Laparoscopic Adrenal Compartment Resection for Paediatric Adrenal Neoplasms: Surgical Technique and Single‐Centre Experience

ABSTRACT

Objective

Laparoscopic adrenalectomy is standard in adults, but evidence in children remains limited. This study describes a standardised transperitoneal laparoscopic adrenal compartment resection technique and evaluates its safety, reproducibility and outcomes.

Methods

All paediatric patients undergoing transperitoneal laparoscopic adrenalectomy at our centre from 2022 to 2025 were retrospectively reviewed. Clinical and intraoperative data were collected. Procedures were standardised with lateral positioning, three to four subcostal trocars and dissection along embryological avascular planes, avoiding direct gland manipulation.

Results

Eleven patients were included, median age 4.3 years. Nine had neuroblastic tumours and two had adrenocortical tumours. Mean tumour volume was 197 cm³, mean diameter 39.7 mm. Conversion to open surgery occurred in two IDRF‐positive neuroblastomas (18%) due to bleeding and adherence to renal vein. Mean operative time was 157 min; mean hospitalisation 5.2 days. No postoperative complications occurred. All patients had complete macroscopic resection; four (36.4%) showed microscopic margin infiltration. No local recurrences; one high‐risk neuroblastoma progressed with metastases.

Conclusions

Standardised laparoscopic adrenal compartment resection is safe and reproducible in selected paediatric patients, feasible even in IDRF‐positive tumours. Exclusive dissection along avascular embryological planes ensures oncological radicality, maintaining minimally invasive benefits.

1. Introduction

Adrenal tumours are a rare clinical entity in children, with a reported prevalence of approximately 13 per 1 000 000 children in the United States [1]. The proportion of malignant cases is higher in the paediatric population compared to adults.

Neuroblastoma (NB) is the most common solid extracranial tumour in children, accounting for 8%–10% of all childhood malignancies [2]. NB arises from the adrenal medulla and represents the majority of paediatric adrenal masses, significantly outnumbering adrenocortical tumours (ACT) and pheochromocytomas (PCC), both considered rare in the paediatric population. ACTs account for approximately 0.2% of all paediatric malignancies, while PCCs have an estimated prevalence of 0.2–0.5 per million children [3, 4]; both are frequently associated with germline predisposition.

All these neoplasms typically require surgical resection at some stage of treatment. While laparoscopic adrenalectomy is considered the gold standard in adults, paediatric literature remains limited regarding its indications, standardisation, applicability, safety and both clinical and oncological outcomes.

Building on previously described laparoscopic approaches, this study focuses on a compartment‐based dissection strategy to paediatric adrenal tumours that standardizes anatomical landmarks and surgical steps to enhance safety, particularly in complex or image‐defined risk factors (IDRFs)‐positive cases, which have often been regarded in the literature as a contraindication to minimally invasive surgery.

2. Materials and Methods

A retrospective review was performed on all paediatric patients who underwent video‐laparoscopic adrenalectomy for adrenal neoplasms at our institution between January 2022 and April 2025.

Clinical and operative data were retrieved from patient records, including age, anthropometric measurements, histopathological findings, presence of IDRFs, tumour size and laterality.

All patients underwent a standardised operative protocol. Under general anaesthesia, patients were placed in the full lateral decubitus position with a 50°–60° tilt relative to the horizontal plane to optimise surgical exposure. During the procedure, the surgeon and assistant stood on the contralateral side of the lesion. Port placement consisted of a 10‐mm optical trocar for a 30° laparoscope at the lateral border of the rectus abdominis and two to three 5‐mm working ports placed in the subcostal region according to tumour location (Figure 1). Dissection followed the well‐defined embryological avascular planes outlining the adrenal compartment (Figure 2), minimising blood loss and facilitating intraoperative anatomical orientation. A strict no‐touch technique was adopted to avoid direct gland manipulation, and tumour removal was accomplished through complete mobilisation and clearance of the adrenal compartment.

FIGURE 1.

Trocar positioning for left adrenalectomy. The larger circle indicates the 10‐mm optical trocar at the lateral border of the rectus abdominis; smaller circles represent 5‐mm working ports along the left subcostal margin.

FIGURE 2.

