Anterosuperior to kidney, asymmetrical,
yellowish, and have their own compartment of renal / Gerota's
- but are independent structures, with a
differing relationship to the kidneys.
Pyramidal, on diaphragm posteriorly, encroaches onto front of R kidney laterally, overlapped medially by IVC medially, anteriorly it contacts the bare-area above and covered by peritoneum of hepatorenal pouch below (crossed by triangular ligament)
Crescentric; lower than R; lies on L crus posteriorly, drapes over medial kidney above hilum; covered by peritoneum of lesser sac anteriorly forming part of stomach bed, lower part contacts body of pancreas, splenic vessels.
3 arterial sources:
superior from inferior phrenic, middle from aorta, inferior from renal artery.
not vry large; can be cauterized or coagulated
- R -> IVC; is very short <1cm; runs to posteromedial IVC; occasionally longer whereby enters lower by renal vein
- L -> enters L renal v. superior aspect
Large, need to be clipped and controlled; often last maneuver
Lymph: to para-aortic nodes
Nerve (325): medulla: preganglionic supply from SNS T5-11; acts as a ganglion. Cortical control hormonal.
Structure: outer yellow cortex, inner grey medulla (20% noradrenaline, 80% adrenaline)
Development: medulla is neural crest (ectodermal); cortex mesodermal.
1. Bilateral adrenalectomy used to be done from the front "open
anterior approach" midline laparotomy
exposure: mobilize hepatic flexure, kocherize duodenum and
mobilize IVC; then incise peritoneum over upper pole of
kidney / above IVC
mobilize splenic flexure; open gastrocolic omentum, stomach and
spleen retracted, open peritoneum above lower border of
pancreas; dissect adrenal vein between aorta and kidney
ligated before arteries, beware tearing the IVC. (prevents
surges of hormone release)
recognizable as yellow colour; abundant adipose cf Gerotas
fat. Avoid bleeding which stains the tissues.
2. Anterolateral approach for lap
Supine with L side propped 45o off horizontal
or in complete L lateral.
Peritoneal white line divided, taking retroperitoneally
Suspensory ligament of spleen divided + some of splenorenal ligament --> spleen falls medially
Find: pancreas below, kidney laterally, adrenal medial
3. Posterior approach.