Adrenal surgery, for the majority of benign disease indications, is performed laparoscopically. Haemostasis is primarily achieved through clip application for the adrenal veins and clips or cauterisation for the adrenal arteries. For partial adrenalectomy, haemosta-sis can be achieved by bipolar coagulation and, finally, sealing with fibrin glue.32 Laparoscopic partial adrenalectomy, involving the use of a vascular stapler has been described. It also achieved perfect haemostasis.33 In cases where significant intraperitoneal scarring is anticipated from prior abdominal surgeries, adrenalectomy may be performed by a trans-thoracic trans-diaphragmatic approach. This avoids both bleeding complication and bowel injury from the division of multiple adhesions.
The safety of endoscopic adrenalectomy depends on careful dissection and appropriate haemostasis. There have been several reports of haemorrhage due to dislodgment of clips, following adrenalec-tomy. When only short length of vessel is a limitation on the number of clips that can be applied safely, one way to overcome this problem is by using a technique which involves open looping of the vessel with a 2-0 dacron suture preloaded on a plastic push-rod (Surgiwhip®, U.S. Surgical Corporation, Norwalk, CT), exteriorisation of the loop, and tying of a Tayside knot. This knot is then slipped, locked, and tightened in place. A square knot is then fashioned with the two tails of the Tayside knot, using an intracorporeal technique, to add holding strength (Fig. 4).34
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