Dissection following the well‐defined embryological avascular planes outlining the adrenal compartment.

2.1. Surgical Steps for Left Adrenalectomy

The procedure begins with mobilisation of the left colic flexure by dividing the phrenocolic and the splenocolic ligaments. Dissection is carried upward along the lateral edge of the spleen, with sectioning of the splenorenal and the splenophrenic ligaments, allowing the spleen to fall medially under the effect of gravity. Full exposure is achieved through extensive mobilisation of the spleen. Dissection is extended superiorly along the retroperitoneum up to the left diaphragmatic crus, where identification of the inferior phrenic artery is required. The avascular plane between the pancreas and Gerota's fascia is identified, with the pancreatic tail mobilised together with the spleen. Once adequate exposure of the retroperitoneal region is obtained, key anatomical landmarks become visible.

Medially, the pancreas and splenic vein are encountered, while laterally the kidney defines the boundary. Within this space, the left renal vein is identified, serving as the primary anatomical landmark, and carefully dissected free from the surrounding perirenal fat. Once the left renal vein is exposed, the following anatomical landmarks are established: inferiorly, the left renal vein; laterally, the kidney; medially, the pancreas and splenic vein; and posteriorly, the psoas muscle.

Dissection along the superior border of the left renal vein with ultrasonic scalpel allows identification of the adrenal vein, which is clipped and divided (Figure 3). The posterior landmark, the psoas muscle, is exposed by dividing small adrenal arteries originating from the left aortic margin.

FIGURE 3.

Laparoscopic view of a left adrenalectomy. (1) Adrenal mass; (2) left kidney; (3) left renal vein; (4) middle adrenal vein branching off the renal vein, clipped and about to be sectioned; (5) spleen.

By gently pushing the gland toward the wall, branches of the middle adrenal artery are exposed and coagulated; conversely, downward push allows exposure and coagulation of the arterial vessels originating from the inferior phrenic artery.

The dissection is completed at the upper renal pole, accessed through Gerota's fascia. Clearance of the adrenal compartment is achieved by coagulating the inferior adrenal artery and joining the lateral and posterior planes along the psoas muscle. To minimise the risk of postoperative wandering spleen, splenopexy is achieved with n‐butyl cyanoacrylate‐based surgical adhesive (video about surgical steps for left adrenalectomy available online on Supporting Information).

2.2. Surgical Steps for Right Adrenalectomy

The right hepatic lobe is carefully mobilized by dividing the right triangular ligament and the subhepatic peritoneum, providing adequate exposure of the adrenal compartment and safe access to the inferior vena cava (IVC).

Elevation of the liver exposes the key landmarks—the kidney, right renal vein, adrenal gland and the IVC, the critical reference on the right. Mobilisation of the ascending colon and hepatic flexure is generally unnecessary, as gravity shifts these structures medially in the lateral position.

The lateral margin of the IVC is then followed as a key anatomical landmark, guiding dissection until the right renal vein is reached. The middle adrenal vein is identified, clipped and divided.

The kidney is then identified as a reliable reference point to orient the surgical field for dissection of the adrenal gland from its upper pole, allowing identification and control of the inferior adrenal artery. Attention is then directed to the psoas muscle, the posterior landmark, which is covered by loose connective tissue. This tissue is dissected and removed together with the gland, allowing full exposure of the muscle.

The following perioperative variables were assessed: operative time, postoperative complications, conversion to open adrenalectomy, resection margin status (as a measure of surgical radicality), postoperative follow‐up imaging, length of hospital stay and oncological follow‐up. The normality of continuous variables was tested using the Shapiro–Wilk Test. Owing to the small sample size, further statistical analyses were not conducted.

