A number of studies have made this comparison and demonstrated that removal of the adrenal by laparoscopy is well tolerated, is associated with little postoperative pain, and typically results in a remarkably quick return to normal function. Through the subcostal incision employed by most surgeons, excellent exposure can be gained to the adrenal and its adjacent organs. The pancreas, spleen, stomach, colon, kidney, and major visceral vascular structures can often be involved within a malignant left adrenal mass, all of which can be accessed through this approach. Similarly, the vena cava, duodenum, colon, and kidney can be encroached upon by a right adrenal cancer necessitating adequate anterior exposure. This approach also provides the exposure needed to assess resectability in those patients with extremely large tumors or in those in which preoperative imaging studies suggest the involvement of contiguous structures.
Adequate exposure is equally necessary for large or malignant lesions of the right adrenal.
Upward retraction of the liver following complete mobilization of the right lobe is essential. Larger lesions may require reflection of the duodenum and downward mobilization of the hepatic flexure of the colon. These techniques are designed to allow sufficient exposure of the adrenal arteries and the short right adrenal vein. Care should be exercised with the right adrenal vein and the surgeon should expect a number of large veins emptying directly into the vena cava from large malignant lesions. A mechanical retractor greatly simplifies the effort needed to gain exposure on the right or left, and of course, wide exposure is the primary reason the transabdominal approach is selected.