A two-centre experience with hand-assisted laparoscopic, transperitoneal laparoscopic and retroperitoneoscopic adrenalectomy

Abstract Introduction Minimally invasive adrenalectomy is the current standard of care for most adrenal lesions. Several techniques exist—transperitoneal laparoscopic (TL), retroperitoneoscopic (RP), hand-assisted laparoscopic (HAL), and robotic adrenalectomy. Methods Perioperative outcomes of 444 patients undergoing HAL ( n = 85), TL ( n = 291) and RP ( n = 68) adrenalectomies across two tertiary institutions between 2009 and 2025 were retrospectively analysed. Results The HAL approach was employed for larger tumours (median 6.5 cm [range 0.8–17.5]) than TL (3.4 cm [0.12–12.5]) and RP (3.8 cm [0.6–13.0]) and was associated with shorter operative times (median 124 min [65–287] vs. 216 min [124–465] vs. 141 min [50–318], respectively). However, HAL demonstrated higher overall postoperative complication rates (16.5% [95% CI 9.3–26.1] vs. 7.6% [95% CI 4.8–11.2] vs. 8.8% [95% CI 3.3–18.2]). Pheochromocytomas were more commonly managed using HAL (31.8%) and TL (27.5%), whereas non-functioning adenomas predominated in RP (23.5%). Malignancies were also more frequently treated with HAL (20 vs. 9.3 vs. 8.8%). Conversion to open surgery occurred in 5.9% (95% CI 1.9–13.2) of HAL cases due to haemorrhage and local invasion, and in 5.8% (95% CI 3.4–9.2) of TL cases due to haemorrhage, difficult dissection, and unclear anatomy. In RP, 4.4% (95% CI 0.9–12.4) required conversion to HAL for technical difficulty. Intraoperative complications included splenic injury (HAL 3.5%, TL 0.3%) and renal artery injury in RP (1.5%). Two perioperative deaths were recorded with TL (0.7%) approach. Median hospital stay was longer following HAL (6 vs. 4 vs. 4 days) technique. Conclusion In this series, one of the largest to our knowledge, HAL provides an effective hybrid minimally invasive technique for larger, more complex adrenal lesions and malignancy, whereas TL and RP are effective for smaller, benign tumours. The RP approach was associated with fewer postoperative complications and shorter hospital stay.