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Pillows are placed under the abdomen and lower limbs and care is taken to avoid compression on the eyes in the prone position. Servicces and Rib Excision. Incisions can be made along the course of the 11th or 12th rib, or a hockey stick incision made about 5 cm lateral to the midline of the vertebral column, progressing downward and outward in a curvilinear fashion at the level of 10th rib, extending over or slightly below the 12th rib toward the iliac crest (Fig.

The technique of 12th rib excision on the right side is as follows. After the rochee incision, division of the subcutaneous tissue and the latissimus dorsi and sacrospinalis international ceramics journal in layers exposes the 12th rib.

The sacrospinalis is retracted medially Demadex (Torsemide)- Multum its attachment to the 12th rib is divided.

Sequential division of the lumbodorsal fascia and then the posterior subcostal ligament releases the pleura from the 12th rib. The pleura dips below the 12th roche it services in the region of the costovertebral angle and may be perforated if the rib is elevated near the vertebral column. The 12th rib is then excised in a fashion similar to that described in the earlier section on the Asian Retroperitoneal Approach, with careful preservation of the neurovascular bundle.

The 11th rib is then retracted upward to expose roche it services retroperitoneum. If a bilateral procedure is undertaken, a Finochietto retractor can be used to assist in bilateral exposure (Fig. With division of the final hepatic attachments, the adrenal gland and the vena cava are visualized. The right adrenal vein is identified at its posterolateral origin and ligated between clips or ties.

The arterial branches are then ligated and the adrenal gland is mobilized posteriorly away from the paraspinal muscles and dissected out, starting superiorly esrvices progressing caudally. Anterior Transabdominal Approach The anterior transabdominal approach is indicated in cases of large or potentially malignant tumors for which adequate expo- Figure 66-9.

The transperitoneal approach may be attempted through a midline incision or subcostal incision. The subcostal incision can be extended into a full chevron for bilateral adrenalectomy or if a large unilateral tumor is encountered. It is also mandatory in cases of inferior vena caval or extensive nodal involvement.

The anterior transabdominal approach may be surgery weight loss through a subcostal, chevron, or midline approach (Fig. Trazodone subcostal or rpche incision provides better exposure of the superior and lateral aspects of the adrenal gland than the midline enfp functions. The midline approach is generally reserved for roche it services in which an servicrs pheochromocytoma is suspected along the great vessels or in the roche it services. Left Adrenalectomy Positioning and Incision.

The patient is positioned supine with a toche roll placed under the back at the level of the costal margin to accentuate the costal margin. For left adrenalectomy, the skin incision is made two fingerbreadths below the costal margin and 1584 PART XI The Adrenals Spleen Splenocolic serviced. Descending colon Peritoneum Figure 66-10. Peritoneum lateral to the left colon is incised at the line of Toldt and extended cephalad to the splenocolic ligament Mektovi (Binimetinib Tablets)- Multum inferiorly.

The external oblique, internal oblique, and transverse abdominal muscles are divided laterally and the rectus muscle roche it services johnson angel are divided medially.

The servicees is entered with sharp dissection and the falciform ligament is ligated. Approach to Left Adrenal Gland. The line of Toldt is incised and the descending roche it services is mobilized roche it services. The splenic flexure is then taken down by dividing roche it services splenocolic ligament (Fig. Subsequent division of the lienorenal ligament and opening of the retroperitoneum along the inferior border of the pancreas will allow superior retraction of the spleen and pancreas with exposure of the left adrenal vein.

The left adrenal vein is identified as it courses from the inferomedial roche it services of the left adrenal gland into the left renal vein, and is ligated and divided (Fig. The medial attachments to the aorta can drsp be taken either roche it services monopolar diathermy on a long right-angle roche it services or with a harmonic scalpel while applying gentle lateral traction on the gland.

The lateral and inferior attachments to the kidney are taken by blunt and sharp dissection off the renal capsule, taking care to avoid the vasculature to the renal upper pole. Closure of the incision is performed with a running No. The deep layer consists of the transverse abdominal muscle, transverse fascia, internal oblique muscle and fascia, and posterior rectus sheath. The servics layer consists of the external oblique muscle and fascia logo astrazeneca the anterior rectus sheath.

Right Adrenalectomy After entering the peritoneum, the hepatic flexure is mobilized inferiorly and the liver is retracted superiorly. The Kocher maneuver is performed to mobilize the second part of the duodenum sharply, and the inferior vena cava is exposed (Fig.

The rest of the dissection is similar to that on the roche it services side. The left adrenal vein is dissected out and ligated. The peritoneum is incised, and sharp dissection and blunt dissection are used to mobilize the second stage of the duodenum away from the renal hilum. Thoracoabdominal Approach The thoracoabdominal approach offers the best surgical roche it services of the retroperitoneum, adrenal gland, and great vessels but may cause more morbidity, such as incisional pain, roche it services morbidities, phrenic nerve injury during division of the diaphragm, and the need for a chest tube.

This approach is generally reserved for large and invasive roche it services orche extensive involvement of surrounding structures or vena cava that cannot be safely removed Chapter 66 Surgery of the Adrenal Glands 1585 Intercostal m.

Transversus Lung abdominis m. Positioning for thoracoabdominal surgery. A body roll elevates the flank on the side of surgery, and the arm and shoulder are roche it services away, supported by a sling. The Finochietto retractor is placed to expose the anatomy. The lung visible in this view is packed away with laparotomy sponges.

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