Updates on Minimally Invasive Treatment of Adrenal Tumors

Adrenal tumors are increasingly diagnosed due to widespread use of cross-sectional imaging and an aging population, making adrenalectomy a progressively more common surgical procedure. Over the past three decades, adrenal surgery has undergone a paradigm shift from open adrenalectomy to minimally invasive (MI) techniques, with laparoscopic adrenalectomy becoming the standard approach for most benign and selected malignant adrenal tumors. More recently, retroperitoneoscopic and robotic approaches have expanded the armamentarium available to adrenal surgeons, allowing for tailored, patient-specific surgical strategies. This review summarizes current evidence on MI adrenalectomy techniques, including transperitoneal and retroperitoneal laparoscopic approaches, hand-assisted adrenalectomy, and robotic adrenalectomy, with particular emphasis on their role in pheochromocytoma and adrenocortical carcinoma. In addition, evolving ancillary technologies such as laparoscopic ultrasound, indocyanine green fluorescence imaging, artificial intelligence, and virtual and augmented reality are reviewed, highlighting their potential to enhance intraoperative decision-making, safety, and surgical precision. Current controversies, including the role of preoperative alpha-blockade, partial versus total adrenalectomy in hereditary pheochromocytoma, the oncologic adequacy of MI surgery for adrenocortical carcinoma, and the selective use of lymph node dissection, are discussed. Available evidence supports MI adrenalectomy as a safe and effective approach in carefully selected patients when performed by experienced surgeons in high-volume centers. Technological innovations continue to refine surgical planning, execution, and training, suggesting that the future of adrenal surgery will increasingly rely on precision-guided, personalized, and data-driven strategies. This review offers a timely and comprehensive synthesis of the evolving landscape of MI adrenalectomy, uniquely integrating current evidence across the full spectrum of surgical techniques with a critical appraisal of emerging ancillary technologies while addressing unresolved clinical controversies relevant to contemporary surgical practice.