腹腔镜手术时肾上腺血管解剖变异与处理

目的：探讨腹腔镜肾上腺手术时肾上腺血管的解剖变异与处理方法。方法：对经腹腔前入路作腹腔镜肾上腺或腺瘤切除术中,游离肾上腺发现7例肾上腺血管解剖变异并予妥善处理。结果：右侧肾上腺血管解剖变异为：中央静脉与右下肝静脉汇合后汇入下腔静脉;中央静脉汇入右肾静脉与下腔静脉的交汇处;多支中央静脉。左侧肾上腺血管解剖变异为：中央静脉与膈下静脉分别汇入左肾静脉;中央静脉与左副肾静脉汇合为主干后汇入左肾静脉。均予仔细分离血管、钛夹夹闭后切断,无一例发生意外。结论：了解并能在术中辨别肾上腺的血管解剖变异,有助于安全地进行腹腔镜肾上腺手术。     

Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity, and cost-effectiveness

Background: Laparoscopic adrenalectomy has rapidly gained widespread acceptance for treatment of benign adrenal neoplasms. A number of authors have compared various anatomic approaches to laparoscopic adrenalectomy, comparing length of inpatient stay, transfusion requirements, and perioperative complications. Separate studies have found inpatient stay reduced 40–60% with the use of laparoscopic adrenalectomy vs. an open procedure. Methods: There have been no studies designed specifically to examine and compare perioperative morbidity, length of stay, and patient charges in patients undergoing laparoscopic adrenalectomy. This report examines the Johns Hopkins Hospital experience with laparoscopic adrenalectomy in 22 patients, comparing length of stay, perioperative morbidity, and patient charges. These data are compared with those seen in 17 patients undergoing open adrenalectomy within our institution and 70 patients at all other nonfederal hospitals in the state of Maryland. Results: Outcomes after laparoscopic versus open adrenalectomy were compared. Resumption of diet (1.6 vs. 6.1 days), independent activity (1.6 vs. 7.9 days), inpatient length of stay (1.7 vs. 7.8 days), and total hospital patient charges ($8,698 vs. $12,610) were all significantly reduced in patients undergoing laparoscopic adrenalectomy at our institution. Similar findings were obtained when our data were compared against adrenalectomy performed at other hospitals within the state of Maryland. Length of stay (1.7 vs. 8.9 days) and total hospital patient charges ($8,698 vs. $13,867) were both significantly reduced compared to state-wide data in patients treated with laparoscopic adrenalectomy. Conclusions: Although a technically challenging procedure, laparoscopic adrenalectomy provides clear advantages over open procedures for the vast majority of adrenal neoplasms. Our data support the conclusion that laparoscopic adrenalectomy should be considered for all patients with benign adrenal neoplasms. Received: 12 January 1998/Accepted: 30 March 1998     

Thoracoscopic transdiaphragmatic left adrenalectomy

The endoscopic approach to adrenal glands has been limited to laparoscopic and retroperitoneal access due to the relative inaccessibility of the retroperitoneal space in the former case and to the limited working space in the latter. We undertook this study to investigate the possibility of performing a left adrenalectomy through a thoracoscopic transdiaphragmatic approach in a swine model. Five pigs were anesthetized, intubated, and ventilated. Four laparoscopic trocars were inserted and a left pneumothorax was accomplished by CO₂ insufflation. A peripheral posterior phrenotomy was made starting from the aortic hiatus and extended laterally for about 6 cm. The resulting pneumoretroperitoneum facilitated the subsequent identification of anatomic structures, allowing an easy exposure of the left adrenal gland. The gland was progressively dissected downward, interrupting the tributary vessels with endoscopic clips, and it was finally extracted through one of the trocar ports. Adrenalectomy was accomplished in all the animals without intraoperative mortality. Complications included splenic injury with prolonged bleeding and difficulty in performing the diaphragmatic suture (one case each). Through this approach direct and rapid exposure of the left adrenal gland was allowed, and adrenalectomy was accomplished in all the animals. These results suggest further investigations of the clinical application of this procedure. Received: 6 November 1995/Accepted: 28 May 1996     

