In 2015 I went to Prof. Walz in Essen, to learn the posterior retroperitoneoscopic adrenalectomy technique. I had always performed laparoscopic adrenalectomy via the anterior transabdominal route, but when I was able to see the retroperitoneoscopic technique I was fascinated by it.
The reason why it is worth going through the lumbar region is not the better cosmetic result, nor the lesser postoperative pain (which are still great goals for the patient).
The real reason is anatomical: the arteries are ligated first. Once the arteries are ligated, the adrenal gland is devascularized: it can be safely handled and mobilized to reach and ligate the main vein (and the accessory one, if any).
Via the anterior route, the most dangerous maneuver is performed first: the vein is dissected first and, if something goes wrong, the adrenal gland is still injected with blood.
This is even more important if you are operating for pheochromocytoma: manipulating a devascularized adrenal gland is safer.
Since then, by applying the retroperitoneoscopic technique, I have been able to verify these considerations, that I published in Surgical Endoscopy, as a multimedia article.
I also applied the retroperitoneoscopic technique in the recurrence of pheochromocytoma: my work can be found on WebSurg, the online university of IRCAD in Strasbourg.
Changing your point of view allows you to better appreciate all the details of the painting, and the work in its entirety.
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