Lesions in the Upper Abdomen and Retroperitoneum

Adrenal primaries often involve regional lymph nodes in the ipsilateral para-aortic or pericaval chains as well as interaortocaval lymph nodes. Indeed, the primary tumor bulk may actually be con fluent, enlarged nodal metastases rather than extension from the primary tumor. As a consequence of this retroperitoneal origin with lymphatic infiltration, the great vessels may be partially or completely encased but not invaded by tumor. Adequate vascular control and retroperitoneal exposure is best obtained using an ipsilateral thoraco-abdominal incision except for very small lesions with minimal regional nodal involvement. A midline extension may be necessary for lesions extending into the lower abdomen. On the left side the spleen and tail of the pancreas are rotated medially to expose the supra-celiac aorta. The celiac axis is the first major vessel identified followed by the superior mesenteric artery about 1 cm below. The left lateral surface of the aorta is cleared to the origin of the left renal artery which can then be followed toward the renal hilus. When a vessel is encased, division of tumor tissue over a clamp is necessary. Vascular injury is possible when the aorta and visceral vessels are cleared. Small side vessels can be controlled with finger pressure and the placement of fine monofilament sutures that approximate the ad-ventitia or superficial media. If the aortic wall is weakened or there is a larger injury, the aorta should be clamped or compressed both proximally and distally. Supra-celiac aortic clamping is usually well tolerated for short periods of time and the aortic pressure must be reduced before sutures are placed or the vessel may tear. Monofilament sutures with reinforcing Dacron pledgets should be used and larger tears may require a patch angioplasty. These maneuvers are rarely required but may be lifesaving.

A right-sided thoraco-abdominal exposure is focused on control of the supra-and infra-renal vena cava. The cava is identified just below the liver and dissection proceeds along its right lateral wall. It is usually best to identify the right renal vein and then move superiorly. The Trendelenburg position may reduce the pressure in the vena cava as well as the chance of air embolism.

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