Robotic Resection of Large Adrenal Tumors: Tips and Tricks

Background: The optimal approach to large adrenal tumors is controversial. 1 – 4 Robotic adrenalectomy has emerged as a viable alternative, offering enhanced dexterity through articulating instruments and improved visualization with 3-dimensional optics. 5 Compared to open surgery, robotic approaches have demonstrated potential advantages across several surgical domains, including reduced blood loss, shorter hospital stays, and faster recovery. 6 – 9 However, the technical challenges of resecting large adrenal masses robotically necessitate advanced surgical skills and strategic planning. This video aims to demonstrate tips and tricks for performing robotic adrenalectomy for large adrenal tumors. Methods: This video shows minimally edited versions of two large adrenal tumors removed robotically. A four-arm technique was used with an Xi system. Results: The 1 st patient was a 51-year-old male with an 8.5-cm ganglioneuroma, and 2 nd patient was an 89-year-old male with a 7-cm pheochromocytoma. Both procedures were completed successfully without conversion to open. Operative time was 238 minutes and 297 minutes, respectively. There were no intraoperative or postoperative complications. Hospital stay was 1 and 2 days, respectively. Surgical margins were clear in both pathologies. Conclusions: In this video, we described our technique for removing large adrenal tumors robotically. We believe that the procedures were done in a similar fashion to open adrenalectomy using the tips and tricks we developed in our experience. Educational points from the video are (1) fully mobilize the adrenal gland prior to identification and ligation of the adrenal vein(s). (2) use ICG and intraoperative US to delineate challenging anatomy. (3) take advantage of instrument articulation for dissection and retraction. Funding: No funding was received for the study. Disclosure statement: E.B. has consulting agreements with Medtronic. Ethicon and Fluoptics: He has received honoraria for consulting work. Other authors declare there are no commercial associations that might create a conflict of interest in connection with the video. Consent: The authors have received and archived patients’ consents for video recording/publication in advance of video recording of the procedure. Video duration: 9:44. Running time: 9 min 43 sec.