We use an open book technique, which involves developing the cleft-like plane just medial to the adrenal gland and lateral to the aorta ( Fig. In patients with large or inferiorly positioned tumors, the splenic flexure of the colon must be mobilized caudally by dividing the splenocolic ligament. It is critical to achieve the correct plane of dissection precisely during this part of the procedure because the tail of the pancreas and splenic vessels are potentially vulnerable to injury.

Splenic mobilization is continued until the greater curvature of the stomach becomes visible at its apex, at which point the spleen and tail of the pancreas are allowed to fall anteriorly with rightward tilting of the table and gentle use of the fan retractor, if necessary. Care must be taken to avoid a capsular tear of the spleen, which may arise from undue tension on a congenital or acquired adhesive band. The lateral attachments of the spleen are taken down first, with the goal of rotating the left upper quadrant viscera anteromedially. For tissue dissection, we employ the hook monopolar cautery and an energy-based tissue sealing or dividing device. It is advisable to leave at least 5 cm (4 fingerbreadths) between each port to minimize external interference of the laparoscopic instruments. The ports are equally distributed along the costal margin, with the posterior port placed as far lateral-posterior as permitted by the position of the colon ( Fig. We generally use three radially dilating trocars, and a fourth may be added in cases in which the spleen and pancreatic tail require additional retraction. This can be performed with the Veress technique or using an optical trocar in most cases. Initial peritoneal access is achieved 2 cm inferior to the costal margin in the midclavicular line (Palmer point).

Townsend JR., MD, in Sabiston Textbook of Surgery, 2022 Left adrenal

The adrenal glands produce