Table 5.

Surgery

	Surgical Steps
1. Incision and exploration of the peritoneal cavity.	Make an ample incision. Subcostal incisions allow for better access than midline incisions. Thoracoabdominal incisions are indicated in select situations.
	Perform a complete and systematic evaluation of the peritoneal cavity.
2. Evaluation of liver for metastasis	Perform intraoperative ultrasound for metastatic deposits not evident on preoperative imaging.
3. Containment	A self-retaining retractor system with towels or laparotomy pads should be placed in such a way as to exclude the rest of the peritoneal cavity from the area of the tumor and other organs requiring resection.
4. Mobilization of organs adjacent to tumor	Fully mobilize adjacent organs overlying the tumor (if not adherent to the tumor).
5. En bloc resection.	Preserve any tissue overlying the tumor. Use a no-direct-touch technique. Extreme caution should be used mobilizing the soft tissue and tumor together as the capsule is easily ruptured or tumor cells are abraded from the surface. The tumor should not be shelled out, but instead removed with the entire retroperitoneal fat pad. Adjacent organs should be included with the en bloc resection if adherent to the tumor rather than creating a plane between the tumor and organ.
6. Regional lymphadenectomy	Perform when feasible for staging purposes and clearance of in-transit tumor. Few lymph nodes directly surround the adrenal. Representative draining lymph node basins can be found near the renal hilum, celiac axis, and superior mesenteric arteries.
7. Provide intact en bloc specimen for pathologic review	Mark the specimen with sutures to correctly orient the pathologist. Communicate any areas of particular concern or clarify potential misconceptions regarding the resection. Do not morcellate the specimen to facilitate removal through a smaller incision as this makes portions of accurate pathological review impossible.
8. Mark field to facilitate postsurgical external beam radiation therapy	Clips should be placed around the periphery of the field of resection to facilitate planning for possible external beam radiation therapy.
9. Dictate operative report	Include specific details of the operation, findings, areas of metastatic disease, any areas of tumor left behind (known or possible), and acts of commission or omission to facilitate communication with the multidisciplinary team.