Laparoscopic partial adrenalectomy

Background: Most laparoscopic adrenalectomies involve total removal of the whole adrenal gland, and reports of laparoscopic partial adrenalectomies have been very few. The criteria for performing a laparoscopic partial adrenalectomy have not been described. Methods: (a) Patients with functioning adrenal tumors smaller than 3 cm in diameter were selected. (b) The solitary adrenal tumors were evaluated by preoperative thin-slice computed tomography (CT) scan. (c) Solitary lesions were reconfirmed with intraoperative ultrasonography. (d) Partial adrenalectomy was performed with at least a 5-mm margin using a vascular stapler. Results: Laparoscopic partial adrenalectomy was performed in five patients using the vascular stapler. Hemostasis was perfect in all five patients. The tumor was located in the inferior part of the right adrenal gland in three cases and in the upper pole of the left adrenal gland in two cases. The postoperation pathologic diagnosis was adrenocortical adenoma in all five patients, and excessive hormonal levels or symptoms all disappeared. Conclusions: Laparoscopic partial adrenalectomy can be performed safely using a vascular stapler. Received: 26 May 1998/Accepted: 30 June 1998     

The use of intraoperative ultrasound in laparoscopic adrenal surgery

Background: Laparoscopic adrenalectomy has been shown to be a safe and effective therapy for benign adrenal lesions. We review our experience with this procedure, including the use of laparoscopic ultrasound. Methods: We retrospectively reviewed our experience with 36 patients who underwent resection of 42 adrenal glands. Data gathered included preoperative evaluation and diagnosis, operative time, blood loss, complications, and follow-up status. Laparoscopic ultrasound was used to guide dissection and characterize a variety of adrenal lesions. Results: Thirty-five of 36 patients underwent successful laparoscopic adrenalectomy. There was one conversion to the open procedure in a patient with bilateral adrenal metastases from an endometrial cancer. For the bilateral laparoscopic procedure, the operative time averaged 262 mins, blood loss was 160 cc, and hospital stay was 3.0 days. For unilateral cases, operative time averaged 193 min, blood loss was 108 cc, and hospitalization was 1.1 days. Six patients experienced perioperative complications, most of which were minor and transient. Laparoscopic ultrasound was useful to define anatomy and to identify the adrenal vein, especially on the left side. Conclusions: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal disease. Laparoscopic ultrasound is useful to localize and aid in the dissection of the left adrenal vein. Received: 24 December 1998/Accepted: 12 February 1999     

Safety of adrenal vein ligation during endoscopic adrenalectomy

Endoscopic adrenalectomy has been recommended for the treatment of several benign adrenal diseases. The safety of this procedure largely depends on a careful surgical dissection and appropriate hemostatic technique. An established slipknotting technique was employed to control the main adrenal vein in a consecutive series of 14 patients undergoing endoscopic adrenalectomy. The operative steps to ligate the adrenal pedicle are described. A Medline search also was conducted to identify all reported bleeding episodes associated with this procedure. All attempted ligatures of the main adrenal vein were completed successfully by the described technique, and none of our patients required perioperative blood transfusion. Twenty-eight episodes of bleeding collected from the literature were analyzed. Hemorrhagic accidents related to dislodgement of clips were documented at least in three patients. The cause of bleeding was unspecified in 10 patients. Extracorporeal ligation of the main adrenal vein is feasible, safe, and advisable to prevent the occurrence of hemorrhage during endoscopic adrenalectomy. Received: 16 February 1998/Accepted: 28 May 1998     

Is Preservation of the Adrenal Vein Mandatory in Laparoscopic Adrenal-Sparing Surgery?

