Posterior retroperitoneoscopic adrenalectomy.

PRA has become our preferred technique for resection of relatively small, benign adrenal masses and isolated metastases to the adrenal glands. PRA offers a direct, minimally invasive approach to the adrenal glands and avoids the need to enter the peritoneal cavity, deal with intraabdominal adhesions, and mobilize adjacent organs-steps necessary during anterior laparoscopic adrenalectomy. In addition, some patients tolerate retroperitoneal CO2 insufflation better than intraperitoneal CO2 insufflation from a hemodynamic and respiratory perspective. Finally, bilateral PRA can be performed without the need for patient repositioning. PRA requires the surgeon to become comfortable with the anatomy of the adrenal gland and surrounding structures from the posterior perspective. In addition, the surgeon must become adept at working in the retroperitoneal space, which is relatively restricted compared with the large cavity created by insufflation of the intraperitoneal space. However, in our experience, the learning curve can be overcome in a relatively short period, and the posterior approach is particularly advantageous in patients who have undergone prior open abdominal surgery or who are moderately obese. Proper patient positioning and trocar placement, high-pressure CO2 insufflation, and mobilization of the inferior aspect of the adrenal gland from the superior pole of the kidney before dividing its other attachments are critical technical details that greatly facilitate the procedure. In experienced hands, PRA is safe and is an ideal option for patients who are candidates for minimally invasive adrenalectomy.