الفهرس 
Anatomy of the AdrenalsOnly 14 pages are availabe for public view
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Abstract
Before the era of laparoscopic procedures, conventional open adrenalectomy was the only surgical approach to adrenal neoplasms. Since the introduction of laparoscopic adrenalectomy by Gagner et al. in 1992, the majority of benign adrenal lesions have been removed by various laparoscopic techniques. The decision to utilize open versus laparoscopic approach should be based on body habitus of the patient, the specific type and characteristics of the tumor and the experience of the surgeon.
The adrenal gland is the fourth most common site of metastasis, and adrenal metastases may be found in as many as 25% of patients with known primary lesions. Therefore, radiologists frequently face the task of determining whether an adrenal mass is benign or malignant. The question can directly affect the clinical management of the case. For instance, the workup for an otherwise resectable lung cancer may reveal the presence of an adrenal mass and suggest the possibility of metastatic disease.
Advantages of laparoscopic surgery include
• The risk of bleeding during surgery is reduced because the size of the incision made is so much smaller than the large incision that is made for open surgery. This reduces the likelihood of a blood transfusion being needed to compensate for blood loss.
• The smaller incision size also reduces the risk of pain and bleeding after surgery. When a large incision has been made, patients usually require long-term pain relief medication while the stitch-line heals. With laparoscopic surgery, the post-surgical wound is much smaller and the healing process much less painful.
• The smaller incision also leads to the formation of a significantly smaller scar after surgery. In cases where the surgical wound is larger, the scar tissue that forms is more likely to become infected as well as being more vulnerable to herniation, particularly in overweight and obese patients.
• Exposure of the internal organs to external contaminants is significantly reduced in laparoscopic surgery compared with open surgery, therefore reducing the risk of post-operative infection.
• The length of hospital stay required is significantly shorter with laparoscopic surgery, since healing is so much faster. Most patients receive a same-day or next-day discharge and can return to their normal everyday lives much more quickly than after an open surgery procedure.
The modalities of choice in the evaluation of an adrenal mass are computed tomography (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomography (PET) scanning. Ultrasonography has a role in the evaluation of a potential adrenal mass in infants, but no appearance is specific for benign adrenal adenoma.
On CT scans and MRIs, the appearance of intracytoplasmic lipid is different from that of macroscopic fat, as in the case of a myelolipoma.
How should the radiologist proceed in evaluating an incidental small adrenal mass? Two important questions must be answered.
• First, does the patient have a hormonal or biochemical abnormality that may be caused by an enlarged adrenal gland? If this is the case, the lesion should be surgically removed regardless of the imaging features.
• Second, does the patient have a known malignancy? In the absence of a known malignancy, the probability that a small, well-circumscribed adrenal mass is malignant is nearly zero. The characterization of an adrenal mass is critical in patients with a known malignancy, in whom the diagnosis of an adrenal metastasis precludes curative surgery.
• The authors of a prominent review article suggest that CT without intravenous contrast enhancement should be the initial study. If the adrenal mass is less than 10 Hounsfield units (HU), a diagnosis of adrenal adenoma can be made. If the adrenal mass is more than 10 HU, CT with intravenously administered contrast material should follow, and the washout should be calculated; benign lesions typically demonstrate more than 50% washout. In cases in which CT findings are equivocal, chemical shift MRI should be performed. When the findings of both modalities are inconclusive, biopsy is advised only when a known extra-adrenal malignancy is present.
Less blood loss. A robotic radical adrenalectomy results in significantly less blood loss during surgery, reducing the need for blood transfusions.
Less post-operative pain and scarring. The robotic procedure’s small incisions avoid the need for a large, disFig.uring scar, resulting in significantly less post-operative discomfort and minimal surface scarring.
Shorter hospital stay and faster recovery. Most patients undergoing robotic radical adrenalectomy leave the hospital in 1 to 3 days versus 3 to 5 days for open surgery, and are able to resume normal activities within 1 to 2 weeks, compared to 4 to 6 weeks for open surgery.
The greater precision and visualization offered by the da Vinci Si enhances the surgeon’s ability to perform certain parts of the procedure, including isolating the adrenal gland from surrounding structures and controlling the multiple arteries and veins supplying the adrenal gland and tumor.