For access to the right adrenal, the transverse colon is reflected inferiorly, the duodenum is reflected to the patient’s left, and the vena cava is clearly exposed

The approach to the left adrenal vein often requires complete mobilization of the spleen and pancreas to gain adequate access

The lymphatic drainage of the adrenal, for both the right and left sides

Vena cava involvement is usually above the right renal vein, which can be isolated, but occasionally the left renal vein must be isolated and controlled. If the tumor extends close to the hepatic vein outflow, then suprahepatic caval control should be considered. T = tumor

Suprarenal infrahepatic tumor thrombus. (a) Extraction of the tumor with isolation of the cava and without caval resection requires extensive mobilization with temporary occlusion of the inferior vena cava below the hepatic veins and above the renal veins. (b) If the tumor extends to the outflow tract of the right and left hepatic veins, these must be clearly isolated with complete mobilization of the right lobe of the liver to the patient’s left. (c) En bloc caval and tumor resection with or without the right kidney is necessary (i.e., adrenal vein intact). Caval resection can be performed above the renal vein with or without resection of the right kidney and isolation of the left renal vein. If tumor extends below the right renal vein, then the right kidney must be removed en bloc. (d) If thrombus exists in the proximal left renal vein, division often can be accomplished without loss of the kidney if the usually distended left adrenal vein enters the renal vein proximal to the gonadal vein