BACKGROUND AND OBJECTIVE: Adrenal tissue-sparing or partial adrenalectomy evolved initially for patients with bilateral synchronous adrenal surgical pathology to preserve vital adrenal volume. In the laparoscopic era, the exact criteria for performing such procedures laparoscopically have yet to be defined. Controversy exists regarding the importance of preserving the adrenal vein, main or accessory. The aim of this retrospective study was to present our short series of laparoscopic tissue-sparing adrenalectomies with vein preservation. Our main goal is not to support partial adrenalectomy as an alternative to total (this is already advocated by many surgeons) but to emphasize the vein-preserving technique. METHODS: Seven patients with peripherally located either aldosterone-producing adenomas (4 cases) or myelolipomas (4 cases) underwent laparoscopic lateral partial adrenalectomy. One patient harbored an aldosterone-producing adenoma and a myelolipoma as well. The main adrenal vein was identified and preserved in 6 patients and the accessory vein in one. RESULTS: No conversion to open adrenalectomy was necessary, and no perioperative morbidity or mortality occurred. Three adenoma patients are normotensive 44, 23, and 20 months postoperatively, while the fourth one's pressure is refractory. CONCLUSIONS: Surprisingly, total adrenalectomies preceded the partial ones, which is controversial compared with other procedures. Laparoscopic lateral partial adrenalectomy is a technically challenging tissue-sparing operation. Meticulous dissection allows preservation of the middle artery and main or accessory vein resulting in a functioning adrenal stump.     

Laparoscopic bilateral adrenalectomy following failed hypophysectomy

Background: Laparoscopic adrenalectomy has recently been shown to be a safe and effective means of treating adrenal pathology with much lower morbidity than the traditional approach. The majority of reports in the literature involve removal of adrenal tumors. Although open bilateral adrenalectomy has been utilized for persistent Cushing's syndrome following attempted hypophysectomy, there is little data available describing the application of laparoscopic adrenal surgery to this problem. Methods: Four patients with persistent Cushing's syndrome after attempted treatment with hypophysectomy underwent laparoscopic bilateral adrenalectomy at our institution. One procedure was done transabdominally in the supine position. Three procedures were done transabdominally using sequential lateral decubitus positions. Results: All procedures were completed laparoscopically. The mean operative time was 4.6 h (range 3.9–5.25). Repositioning and reprepping the patients resulted in a slight increase in operative time, but visualization was improved using the lateral decubitus position. Average blood loss: 156 cc (range 50–300). One patient required early reoperation for bleeding from the left adrenal bed, which was controlled laparoscopically. Three patients were eating the following day and were discharged on postoperative days 1, 2, and 5. The fourth patient remained hospitalized for 18 days due to problems unrelated to surgery. After a mean follow-up of 10 months, all patients have done well and have no clinical or biochemical evidence of recurrent disease. Conclusion: Our clinical experience indicates that laparoscopic bilateral adrenalectomy is a viable treatment option for Cushing's syndrome following failed hypophysectomy. Received: 29 March 1996/Accepted: 12 June 1996     

Laparoscopic cholecystectomy, Calot's triangle, and variations in cystic arterial supply

Background: The extrahepatic biliary tree with the exact anatomic features of the arterial supply observed by laparoscopic means has not been described heretofore. Iatrogenic injuries of the extrahepatic biliary tree and neighboring blood vessels are not rare. Accidents involving vessels or the common bile duct during laparoscopic cholecystectomy, with or without choledocotomy, can be avoided by careful dissection of Calot's triangle and the hepatoduodenal ligament. Methods: We performed 244 laparoscopic cholecystectomies over a 2-year period between January 1, 1995 and January 1, 1997. Results: In 187 of 244 consecutive cases (76.6%), we found a typical arterial supply anteromedial to the cystic duct, near the sentinel cystic lymph node. In the other cases, there was an atypical arterial supply, and 27 of these cases (11.1%) had no cystic artery in Calot's triangle. A typical blood supply and accessory arteries were observed in 18 cases (7.4%). Conclusion: Young surgeons who are not yet familiar with the handling of an anatomically abnormal cystic blood supply need to be more aware of the precise anatomy of the extrahepatic biliary tree. Received: 1 November 1998/Accepted: 22 March 1999     

