Optimizing the technique of right laparoscopic adrenalectomy with amodified trocar arrangement and dynamic liver retraction: Acomparative study with standard technique

Objectives: Right Laparoscopic adrenalectomy (LA) is technically more challenging than left LA, because of the anatomical position of the right adrenal gland and vein. We modified the technique for right LA to optimize the procedure, and compared the operative outcome with standard technique. Patients and methods: The operative outcome of 13 cases of right adrenal mass treated with modified LA were compared retrospectively with 29 cases of standard right LA. For modified right LA, we used a 4-port transperitoneal laparoscopic approach that omitted the subxiphoid trocar (classically used for liver retraction), and instead, an assistant applied continuous, dynamic upward liver retraction in a plane perpendicular to the inferior vena cava (IVC). Results: Modified Right LA was done in 13 patients (3 men, 23.1%), without difficulty and with excellent direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. Mean operative time was significantly shorter compared with standard technique (122.3±20.1 vs. 165±33.6min; P<0.0001) There were no bleeding complication and open conversion in modified technique which was promising compared with 2 bleeding complications in our experience with 29 cases of right LA using standard technique. Conclusion: Modified right LA with a 4-port approach and dynamic upward liver retraction in a plane perpendicular to IVC resulted in direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. This approach can be effective in challenging cases when the infrahepatic fossa is poorly exposed.