Adrenal Gland Surgical Anatomy-Relations

Embryology Right adrenal:

adrenal medulla neuroectodermal Anterior
adrenal cortex mesodermal Superior: "bare area" of the liver.
Medial: inferior vena cava
The cells of Future medulla travel along the nerves of the
Lateral: "bare area" of the right lobe of the liver.
6th to 12th segments into the developing cortical
Inferior: peritoneum and 1st part of duodenum
primordia.
Posterior surface:
Within the cortical tissue, the migrating cells proliferate
Superior: Diaphragm.
and differentiate into chromaffin cells at around the third
Inferior : Anteromedial aspect of the right kidney
month of gestation.
The mesodermal component of the cortex is visible as
Left adrenal:
early as the fourth week.
Anterior surface :
Differentiation of cortical zones begins in the eighth
Superior: peritoneum (posterior wall of the
week.
omental bursa) and the stomach.
These zones may be distinguished at birth although they
Inferior : Body of the pancreas
do not appear in the final adult form until the fourth year
Posterior surface:
of postnatal life
Medial: left crus of the diaphragm
Lateral: medial aspect of the left kidney
Surgical Anatomy
The adult adrenal gland weighs 4 to 8 g and measures 4 x
Vascular Supply
3 x 1 cm.
Arterial Supply :
It is larger in women than in men.
The adrenal glands and the thyroid gland are the viscera
The adrenal glands are composed of two distinct parts,
having the greatest blood supply per gram of tissue.
with differing functions and embryonic origins.
As many as 60 arterial twigs may enter the adrenal
The volume of the larger portion, the cortex, is 8 to 20
gland.
times that of the medulla.
The arterial supply of the adrenal glands arises, in most
The adrenal glands lie on the anteromedial surface of the
cases, from three sources 1)Superior adrenal arteries
kidneys near the superior poles; both the glands and the
2)Middle adrenal artery 3) Inferior Adrenal artery
kidneys are retroperitoneal.
All these arteries branch freely before entering the
The two glands differ in shape.
adrenal gland, so 50-60 arteries penetrate the capsule
The left is more flattened and has more extensive contact
over the entire surface.
with the kidney.
It is crescentic or semilunar in form, and may extend on
Venous Drainage
the medial surface of the kidney almost to the hilum
The adrenal venous drainage does not accompany the
The right gland is more triangular or pyramidal and lies
arterial supply, and is much simpler.
higher on the kidney.
A single vein drains the adrenal gland, emerging at the
Each adrenal gland, together with the associated kidney,
hilum.
is enclosed in the renal fascia (of Gerota)
The left vein passes downward over the anterior surface
It is surrounded by fat, although the adrenal gland is
of the gland. This vein is joined by the left inferior phrenic
separated from the kidney by a partition of connective
vein before entering the left renal vein.
tissue.
The right vein is typically very short; it may be 0.5 cm
The perirenal fat is more yellow and of a firmer
long, or even less.
consistency than fat elsewhere in the abdomen.
The right adrenal vein passes obliquely to open into the
The adrenal glands are firmly attached to the fascia,
posterior side of the inferior vena cava.
which is in turn firmly attached to the abdominal wall and
The right adrenal vein does not usually have any
to the diaphragm.
tributaries other than from the adrenal gland.
The inferior phrenic arteries pass superior to the adrenals
The right adrenal vein may drain into the right hepatic
to reach the diaphragm.
vein, close to the junction of the hepatic vein with the
The inferior phrenic arteries give off a series of branches,
inferior vena cava.
the superior adrenal arteries, like teeth of a comb.
A layer of loose connective tissue separates the capsule
of the adrenal gland from that of the kidney
Lymphatic Drainage Adrenelectomy
The lymphatics of the adrenal gland are usually said to Indications for Adrenelectomy :
consist of a profuse subcapsular plexus that drains with Unilateral
the arteries and a medullary plexus that drains with the 1) Aldosteronoma
adrenal veins. 2) Cortisol secreting Adenoma (Cushing syndrome)
Drainage is to renal hilar nodes, lateral aortic nodes, and 3) Unilateral pheochromocytoma
to nodes of the posterior mediastinum above the 4) Virilizing or feminizing tumours
diaphragm by way of the diaphragmatic orifices for the 5) Non functioning unilateral tumors (Size >4-5 cm)
splanchnic nerves. 6) Adrenalcortical carcinomas
The majority of capsular lymphatic vessels pass directly to 7) Solitary unilateral metastasis.
the thoracic duct without the intervention of lymph
nodes. Bilateral
1)Bilateral pheochromocytoma.
Innervation 2) Cushing syndrome due to B/L nodular adrenal hyperplasia.
The adrenal cortex appears to have only vasomotor 3) Cushings disease (pituitary tumour) unsuccessfully treated
innervation. by surgery or radiation.
Most of the fibers reaching the gland from the splanchnic
nerves, the lumbar sympathetic chain, the celiac Anterior Approach for Right Adrenalectomy
ganglion, and the celiac plexus enter the medulla. On the right, the anterior approach to the adrenal gland
These fibers are preganglionic and end on the medullary begins with the mobilization of the hepatic flexure of the
chromaffin cells. colon.
Mobilization of the colon will expose the duodenum. The
Histology second portion of the duodenum is freed by incision of its
Adrenal Cortex : lateral avascular peritoneal reflection.
The vascularity of the adrenal cortex is among the It can now be separated from retroperitoneal structures
greatest in the entire body. and reflected forward and to the left (Kocher maneuver).
The adrenal cortex is composed of three zones: the zona
glomerulosa, the zona fasciculata, and the zona
reticularis.
In all three zones, all cells produce steroids.
In the zona glomerulosa (the outermost layer), small cells
are arranged in roughly spherical groups. This zone
secretes the mineralocorticoid aldosterone.
In the zona fasciculata, larger cells are arranged in
columns which are oriented radially. Posterior Approach
The carbohydrate-active steroid, cortisol, and the adrenal
sex steroids are produced here. Vitamin C is abundant in
these cells.
In the third layer, the zona reticularis, small cells are
arranged in strands forming an irregular network.
These cells secrete cortisol, androgens, and estrogens.
Cholesterol is present as a precursor to the genesis of the
steroids.
Thoracoabdominal Approach
Adrenal Medulla
The cells in the adrenal medulla are large and pale. They
secrete epinephrine and have a chromaffin reaction.
These cells are called chromaffin cells, pheochromocytes.
Distributed throughout the medulla, but few in number,
are postganglionic sympathetic neurons.
Most medullary cells secrete epinephrine, but some
secrete norepinephrine instead.