title: Optimizing the technique of right laparoscopic adrenalectomy with a modified trocar arrangement and dynamic liver retraction: a comparative study with standard technique.
abstract: OBJECTIVE
  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.
  
  
  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 ± 33.6 min; 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Urology, Laparoscopy Research Center, Stem Cell and Transgenic Technology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. aminsharifi_ar@yahoo.com
authors.forename: Alireza
authors.initials: A
authors.lastname: Aminsharifi
authors.forename: Reza
authors.initials: R
authors.lastname: Mohammadian
authors.forename: Reza
authors.initials: R
authors.lastname: Niroomand
authors.forename: Firoozeh
authors.initials: F
authors.lastname: Afsar
mesh_terms: D000293:Adolescent; D000315:Adrenalectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D000328:Adult; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D008099:Liver / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013525:Surgical Instruments; D016896:Treatment Outcome