Three routes to the adrenal, matched to three kinds of lesion

Design

retrospective two-centre cohort, 2009 to 2025, non-randomised approach selection

Population

444 minimally invasive adrenalectomies: 85 hand-assisted, 291 transperitoneal laparoscopic, 68 retroperitoneoscopic

Primary outcome

perioperative outcomes including complications, conversion and length of stay

Effect

complications 16.5% vs 7.6% vs 8.8%; operative time 124 vs 216 vs 141 min; stay 6 vs 4 vs 4 days

Two tertiary centres reviewed 444 minimally invasive adrenalectomies performed between 2009 and 2025: 85 hand-assisted laparoscopic, 291 transperitoneal laparoscopic and 68 retroperitoneoscopic. The approaches were not randomly assigned, and the case mix differs sharply between them, which is itself the finding.

Hand-assisted surgery was used for the largest lesions (median 6.5 cm, up to 17.5 cm) and the highest proportion of malignancy (20%), and had the shortest median operative time at 124 minutes against 216 for transperitoneal and 141 for retroperitoneoscopic. It also carried the highest overall complication rate (16.5%, 95% CI 9.3-26.1, against 7.6% and 8.8%), the longest stay (6 against 4 and 4 days), and splenic injury in 3.5% of cases. Conversion to open surgery occurred in 5.9% of hand-assisted and 5.8% of transperitoneal cases, driven by haemorrhage and difficult dissection. Retroperitoneoscopic surgery had the lowest complication rate and shortest stay, with renal artery injury in 1.5% and conversion to hand-assisted in 4.4%. Two perioperative deaths occurred, both after transperitoneal surgery.

Because case selection drove the differences, the complication rates cannot be read as a ranking of the techniques. What they support is the selection logic already implicit in the series: small benign lesions to retroperitoneoscopic, larger or malignant ones to a hand-assisted hybrid that keeps tactile control and a route to rapid open conversion.

For a general surgeon operating without an endocrine subspecialist, the useful part is the failure modes. The hazards are approach-specific and predictable — spleen in the hand-assisted left-sided case, renal artery in the retroperitoneoscopic one, haemorrhage as the reason for conversion in both laparoscopic routes.

• Match the route to the lesion: retroperitoneoscopic for small benign tumours, a hand-assisted hybrid for large or malignant ones
• Warn the patient of about a one in seventeen conversion rate for laparoscopic and hand-assisted approaches
• Anticipate splenic injury as the specific hazard of left-sided hand-assisted dissection
• In retroperitoneoscopic surgery, identify the renal artery early — it was the injury specific to that route
• Confirm biochemical work-up and alpha blockade before any adrenalectomy where phaeochromocytoma is possible; a third of hand-assisted cases here were phaeochromocytomas

Why it matters

The approach a unit defaults to is usually historical, and this shows the hazards differ by route rather than by surgeon skill.

Don't overread it

This is a retrospective series with non-random approach selection; the complication rates reflect case mix, not technique.

The statistics, in plain English

The complication rates are not comparable between groups because the surgeons chose the approach: the hand-assisted group had bigger tumours and more cancers, which would raise complications whatever technique was used. Confidence intervals here are wide where the groups are small — 9.3% to 26.1% for hand-assisted complications on 85 cases — so a difference of a few percentage points between routes is not interpretable. Read the numbers as a description of what happens in practice, not as an effect of the approach.

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