Adrenal surgery has experienced vast advances over the past decade, including optimization of the laparoscopic technique. Currently, the transabdominal laparoscopic and retroperitoneoscopic procedures are two mainstay approaches to minimally invasive adrenalectomy. The latter approach is associated with decreased hospital stay and reductions in post-operative pain, allowing for smoother patient recovery when compared with transabdominal laparoscopic procedures. Despite the steep learning curve

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... ssociated with this procedure, standardization of the posterior retroperitoneoscopic approach (PRA) has allowed for wider recognition and adoption within high-volume endocrine surgery centers and, as a result, this approach has become widely accepted in the field of endocrine surgery. This procedure is currently indicated in patients presenting with either functional or non-functional adrenal tumors. This can also be advantageous for cases requiring a bilateral adrenalectomy as the need for repositioning is eliminated. Notably, surgeons have successfully used this approach in the treatment of pheochromocytomas and metastatic disease in select patients. Contraindications to this approach include patients with BMI >40, cases with tumor sizes exceeding 7 cm, and cases where there is a high clinical suspicion of invasion into surrounding organs or malignancy. Steps to this approach have been summarized with an algorithmic approach, considering the differences in anatomic landmarks depending on the laterality of the tumor. Taken together, the ability to treat adrenal tumors regardless of functional status, option for bilateral mass resection, standardization of steps and direct access to the tumor all make the PRA an excellent option for minimally invasive adrenalectomies in the appropriate patient population.