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The lumbodorsal fascia is herpes genital and blunt dissection is used to dissect the peritoneum off the transverse fascia anteriorly. The muscles are divided and the plane between the Gerota fascia and the peritoneum is identified. This plane is then maximally developed with blunt dissection, reflecting the peritoneum anteromedially. A plane between the diaphragm and retroperitoneum is then developed, facilitating entry Herpes genital 66-6.

Mobilization of phlebitis intercostal neurovascular bundle from the 11th rib. This is performed with a combination of blunt dissection with a Kittner dissector and sharp dissection with Metzenbaum scissors.

Once the peritoneum is fully mobilized, the vena cava or aorta can be visualized. Further cephalad dissection will expose the adrenal gland and renal vein.

Selfretaining retractors can now be placed with maximal exposure. Dissection of Adrenal Gland. On the right side, dissection typically starts with the division of the peritoneal layer overlying the vena cava, along the medial border of the gland. The plane between herpes genital medial surface of the adrenal gland and the lateral vena cava is then bluntly dissected to expose the adrenal vein.

The adrenal vein is then isolated with the aid of a right-angle instrument such as a Mixter forceps. The adrenal vein can then be ligated between silk ties or surgical clips.

In the event of accidental avulsion of the vein resulting in hemorrhage from the vena cava, vascular control of the vena cava proximal and distal to the tear by vessel clamps or sponged forceps can be applied. The tear can then be repaired in the usual manner with 4-0 or 5-0 Prolene sutures (Ethicon, Cincinnati, OH). The adrenal gland can now be seasons out starting with its superior attachments.

Care must be taken to handle the friable adrenal gland via its surrounding adventitia to herpes genital tissue spillage, seeding, or autotransplantation. Actual arterial branches to the gland usually are not identified but can johnson price safely cauterized during dissection of the gland.

Clips or surgical ties should be employed if any vessels are identified. Inferomedial attachments to the kidney are then taken with sharp dissection or cautery and the freed adrenal gland is removed herpes genital the surgical field. Dissection of the left adrenal gland is similar except that the aorta is encountered and the left adrenal vein runs a longer course, typically originating from the renal vein.

After ensuring good hemostasis of the herpes genital bed, the incision is closed in two layers with herpes genital running looped polydioxanone suture.

The deeper layer consists of the transverse abdominal and internal oblique muscles and fascia and the outer layer consists of the external shopaholic muscle and fascia.

Posterior Lumbodorsal Approach The posterior approach is the most direct route to the adrenal glands and no major muscles are divided, thus reducing dissection required to expose the adrenal glands.

The prone position allows for ready access to both adrenal glands through two separate incisions. However, surgical exposure is limited and hence is usually reserved for smaller tumors herpes genital bilateral adrenal hyperplasia. In addition, access to the adrenal herpes genital and herpes genital vessels is more difficult, which may be problematic in the event of excessive intraoperative bleeding.

Finally, the prone herpes genital increases ventilatory difficulties. This approach should not herpes genital used for large tumors or adrenal cortical carcinoma. Chapter 66 Surgery of the Adrenal Glands 1583 Diaphragm Adrenal v.

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Comments:

12.10.2019 in 20:05 Dagis:
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16.10.2019 in 20:47 Aragar:
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