Surgical anatomy of adrenal gland

1. Anatomy of Adrenal Gland
Dr.P.Viswakumar. M.S
Assistant professor,
Dept.of General surgery

2. Embryology
• The adrenal glands form from two separate
primordia: the neuroectodermal component
develops into the adrenal medulla.
• The mesodermal component becomes the
adrenal cortex.
• The cells of Future medulla travel along the
nerves of the 6th to 12th segments into the
developing cortical primordia.

5. • Within the cortical tissue, the migrating cells
proliferate and differentiate into chromaffin
cells at around the third month of gestation.
• The mesodermal component of the cortex is
visible as early as the fourth week.
• Differentiation of cortical zones begins in the
eighth week.
• These zones may be distinguished at birth
although they do not appear in the final adult
form until the fourth year of postnatal life

7. Accessory Adrenal Tissue

8. Surgical Anatomy
• The adult adrenal gland weighs 4 to 8 g and
measures 4 x 3 x 1 cm.
• It is larger in women than in men.
• The adrenal glands are composed of two
distinct parts, with differing functions and
embryonic origins.
• The volume of the larger portion, the cortex, is
8 to 20 times that of the medulla.

9. Surgical Anatomy
• The adrenal glands lie on the anteromedial
surface of the kidneys near the superior poles;
both the glands and the kidneys are
retroperitoneal.
• The two glands differ in shape.
• The left is more flattened and has more
extensive contact with the kidney.
• It is crescentic or semilunar in form, and may
extend on the medial surface of the kidney
almost to the hilum

10. Surgical Anatomy
• The right gland is more triangular or pyramidal
and lies higher on the kidney.
• Each adrenal gland, together with the associated
kidney, is enclosed in the renal fascia (of Gerota)
• It is surrounded by fat, although the adrenal gland
is separated from the kidney by a partition of
connective tissue.
• The perirenal fat is more yellow and of a firmer
consistency than fat elsewhere in the abdomen.

12. Surgical Anatomy
• The adrenal glands are firmly attached to the
fascia, which is in turn firmly attached to the
abdominal wall and to the diaphragm.
• The inferior phrenic arteries pass superior to the
adrenals to reach the diaphragm.
• The inferior phrenic arteries give off a series of
branches, 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

13. Surgical Anatomy-Relations
• Right adrenal :
Anterior
Superior: "bare area" of the liver.
Medial: inferior vena cava
Lateral: "bare area" of the right lobe
of the liver.
Inferior: peritoneum and first part of
the duodenum.

14. • Posterior surface:
Superior: Diaphragm.
Inferior : Anteromedial aspect of the
right kidney.

15. LEFT ADRENAL GLAND :
• Anterior surface :
Superior: peritoneum (posterior wall of the
omental bursa) and the stomach.
Inferior : Body of the pancreas
• Posterior surface:
Medial: left crus of the diaphragm
Lateral: medial aspect of the left kidney

18. Vascular Supply
Arterial Supply :
• The adrenal glands and the thyroid gland are the
viscera having the greatest blood supply per gram
of tissue.
• As many as 60 arterial twigs may enter the
adrenal gland.
• The arterial supply of the adrenal glands arises, in
most cases, from three sources 1)Superior
adrenal arteries 2)Middle adrenal artery 3)
Inferior Adrenal artery

20. • All these arteries branch freely before
entering the adrenal gland, so 50-60 arteries
penetrate the capsule over the entire surface.

21. Venous Drainage
• The adrenal venous drainage does not
accompany the arterial supply, and is much
simpler.
• A single vein drains the adrenal gland,
emerging at the hilum.
• The left vein passes downward over the
anterior surface of the gland. This vein is
joined by the left inferior phrenic vein before
entering the left renal vein.

22. Venous Drainage
• The right vein is typically very short; it may be 0.5
cm long, or even less.
• The right adrenal vein passes obliquely to open
into the posterior side of the inferior vena cava.
• The right adrenal vein does not usually have any
tributaries other than from the adrenal gland.
• The right adrenal vein may drain into the right
hepatic vein, close to the junction of the hepatic
vein with the inferior vena cava.

24. Lymphatic Drainage
• The lymphatics of the adrenal gland are usually said
to consist of a profuse subcapsular plexus that
drains with the arteries and a medullary plexus that
drains with the adrenal veins.
• Drainage is to renal hilar nodes, lateral aortic
nodes, and to nodes of the posterior mediastinum
above the diaphragm by way of the diaphragmatic
orifices for the splanchnic nerves.
• The majority of capsular lymphatic vessels pass
directly to the thoracic duct without the
intervention of lymph nodes.

25. Innervation
• The adrenal cortex appears to have only
vasomotor innervation.
• Most of the fibers reaching the gland from the
splanchnic nerves, the lumbar sympathetic
chain, the celiac ganglion, and the celiac plexus
enter the medulla.
• These fibers are preganglionic and end on the
medullary chromaffin cells.

26. Histology
Adrenal Cortex :
• The vascularity of the adrenal cortex is among
the greatest in the entire body.
• 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.

27. • In the zona fasciculata, larger cells are arranged
in columns which are oriented radially.
• 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.

28. 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, or pheochromocytes.
• Distributed throughout the medulla, but few
in number, are postganglionic sympathetic
neurons.
• Most medullary cells secrete epinephrine, but
some secrete norepinephrine instead.

33. Adrenelectomy
Indications for Adrenelectomy :
Unilateral
1) Aldosteronoma
2) Cortisol secreting Adenoma (Cushing syndrome)
3) Unilateral pheochromocytoma
4) Virilizing or feminizing tumours
5) Non functioning unilateral tumors
(Size >4-5 cm)
6) Adrenalcortical carcinomas
7) Solitary unilateral metastasis.

34. Adrenelectomy
Bilateral
1)Bilateral pheochromocytoma.
2) Cushing syndrome due to B/L nodular adrenal
hyperplasia.
3) Cushing’s disease (pituitary tumour)
unsuccessfully treated by surgery or radiation.

35. Anterior Approach for Left
Adrenalectomy

36. Exposure and Mobilization of Left
Adrenal Gland

38. Anterior Approach for Right
Adrenalectomy
• On the right, the anterior approach to the
adrenal gland begins with the mobilization of
the hepatic flexure of the colon.
• Mobilization of the colon will expose the
duodenum. The second portion of the
duodenum is freed by incision of its lateral
avascular peritoneal reflection.
• It can now be separated from retroperitoneal
structures and reflected forward and to the
left (Kocher maneuver).

40. Posterior Approach for
Adrenalectomy

41. Thoracoabdominal Approach for
Adrenalectomy

42. Laparoscopic Adrenelectomy

43. THANK YOU