下腔静脉在后腹腔镜右侧肾上腺切除术中作为解剖标志的应用探讨

目的基于对右侧肾上腺血管的手术经验总结,探讨后腹腔镜右侧肾上腺切除术中以下腔静脉为解剖标志准确分离出肾上腺动静脉层面的临床可行性及意义。 方法回顾性分析2020年1月至2021年9月,临沂市人民医院收治的36例右侧肾上腺腺瘤患者,均行后腹腔途径手术,手术由同一名手术医师(高年资主治医师,肾上腺总手术量大于300例)完成,以下腔静脉为解剖标志寻找并处理肾上腺动静脉并切除或部分切除右侧肾上腺。 结果本组36例手术均顺利完成。平均手术时间32 min,平均术中出血量20 ml,平均下床活动时间为术后16 h,平均术后住院时间2.4 d。 结论后腹腔镜下右侧肾上腺手术过程中以下腔静脉为解剖标志进行肾上腺血管的解剖分离,可将肾上腺动静脉的前后层次关系安全显露,有利于准确控制中央静脉、更好地显露手术视野和减少术中出血。     

Minimally invasive adrenalectomy and malignant adrenal tumours

Summary   Background: Minimally invasive adrenalectomy is the standard procedure for the treatment of small benign adrenal neoplasms. The question of whether this technique is also suitable for treating adrenal malignancies has recently been discussed with controversy. Methods: A literature search was performed to gather published experience and opinions concerning the role of endoscopic adrenalectomy in the treatment of primary adrenal malignancies and adrenal metastases. Results: Adrenocortical carcinomas (ACCs) have been approached laparoscopically, and this technique has even been advocated for large tumours. Several small ACCs have been successfully removed laparoscopically. Oncological catastrophes with peritoneal carcinomatosis have been reported. Reoperation after laparoscopic adrenalectomy for unsuspected ACC was usually not performed. There are no data demonstrating a survival benefit of systematic lymphadenectomy. Adrenal metastases are firm and rarely penetrate the capsule of the adrenal gland. Several reports on endoscopic adrenalectomy for metastases have been published. Conclusions: Laparoscopic adrenalectomy for ACC should be considered with great reluctance. If ACC is diagnosed postoperatively upon histological examination after laparoscopic adrenalectomy for a presumably benign tumour, reoperation is not mandatory provided oncological principles were respected during the primary operation. Adrenal metastases confined to the adrenal gland can be removed laparoscopically.      

Does hormonal function of the tumor influence the outcome of laparoscopic adrenalectomy?

Background: Patients with hypertension, with catecholamine hypersecretion, and with cortisol excess may associate intraoperative cardiovascular instability and postoperative complications. Methods: To compare the outcome of laparoscopic adrenalectomy (LpA) in patients with aldosterone adenoma (11), Cushing's adenoma (six), Cushing's disease (four), pheochromocytoma (Pheo) (11), and nonfunctioning tumor (five). Intra- and postoperative parameters were studied and in patients with Pheo intraoperative catecholamine plasma levels were correlated with cardiovascular derangements. Results: Operative time, estimated blood loss, hospital stay, analgesic requirements, and time to return to normal activity were significantly higher in patients undergoing total bilateral adrenalectomy for Cushing's syndrome compared with other groups undergoing unilateral adrenalectomy, but these latter groups showed no significant differences among themselves in all parameters analyzed. One patient with nonfunctioning tumor and another with Cushing's adenoma were converted to open surgery, and two patients with Cushing's disease had urinary infection. Isolation of Pheo was associated with significant release of catecholamines but not with hemodynamic changes. Conclusion: LpA may be the most suitable method for removing functioning adrenal tumors. Received: 20 March 1996/Accepted: 28 May 1996     

Portal venous flow during CO2 pneumoperitoneum in the rat

Backround: CO₂ gas insufflation is routinely used to extend the abdominal wall. The resulting pneumoperitoneum has a number of local and systemic effects on the organism. Portal blood flow, which plays an important role in hepatic function and cell-conveyed immune response, is one of the affected parameters. Methods: An established animal model (rat) of laparoscopic surgery was modified by implanting a perivascular flow probe. Hemodynamics in the portal vein were then measured during increasing intraabdominal pressure generated by carbon dioxide insufflation. Results: Using this technique, an adequate flowmetry of the portal vein was achieved in all animals. The creation of a CO₂ pneumoperitoneum with increasing intraabdominal pressure led to a linear decrease in portal venous flow. Conclusions: Elevated intraabdominal pressure caused by carbon dioxide insufflation may compromise hepatic function and cell-conveyed immune response during laparoscopic surgery. Received: 28 January 1998/Accepted: 22 June 1998     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

