it extends further inferiorly along the medial surface
carcinoma is determined to be resectable, preoperative of the kidney than the right adrenal gland. The left adre-
assessment of renal function should be completed. Excre- nal gland is posterior to the stomach and the tail of the
tion of contrast material from the contralateral kidney is
also assessed on computed tomography. In patients with
tumor invasion of the kidney and abnormal contralateral
renal function, an ipsilateral partial nephrectomy should
be considered as a surgical option.
In patients undergoing an open left adrenalectomy, a
urinary catheter is used to monitor urine output, and an
orogastric tube is used to temporarily decompress the
stomach. The orogastric tube can be removed at the com-
pletion of the operation.

SURGICAL ANATOMY OF THE LEFT

ADRENAL GLAND
On average, an adrenal gland is 5 cm in length, 3 cm in
width, 6 mm in thickness, and 5 g in weight. The left
adrenal gland is located high in the retroperitoneum on
the superior medial surface of the left kidney surrounded
by perirenal fat and Gerota’s fascia. The adrenal gland is
distinguished from perirenal fat by its darker yellow
color, granular surface, and firm consistency.4 The sur-
rounding perirenal fat can make it difficult to find the left
adrenal gland especially in obese patients with small tu-
mors. Fig 2. Computed tomographic image of the left adrenal gland
The left adrenal gland is crescent shaped (Fig 1) and on (arrow) and its relationship to the surrounding viscera. (C ⫽
computed tomographic imaging, appears like an inverted celiac artery, P ⫽ tail of the pancreas, S ⫽ spleen, K ⫽ kidney).
290
pancreas, medial to the medial border of the spleen and
attached to the diaphragm in close proximity to the left
diaphragmatic crus. The left adrenal gland may be infe-
rior, superior, or directly behind the pancreas. Unlike the
right adrenal gland, the superior portion of the left adre-
nal gland is covered anteriorly by the peritoneum of the
lesser sac separating it from the cardioesophageal junc-
tion of the stomach. The left adrenal gland lies within 7
mm of the abdominal aorta just lateral to the origin of the
celiac trunk (Fig 2).
The adrenal glands are highly vascular receiving abun-
dant arterial branches from three main sources: the infe-
rior phrenic artery, the aorta and the renal artery. The
inferior phrenic artery is superior and medial to the adre-
nal gland and gives off multiple branches to the upper
part of the adrenal gland known as the superior adrenal
arteries. The middle adrenal arteries are branches that
come directly off the aorta. The inferior adrenal arteries
are branches from the renal artery. There are numerous
tiny arterial branches supplying the adrenal gland, rather
than three large, well-defined arteries as is often depicted
in anatomy books.
In contrast to the numerous arterial branches supply-
ing the adrenal gland, the venous drainage is by a single
adrenal vein. The left adrenal vein exists from the hilum
of the adrenal gland anteriorly, at its inferomedial aspect,
and extends inferiorly emptying into the left renal vein. It
may empty into the inferior phrenic vein before it enters
the left renal vein. The left adrenal vein is long in com-
parison to the right adrenal vein measuring up to 3 cm in
length.
OPEN ANTERIOR TRANSPERITONEAL
EXPOSURE OF THE LEFT
ADRENAL GLAND
The open anterior transperitoneal removal of the left ad-
renal gland is performed under general anesthesia with
Fig 3. Left subcostal, upper vertical midline, and left thoracoabdominal incisions.
McHenry and Wolfe
the patient in the supine position. The patient’s arms are
tucked to facilitate use of the Bookwalter self retaining
retractor. The abdomen is entered either through a left
subcostal or an upper vertical midline incision (Fig 3). A
vertical midline incision may be preferable in patients
with a narrow costal angle or when infraumbilical expo-
sure is necessary, such as in patients with a paragangli-
oma involving the paraortic ganglia or the organ of Zuck-
erkandl. In patients with a very large adrenal tumor or
when invasive adrenocortical carcinoma is suspected, the
chest is prepped anticipating the potential need for im-
proved exposure provided by a thoracoabdominal inci-
sion (Fig 3).
The operation begins with a complete exploration of
the abdomen including a thorough examination of the
liver for metastases. The left adrenal gland is then prefer-
