Adrenals (314) (333 in 3rd)

Anterosuperior to kidney, asymmetrical, yellowish, and have their own compartment of renal / Gerota's fascia.

- but are independent structures, with a differing relationship to the kidneys.

-           Right gland
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)

-           Left gland
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.

Blood (314):
3 arterial sources:
superior from inferior phrenic, middle from aorta, inferior from renal artery.
not vry large; can be cauterized or coagulated

single veins;
- 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.

Surgical anatomy:

1. Bilateral adrenalectomy used to be done from the front "open anterior approach" midline laparotomy

-           R exposure: mobilize hepatic flexure, kocherize duodenum and mobilize IVC; then  incise peritoneum over upper pole of kidney / above IVC

-           L: mobilize splenic flexure; open gastrocolic omentum, stomach and spleen retracted, open peritoneum above lower border of pancreas; dissect adrenal vein between aorta and kidney

Vein ligated before arteries, beware tearing the IVC. (prevents surges of hormone release)

Adrenal gland 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.

 Uncommon now, but was useful.
 Through bed of 11th rib for R and 12th rib for L
Incise flank muscles, lat dorsi (retract?) serratus posterior
Then incise diaphragm if necessary
Seek and preserve rib neurovascular bundle during this access.
Orient to adrenal from superior pole of kidney.