The adrenal glands have a tripartite arterial supply: the superior suprarenal arteries arise from the inferior phrenic arteries, the middle suprarenal arteries arise directly from the aorta, and the inferior suprarenal arteries arise from the renal arteries. This triple supply makes the adrenal glands extremely resistant to infarction but creates multiple vessels requiring individual control during adrenalectomy.
Understanding the tripartite adrenal blood supply is essential for laparoscopic and open adrenalectomy, where all three arterial pedicles and the single adrenal vein must be controlled. The right adrenal vein drains directly and very briefly into the posterior IVC, making right adrenalectomy the more technically demanding procedure. The left adrenal vein drains into the left renal vein. In phaeochromocytoma surgery, the adrenal vein is ligated before the arteries to prevent catecholamine surges from tumour manipulation.
The right adrenal vein drains directly into the posterolateral IVC through a very short (5-10 mm) segment, making inadvertent avulsion during right adrenalectomy a risk of catastrophic IVC haemorrhage requiring immediate proximal and distal IVC clamping.
Manipulation of phaeochromocytoma before adrenal vein ligation causes massive catecholamine release producing hypertensive crisis, arrhythmias, and cardiac dysfunction; the adrenal vein is therefore secured before any tumour palpation, requiring preoperative phenoxybenzamine alpha-blockade for haemodynamic preparation.