entially exposed by entering the lesser sac through the
gastrocolic ligament (Fig 4) or by releasing the omentum
off of the transverse colon. Some of the short gastric
vessels are divided and suture ligated to facilitate the
exposure of the body and tail of the pancreas. Adhesions
from the posterior wall of the stomach to the pancreas are
divided sharply and the anterior surface of the pancreas is
exposed. The peritoneum along the inferior border of the
pancreas is then incised (Fig 5). The pancreas is retracted
superiorly, the kidney is retracted inferiorly and Gerota’s
fascia is opened superiorly to expose the left adrenal gland
(Fig 6). The advantage of exposing the left adrenal gland
through the lesser sac is that the spleen does not have to
be manipulated and is less likely to be injured. Occasion-
ally, the left adrenal gland may be located above the su-
perior edge of the pancreas, and it can be exposed by
dividing the gastrohepatic omentum while the stomach is
retracted downward. In patients with very large tumors,
the left adrenal gland may be preferentially exposed by
formal medial visceral rotation. The lienorenal, lieno-
colic, and lienophrenic ligaments are divided. The stom-
Open Anterior Left Adrenalectomy
Fig 4. Division of the gastrocolic ligament allowing for entry into the lesser sac. The gastrocolic ligament can be divided between
hemostats.
ach, the tail of the pancreas, and the spleen with the
splenic artery and vein are reflected medially, and if nec-
essary, the splenic flexure of the colon is also mobilized
medially (Fig 7).
During exposure of the left adrenal gland, involvement
of adjacent organs is assessed, particularly the kidney, the
tail of the pancreas and the diaphragm, and an evaluation
for retroperitoneal lymphadenopathy is performed. The
need for extension of the incision into the left chest to
provide for wider exposure is also determined. When
necessary, a thoracic extension of the incision is made
across the costal margin into the eighth intercostal space
(Fig 3) and the diaphragm is divided. The thoracoab-
dominal approach provides the best exposure of the ad-
renal gland and its surrounding structures in the renal
fossa, facilitating an en bloc resection of the adrenal gland
and the contiguous structures involved by tumor. Ex-
treme care should be exercised to avoid rupture of the
capsule of the adrenal tumor that can lead to the develop-
ment of local recurrence.5
Once the left adrenal gland is exposed, mobilization is
completed by picking up on the adjacent periadrenal fat
rather than the adrenal gland itself (Fig 8). This helps
avoid troublesome bleeding from the highly vascular ad-
renal gland. The left adrenal vein is longer and easier to
control than the right adrenal vein. The left adrenal vein is
anterior in location and passes medially and inferiorly to
291
drain into the left renal vein. If it is easy to identify, the left
adrenal vein should be ligated first. It can be ligated with
suture or hemoclips (Fig 9). Although early control and
ligation of the adrenal vein is performed for patients with
pheochromocytoma to reduce the release of cat-
echolamines into the systemic circulation during manip-
ulation of the tumor, it is not always easy to accomplish.
When it is not easily achieved, it is appropriate to com-
pletely mobilize the adrenal gland and leave the ligation
of the adrenal vein until the end. Initial superior and
lateral mobilization is often preferable in patients with
very large adrenal masses, facilitating ligation of the left
adrenal vein later in the dissection.
Numerous tiny arterial branches typically enter the su-
perior, medial and inferior aspects of the adrenal gland.
These are sequentially ligated with hemoclips and divided
as they are encountered. It is preferential to begin with
superior mobilization of the left adrenal gland to facilitate
downward retraction of the gland from beneath the pan-
creas. The plane between the posterior aspect of the ad-
renal gland and the kidney and diaphragm is then devel-
oped. This is normally avascular and can be easily mobilized
with a combination of blunt and sharp dissection.
POSTOPERATIVE CARE
The postoperative course for patients who have under-
gone an open, anterior adrenalectomy is similar to that for
292 McHenry and Wolfe

Fig 5. The peritoneum of the inferior

border of the pancreas is divided using
a right angle clamp and the electro-
cautery.

