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The external oblique, internal oblique, and transverse abdominal muscles are divided laterally and the rectus muscle and sheath are Deflazacort Oral Suspension (Emflaza)- FDA medially. The peritoneum is entered with sharp dissection and the falciform ligament is ligated. Approach to Left Adrenal Gland.

The line of Toldt is incised and the descending colon is mobilized medially. The splenic flexure Deflazacort Oral Suspension (Emflaza)- FDA then taken down by dividing the splenocolic ligament (Fig. Subsequent division of the lienorenal ligament and opening of the retroperitoneum along the inferior border of the pancreas will allow superior retraction of the spleen and pancreas with exposure of the left adrenal vein.

The left adrenal vein is identified as it courses from the inferomedial border of the left adrenal gland into the left renal vein, and is ligated and divided (Fig. The Deflazacort Oral Suspension (Emflaza)- FDA attachments to the aorta can now be taken either with monopolar diathermy on a long right-angle instrument or with a harmonic scalpel while applying gentle lateral traction on the gland.

The lateral and inferior attachments to the kidney are taken by blunt and sharp dissection off the renal capsule, taking care to avoid the vasculature to the renal upper pole.

Closure of the incision is performed with a running No. The deep layer consists of the transverse Deflazacort Oral Suspension (Emflaza)- FDA muscle, transverse fascia, internal oblique muscle and fascia, and posterior rectus sheath. The superficial layer consists of the external oblique muscle and fascia and the anterior rectus sheath. Right Adrenalectomy After entering the peritoneum, the hepatic flexure is mobilized inferiorly and the liver is retracted superiorly.

The Kocher maneuver is performed to mobilize the second part of the duodenum sharply, and the inferior vena cava is exposed (Fig. The rest of the dissection is similar to that on the left Deflazacort Oral Suspension (Emflaza)- FDA. The left adrenal vein is dissected out and ligated. The peritoneum is incised, and sharp dissection and blunt dissection are Deflazacort Oral Suspension (Emflaza)- FDA to mobilize the second stage of the duodenum away from the renal hilum.

Thoracoabdominal Approach The thoracoabdominal approach offers the best surgical exposure of the retroperitoneum, adrenal gland, and great vessels but may cause more morbidity, such as incisional pain, pulmonary morbidities, phrenic nerve injury during division of the diaphragm, Deflazacort Oral Suspension (Emflaza)- FDA the need for a chest tube. This approach is generally reserved for large and invasive tumors with extensive involvement of surrounding structures or vena cava that cannot be safely removed Chapter 66 Surgery страница the Adrenal Glands 1585 Intercostal m.

Transversus Lung abdominis m. Positioning for thoracoabdominal surgery. A body roll Deflazacort Oral Suspension (Emflaza)- FDA the flank on the side of surgery, and the arm Deflazacort Oral Suspension (Emflaza)- FDA shoulder are rotated away, supported by a sling. The Finochietto retractor is placed to expose the anatomy. The lung visible in this view is packed away with laparotomy sponges.

Cos tal m 8th rib 9th rib Rectus m. Incision at the eighth intercostal space. The costal margin, external intercostal muscle and fascia, and anterior rectus sheath are divided. The thoracoabdominal approach is particularly useful in right-sided tumors since the liver and inferior vena cava can limit exposure whereas, on the left side, the spleen and pancreas can generally be elevated to provide adequate exposure.

The patient is placed in a semioblique position at an angle of 45 degrees to the table with the operating side upward and the opposite side decubitus. A body roll or pillow is placed longitudinally along the hemithorax and flank to achieve and maintain this position. The ipsilateral arm is placed across the chest on a padded arm rest and the other arm is secured to an armboard (Fig.

Incision and Dissection of Adrenal Gland. The incision is made along the eighth or ninth intercostal space extending from the posterior Deflazacort Oral Suspension (Emflaza)- FDA line and curving over the costal margin into the abdomen (Fig. The latissimus dorsi, serratus anterior, and intercostal muscles are divided. The costal cartilage is then divided with cautery and the incision is carried through the anterior and posterior rectus sheaths and the t slim x2 insulin pump abdominis muscle.

The pleura is entered along the superior margin of the rib to avoid injury to the neurovascular bundle and the lung is packed away (Fig. The diaphragm is divided in a circumferential fashion along its periphery. The surgeon must not cut directly to the center of the diaphragm because the phrenic nerve can be damaged. Marking sutures can be placed on either side of the divided diaphragm to aid alignment during closure.

Once the diaphragm is divided, a Finochietto self-retaining retractor is placed. The rest Deflazacort Oral Suspension (Emflaza)- FDA the dissection is similar to the previously described techniques.

The relationship of the thoracoabdominal incision to the adrenal gland is illustrated in Figures 66-16 and 66-17. A chest tube is placed and the diaphragm is closed with either running suture or interrupted figure-of-eight stitches with nonabsorbable sutures. In order to take tension off the diaphragmatic closure, the ribs should be reapproximated with several Figure 66-16.

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Comments:

05.10.2020 in 05:02 lorcrekomp93:
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11.10.2020 in 22:05 Милана:
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