Should the adrenal vein or adrenal artery be ligated first during an adrenalectomy?

Adrenal Vessel Ligation During Adrenalectomy

The adrenal vein should be ligated first during adrenalectomy in most cases, as this is the critical step in the procedure that provides safe control of the main venous drainage before manipulation of the gland. This approach is particularly important for functional tumors like pheochromocytomas where controlling venous outflow helps prevent catecholamine release into circulation.

Anatomical Considerations

• The venous drainage of the adrenal gland is typically via a single main vein:

  • Right adrenal vein drains directly into the inferior vena cava
  • Left adrenal vein drains into the left renal vein 1
  • Variants exist but are uncommon (approximately 3% of cases) 1

• Arterial supply is less discrete and clinically significant:

  • Multiple small arterial branches supply each adrenal gland
  • Formal identification and ligation of adrenal arteries is rarely necessary (only 1.1% of cases in large series) 2

Evidence-Based Approach to Vessel Ligation

Standard Approach: Vein First

• Early identification and ligation of the adrenal vein is considered a critical step in laparoscopic adrenalectomy 3, 1
• This approach:
  • Minimizes risk of venous bleeding during dissection
  • Reduces tumor manipulation before controlling venous outflow
  • Allows for safer subsequent dissection of the gland

Special Considerations for Pheochromocytomas

1. Traditional approach: Early adrenal vein ligation to prevent catecholamine release into circulation

2. Alternative approach for difficult cases:

   • "Vein last" technique may be considered when patient anatomy or tumor size makes early vein dissection difficult
   • Studies show comparable hemodynamic parameters between "vein first" and "vein last" techniques 4

3. For giant right adrenal pheochromocytomas:

   • Two-step technique of early adrenal artery ligation may be beneficial
   • This involves ligating arterial supply before venous control to reduce catecholamine release 5

Practical Recommendations

1. For most adrenalectomies:

   • Identify and ligate the main adrenal vein first
   • Use secure ligation methods (clips, vessel-sealing devices, or extracorporeal knots) 3
   • Proceed with dissection of the gland after venous control

2. For pheochromocytomas:

   • Standard approach: Early vein ligation
   • For giant tumors (>10 cm): Consider early arterial control if technically feasible 5
   • For difficult anatomy: "Vein last" technique is a safe alternative 4

Common Pitfalls and Caveats

• Clip dislodgement: Has been reported as a cause of hemorrhage during endoscopic adrenalectomy 3
• Venous variants: Be vigilant for multiple adrenal veins, especially in patients with pheochromocytomas or adrenocortical carcinoma 1
• Arterial control: While formal arterial ligation is rarely necessary, be prepared to control small arterial branches during dissection using electrocautery or ultrasonic energy 2
• Preoperative preparation: Complete hormonal evaluation is mandatory before surgical intervention for functional tumors to prevent perioperative complications 6

The laparoscopic approach provides excellent visualization of adrenal vasculature, allowing for safe identification and control of the venous drainage in most cases 1.