Fig 6. Exposure of the left

adrenal gland by superior
retraction of the pancreas
and inferior retraction of
the kidney.
Open Anterior Left Adrenalectomy 293

Fig 7. Exposure of the left adrenal

gland by medial visceral rotation, reflect-
ing the stomach and spleen medially.

Fig 8. The adrenal gland is excised by handling the peri-adrenal fat to avoid bleeding from the adrenal gland.
294
an open cholecystectomy. Oral fluids are begun on the
day of surgery. Patients are maintained on lactated ringers
with 5% dextrose intravenously until a clear liquid diet is
tolerated. An intravenous narcotic analgesic is used until
patients are able to switch to an oral agent. Patients are
encouraged to ambulate early; most on the evening of
surgery and certainly all by the next morning. The urinary
catheter is also removed that morning. Prophylaxis
against thromboembolism is continued until the patient
is fully ambulatory. Decisions regarding the need for hor-
monal support and adjustments in antihypertensive med-
ications are made. Most patients are discharged in 48 to
72 hours after surgery.
COMPLICATIONS OF ADRENALECTOMY
Patients with hypercortisolism secondary to an adrenal
tumor will have suppressed adrenocorticotropin (ACTH)
and corticotropin-releasing factor (CRF) levels, and the
responsiveness of the normal remaining adrenal gland
will be suppressed. As a result, the hypothalamic-pitu-
itary-adrenal axis is unable to respond to the stress of the
operation, and acute adrenal insufficiency may occur
postoperatively, which is manifested by hypotension, hy-
ponatremia, hyperkalemia, nausea, vomiting, and confu-
sion. As a result, stress doses of steroids are administered
perioperatively followed by maintenance doses of ste-
roids postoperatively until the hypothalamic-pituitary-
adrenal axis recovers.
McHenry and Wolfe
Fig 9. Ligation of the left adrenal vein.
Patients with pheochromocytoma are at risk for devel-
oping profound hypotension following adrenalectomy
secondary to generalized vasodilatation and unrecog-
nized volume depletion. Volume loading preoperatively
and intraoperatively, before ligation of the adrenal vein, is
important to prevent this complication. A continuous
dopamine infusion may also be used for treatment of
hypotension after the tumor is excised.
Respiratory problems, such as atelectasis or pneumo-
nia, are the most frequent complications occurring in
approximately 6% of patients following open anterior ad-
renalectomy.6 Wound infection has been reported in 3%
of patients. Visceral injury may also occur during a left
adrenalectomy. Injury to the spleen, often requiring sple-
nectomy, occurs in approximately 1.5%, but has been
reported in up to 19% of patients undergoing a left adre-
nalectomy.7 Splenic injury is more likely to occur when a
medial visceral rotation is used to expose the left adrenal
gland. For patients who undergo splenectomy, a pneumo-
coccal vaccine is given postoperatively. Injury to the tail
of the pancreas with pancreatic fistula formation and/or
postoperative pancreatitis may also occur as a result of
mobilization, retraction, or partial resection of the pan-
creas. As a result of the proximity of the left adrenal gland
to the renal vessels, renovascular injury with hyperten-
sion as a sequela may also rarely occur. Other potential
morbidity includes: postoperative bleeding, ileus second-
ary to manipulation of the small intestine, adhesive small
Open Anterior Left Adrenalectomy
bowel obstruction, deep vein thrombosis, and pulmonary
embolism. Patients with hypercortisolism have a higher
incidence of wound infection related to the adverse effects
of increased cortisol on immune function. They also have
a higher incidence of deep vein thrombosis and pulmo-
nary embolism.8
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tions in Cushing’s syndrome. Clin Endocrinol 19:503-511, 1983
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3. Graham DJ, McHenry CR: The adrenal incidentaloma, guidelines
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4. Avisse C, Marcus C, Patey M, et al: Surgical anatomy and embry-
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