腹腔镜胆囊切除术中右副肝管及右肝管损伤的预防及处理

目的 总结腹腔镜胆囊切除术中防治右副肝管及右肝管损伤的经验. 方法回顾性分析21例腹腔镜胆囊切除术右副肝管或左右肝管低位汇合、胆囊管汇入右肝管病例资料.结果 通过术中解剖肝门及胆道造影相结合的方法,21例病例中发现右副肝管18例(I-V型),左右肝管低位汇合、胆囊管汇入右肝管3例(Ⅵ型).其中,18例具有右副肝管病例中,术中发现11例,保留副肝管未做处理3例;夹闭7例,术后皆无胆漏;术中缝合1例,术后出现胆漏,保守治疗成功.损伤右副肝管7例,2例术中夹闭损伤肝管;2例中转开腹端端吻合损伤肝管;3例术后出现胆漏,二次腹腔镜探查证实右副肝管夹闭损伤.3例左右肝管低位汇合、胆囊管汇入右肝管病例,其中术中发现2例;损伤1例,中转开腹行右肝管端端吻合.21例随访2年,皆无腹痛、黄疸、肝功能不良.结论 为防止在腹腔镜胆囊切除术中损伤右肝管及右副肝管,应熟悉胆管变异的各种类型、正确解剖胆囊三角、合理应用术中胆道造影、困难病例术后放置腹腔引流管及术后剖视胆囊等多种方法相结合.不同类型的胆道损伤处理上应分别对待.     

Laparoscopic right and left adrenalectomies

Background: Laparoscopic approach for adrenalectomy was recently described and the operative technique is not yet well defined. Methods: Twenty-seven laparoscopic adrenalectomies were performed between 1992 and 1995. There were 18 women and nine men ranging in age from 31 to 70 years (mean, 50.8 years). The surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one. Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, nonfunctional adenoma in four patients, Cushing adenoma in two, and an adrenal cyst in one. Median adrenal gland size was 2.0 cm (range 0.5–8 cm). Results: Five patients were converted to laparotomy (18%)—for dissection problems in four and for an unrecognized gland in one. The median anesthesia time was 200 min and the median surgical time was 140 min. Operative morbidity was one adrenal vein injury sectioned close to the vena cava. The hemorrhage was controlled by laparoscopic suturing without conversion. This patient required a three-unit blood transfusion. No mortality occurred and postoperative morbidity was one minor chest infection. The median postoperative in-hospital stay was 4.6 days (range 2–8) for nonconverted patients. Conclusions: Laparoscopic adrenal gland removal is safe and offers fast recovery and short in-hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.     

Outflow reconstruction in right hepatic live donor liver transplantation

BACKGROUND: Inconstant venous anatomy increases the risk of outflow complications in right hepatic live donor liver transplantation (RH-LDT), but no consensus has emerged guiding optimal reconstruction for venous outflow. METHODS: We retrospectively analyzed surgical venous reconstruction using a flexible approach to anterior accessory veins in 48 RH-LDTs performed between April, 1998 and July, 2002. RESULTS: Actuarial recipient graft and patient survival was 79% and 85%, respectively. Single hepatic venous anastomosis was performed in 74% of the patients. Twelve patients underwent reconstruction of 20 accessory veins, including 7 posterior segment veins and 13 anterior segment veins. Anterior vein reconstruction techniques included end-to-end anastomosis to the middle hepatic vein, interposition conduit, venoplasty, or a combination of techniques. Documented complications related to the venous anastomosis occurred in only 1 patient (2%), with no patient having a documented venous thrombosis of either the main RHV or a reconstructed accessory vein. There were no differences in outcome based on single versus multiple venous reconstruction. Anteromedial congestion was noted in 3 patients in the absence of anatomic venous anastomotic complication, but the clinical significance of this finding is unclear. CONCLUSIONS: Despite variations in segmental venous drainage and a propensity for anteromedial congestion in right hepatic grafts, RH-LDT can be performed without outflow obstruction with close attention to a wide RHV anastomosis. In addition, anterior accessory vein reconstruction can be reserved for grafts of marginal size or quality where early postoperative venous congestion may impair early graft function. Routine extended hepatectomy incorporating the MHV with the graft is unnecessary.     

