Minimally invasive adrenal surgery.

The adrenals can be approached endoscopically using either transperitoneal or retroperitoneal access, most surgeons favouring the transperitoneal flank approach with the patient in the lateral decubitus position. Endoscopic retroperitoneal adrenalectomy can be performed via either a posterior or a lateral approach. The main advantage of the retroperitoneal approach in the prone position is that it allows bilateral adrenalectomy without repositioning the patient. Although technically more demanding, endoscopic adrenalectomy provides clear advantages over open procedures for tumours less than 5-6 cm in diameter. The small working space provided by the retroperitoneal approach is a contra-indication for the dissection of tumours over 5-6 cm in diameter. Peritoneal adhesions caused by previous abdominal surgery or a large right lobe of the liver may contra-indicate transperitoneal access. For small benign tumours, the transperitoneal and retroperitoneal routes are safe and effective, and there is no clear advantage of one procedure over the other. Invasive adrenal carcinoma is an absolute contra-indication for endoscopic adrenalectomy. Whether large (>5-6 cm) and potentially malignant tumours should be removed laparoscopically remains debatable.