Experience in Identifying the Venous Drainage of the Adrenal Gland During Laparoscopic Adrenalectomy

Department of Surgery, Western Infirmary, Glasgow, Scotland, UK.
Clinical Anatomy (Impact Factor: 1.33). 10/2008; 21(7):660-5. DOI: 10.1002/ca.20706
Source: PubMed


Laparoscopic adrenalectomy (LA) is the procedure of choice for most adrenal tumors. An important part of LA is the early identification and ligation of the adrenal veins. The venous drainage from each adrenal gland is usually via a single vein: the right vein draining into the inferior vena cava (IVC) and the left vein into the left renal vein. Although infrequent, variable venous drainage has been documented. The aim of the study was to clarify if LA identified venous drainage and its variants. Between January 1999 and January 2008, 142 consecutive patients underwent LA. Adrenal vein anatomy was documented on a prospective database. In total, 142 patients underwent 162 LA (right = 62, left = 66, bilateral = 17). All adrenal veins were identified at the time of laparoscopy. For 157 LA, the adrenal venous drainage was constant: right vein drained into the IVC and left vein drained into left renal vein. Five patients had adrenal vein variants: two right veins draining separately into IVC (n = 1), two right veins draining into the IVC and right renal vein (n = 1), and two left veins draining separately into the left renal vein (n = 3). Adrenal vein variants were present in patients with phaeochromocytomas (n = 4) or adrenocortical carcinoma (n = 1). The laparoscopic approach allowed an excellent view of the main adrenal venous anatomy. This has helped confirm the constant nature of the venous drainage and successfully identify variant adrenal veins.

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    • "There were two right adrenal veins in one subject (Fig. 4b), and three in another (Fig. 4c); both variations were observed by Scholten et al. (2013) in their laparoscopic study of 546 patients. In a study of 142 laparoscopic adrenalectomy patients, Parnaby et al. (2008) discovered two patients with two right adrenal veins. In the first, both adrenal veins directly drained into the IVC (Fig. 4c). "
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    ABSTRACT: The adrenal veins may present with a multitude of anatomical variants, which surgeons must be aware of when performing adrenalectomies. The adrenal veins originate during the formation of the prerenal inferior vena cava (IVC) and are remnants of the caudal portion of the subcardinal veins, cranial to the subcardinal sinus in the embryo. The many communications between the posterior cardinal, supracardinal, and subcardinal veins of the primordial venous system provide an explanation for the variable anatomy. Most commonly, one central vein drains each adrenal gland. The long left adrenal vein joins the inferior phrenic vein and drains into the left renal vein, while the short right adrenal vein drains immediately into the IVC. Multiple variations exist bilaterally and may pose the risk of surgical complications. Due to the potential for collaterals and accessory adrenal vessels, great caution must be taken during an adrenalectomy. Adrenal venous sampling, the gold standard in diagnosing primary hyperaldosteronism, also requires the clinician to have a thorough knowledge of the adrenal vein anatomy to avoid iatrogenic injury. The adrenal vein acts as an important conduit in portosystemic shunts, thus the nature of the anatomy and hypercoagulable states pose the risk of thrombosis. Clin. Anat., 2014. © 2014 Wiley Periodicals, Inc.
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    ABSTRACT: The aim of this paper is to review the current state of laparoscopic and robotic surgery in the mannagement of benign and malignant disease of the adrenal gland. Adrenal lesions can be adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal cysts, hematomas, adrenal cortical carcinomas, metastases from other cancers, or other rare causes. Laparoscopic adrenalectomy (LA) has become the new standard of care for benign adrenal neoplasms and is being increasingly utilized for malignant disease. Robotic assistance offers unique advantages in visualizing and dissecting the adrenal gland, especially considering its challenging vasculature. Series of robotic adrenalectomy (RA) and LA show that techniques are both safe and effective compared to open. There is also growing evidence in using minimally invasive approaches in adrenal sparing-surgery. Success in these procedures depends on a firm understanding of adrenal anatomy and in careful patient selection. Both LA and RA are offer advantages to patients and are comparable in outcomes. RA offers the potential for increased visualization and faster learning curve which may allow for both faster, and more precise dissection, as well as increased utilization of minimally invasive techniques. While LA remains the standard of care, RA is an excellent option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.
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