The laparoscopic management of post-transplant lymphocele

Background: The management of lymphocele in patients following kidney (KT) and kidney pancreas (KPT) transplants is evolving. Open surgery has been the traditional treatment, but some authors have advocated laparoscopic drainage in selected patients. Methods: We retrospectively reviewed our results in lymphocele treatment since developing a laparoscopic program at our institution. Results: Between May 1994 and June 1995, 186 KTs and 48 KPTs were performed, and 1,354 patients are currently being followed. Eight patients developed symptomatic lymphoceles an average of 26 months (range 4–59) following 6 KTs and 2 KPTs. All patients diagnosed were successfully drained laparoscopically, with no conversions to open surgery. Laparoscopic ultrasound was used to help with localization of the fluid collection. Operative time averaged 59 min, median hospital stay was 1 day (range 1–4), and there were no perioperative complications. Follow-up imaging was obtained on six patients, 3–16 months following their procedures, and no recurrences were noted. A review of the literature demonstrates a 5.3% rate of major complications and a 7% incidence of lymphocele recurrence. Conclusions: Intraoperative laparoscopic ultrasound can help localize fluid collections and prevent organ injuries. Laparoscopic drainage of lymphocele following transplantation results in minimal disability and an acceptable complication rate, although it is higher than with open drainage. Therefore, laparoscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphocele. Received: 15 March 1996/Accepted: 3 July 1996     

Retrohepatic veins of the posterior section of the right hepatic lobe--terminology and surgical significance

Three main hepatic veins: right, middle and left are constant, but there is a variable number of retrohepatic vessels called accessory or minor hepatic veins. The most important of them are veins reffered to as middle right hepatic vein (MRHV) draining segment VII and inferior right hepatic vein (IRHV) draining segment VI. The incidence of large MRHV and IRHV reaching or exceeding a caliber of 5mm, their arrangement in the liver and drainage territories were investigated in our collection of 142 injection-corrosion specimens of the liver. In 1/5 of the cases with large IRHV this vein drains small part of segment VI, sometimes its insignificant marginal part so it couldn't be used for segment VI preservation when it is necessary. A precise knowledge of the vein anatomy of right posterior sector of the liver and its vein drainage territories is very important during complex dissections of the retrohepatic areas, resections and preservation liver parenchima.     

腹腔镜肾上腺解剖学与手术入路研究

目的:借助腹腔镜进行肾上腺解剖学研究并建立合理的手术入路。方法:1999年10月至2009年3月我院共行腹膜后腹腔镜肾上腺手术45例;左侧27例,右侧18例。术前拍摄CT和/或MRI,术中摄取录相,术中、术后反复观察肾上腺的解剖部位、层面、周围筋膜、与肾筋膜腔关系等,并设计合理的手术入路。结果:肾前融合筋膜、腰肌筋膜、侧锥筋膜围成肾周间隙。肾周间隙又可再分为肾上腺间隙和肾筋膜间隙两部分。肾筋膜间隙由肾筋膜前后叶环形包绕而成,容纳肾脏、肾周脂肪和肾盂输尿管鞘。肾上腺间隙的前侧边是肾前融合筋膜,外侧边是肾筋膜,内侧边是膈肌脚。肾上腺间隙内包含肾上腺和肾上腺周围脂肪。结论:肾上腺位于肾筋膜腔外,术中沿肾脂肪囊外平面可迅速到达肾上腺。