A cadaveric anatomical study of the adrenals: Relationship with the posterior abdominal wall muscles revisited

AIM OF THE STUDY

The main difficulties during retroperitoneal laparoscopic adrenalectomies are due to its location. Our objective was to define the relationship of the adrenals with the diaphragm and the psoas muscle.

METHODS

Our work is an anatomical dissection of 80 fresh cadavers' adrenals. To study the right adrenal, we performed a right nephrectomy and adrenal remained attached to the Inferior vena cava by its main vein. On the left, the edges of the adrenal have been identified by needles and the adrenal was reclined to study its projection on the posterior muscular wall.

RESULTS

The right adrenal is located higher, 13mm [4-20mm] above the medial arcuate ligament (MAL) in 16 cases (40%). Its lower border was at the same level as the MAL in 18 cases (45%) and 11mm [10-17mm] below the MAL in 6 cases (15%). The posterior support of the right adrenal was the right crus of the diaphragm (Right-CD) in 34 cases (85%) and straddling the Right-CD and the psoas in 6 cases (15%). The study of the relationships of the left adrenal with the MAL showed that the lower edge of the gland was at its same level in 16 cases (40%) and below in 24 cases (60%) by 14mm [8-24mm]. The posterior support of the left adrenal was the left crus of the diaphragm (Left-CD) in 16 cases (40%) and straddling the Left-CD and the psoas in 24 cases (60%).

CONCLUSIONS

Our results showed that the right adrenal is higher. The MAL is an important posterior element to the adrenal gland that could serve as an anatomical landmark to identify the adrenal during laparoscopic adrenalectomy.

Retro-peritoneal paraganglioma, diagnosis and management

INTRODUCTION

Paragangliomas, defined as extra-adrenal chromaffin-cells tumors, are rarely located in the retro-peritoneum. Clinical presentation is similar to pheochromocytoma, and mainly depends on the producing character of the tumor. Positive diagnosis requires plasmatic and urinary hormonal assays. Radiological and isotopic explorations are essential before surgery. The only curative therapeutic strategy is surgical, associated to peri-operative prevention and monitoring of the frequently reported hemodynamic and cardiovascular disorders. Outcome depends of the metastatic character of the tumor, the presence of tumor remnant after surgical resection. Genetic study is recommended; the risk of recurrence and association to other neoplasm is more described in genetic forms.

MATERIAL AND METHODS

Authors report 5cases of retro-peritoneal paraganglioma, operated in the department of urology of Hospital, between 2013 and 2017. Observations are about 2men and 3women. Clinical presentation is not always specific and paraganglioma may be discovered fortuitously. Two patients have been operated by coelioscopic approach, midline incision was performed in two other cases, and dorsal lumbotomy associated to a Rutherford-Morrison incision in a patient.

RESULTS

Two patients presented resistant hypertension and palpitation associated to suspect retro-peritoneal masses in imagery and elevated urinary methoxylated derivates before surgery. One patient was asymptomatic and the tumor was discovered in imagery. Per-operative hypertensive crisis and sinus tachycardia occurred in a case. The average follow-up period is 22.8months. Hypertension and palpitation disappeared after surgery. There was no recurrence for all the operated patients.

CONCLUSION

Retro-peritoneal paraganglioma is a rare condition. Symptoms are not specific and clinical presentation may be similar to pheochromocytoma. Abdominal CT-scan and MRI, in association with MIBG scintigraphy are strongly evocative. Histological examination ensures diagnosis. Per-operative cardio-vascular disorders are to consider and must prevented and managed by anesthesiologists. Complete surgical resection is the only curative treatment and avoids recurrences.