3. Results

A total of 11 patients met the inclusion criteria (10 males, 1 female). The median age at surgery was 4.27 years (range 0.2–17.37) and the median body weight was 16 kg (range 6.5–68). Nine patients had neuroblastic tumours, five of which presented IDRFs, while two patients were diagnosed with ACT (Table 1). The mean tumour volume was 197.23 ± 18.0 cm³, with a mean maximum diameter of 39.73 mm. Conversion to open surgery was required in two cases (18%), both involving IDRF‐positive NB: one due to intraoperative bleeding during ligation of the right adrenal vein with clips, and the other because of firm adherence of the tumour to the renal vein, preventing safe separation. The mean operative time was 157 ± 41.6 min. The mean postoperative hospital stay was 5.2 ± 1.7 days. No postoperative complications were recorded. Complete macroscopic resection was achieved in all cases, although microscopic focal margin infiltration was present in four patients (36.4%). The mean follow‐up duration was 19.27 ± 11.5 months. No residual disease was observed at the primary tumour site on postoperative follow‐up imaging in any of the cases. No local recurrences were reported. One patient with high‐risk NB and lung metastasis at diagnosis developed progression with pulmonary and hepatic metastases (Table 2).

TABLE 1.

Patients' characteristics.

Patients	11
Sex
Males	10
Females	1
Age at Surgery (Years)	Median 4.27 (range 0.2–17.37)
Weight (kg)	Median: 16 (range 6.5–68)
Histological diagnosis
NB	6
GNB intermixed	2
Ganglioneuroma	1
ACT	2
Tumour Dimensions (mm)	39.73 (SD 18.0)
Laterality
Left	9
Right	2
IDRF+	5
Pre‐operative chemotherapy	4

TABLE 2.

Results.

Conversion to open	2
Operative duration (min)	Mean: 157 (SD 41.6)
Intraoperative complication	1
Postoperative complications	0
Margins	Macroscopic: 11 negative Microscopic: 7 negative
Residual disease at primary tumour site	0
Local recurrence	0
Length of stay (days)	Mean 5.2 (SD 1.7)

4. Discussion

Laparoscopic adrenalectomy has not yet been established as the gold standard for adrenal resection in the paediatric population; adoption has been slower owing to the higher rate of malignant adrenal disease and the ongoing lack of consensus regarding indications and contraindications for minimally invasive approaches.

According to the published series, in benign adrenal neoplasms, where the oncological risks associated with malignancy are not a concern, laparoscopy can be considered the gold standard in appropriately equipped, high‐expertise centres [5]. Fascetti‐Leon et al. observed that mean operative time for minimally invasive procedures decreases with procedural volume in experienced centres, reinforcing that the advantages of laparoscopy over open surgery become most evident when adopted as the standard practice [6].

Literature consistently cites the presence of IDRFs on preoperative imaging and, to a lesser degree, tumour size as the main contraindications to laparoscopic resection of adrenal NB. According to Tanaka et al., the absence of IDRFs—based on updated criteria—is an indication for preferring a laparoscopic over an open approach. They emphasise, however, that even partial (< 50%) encasement of major vessels, particularly the IVC, warrants careful evaluation and should be regarded as a significant factor in surgical planning [7]. Several other studies support the view that the absence of IDRFs represents the primary indication for laparoscopy, whereas tumour size alone does not appear to constitute a definitive limitation to minimally invasive surgery [8, 9]. Nonetheless, Fascetti‐Leon et al. contend that positive IDRFs should not be regarded as an absolute contraindication to a laparoscopic approach in adrenal NB [6].

In our experience, the presence of IDRFs is pivotal in determining the suitability of a minimally invasive approach for adrenal NB, with procedural safety dictated primarily by the tumour's relationship to major vascular structures. The presence of IDRFs should not be regarded as an absolute contraindication to laparoscopy, nor does their absence ensure feasibility or safety. Surgical decision‐making should therefore be individualised and multidisciplinary, involving radiologists, oncologists and the surgical team. Moreover, avoiding direct manipulation of the tumour mass and approaching the adrenal compartment through identification of key vascular landmarks and dissection along embryological avascular planes, allows the application of laparoscopy even in selected IDRF‐positive cases. Despite increasing interest in minimally invasive adrenal surgery, its application in the paediatric population remains limited, with few reported experiences, particularly in malignant disease [10, 11]. In this context, our experience adds further evidence supporting the feasibility and safety of a laparoscopic approach in carefully selected paediatric patients, including selected IDRF‐positive cases, when performed in high‐expertise centres within a multidisciplinary framework and using a compartment‐oriented approach.

Adequacy of lymph node sampling remains a concern, as laparoscopic procedures may be limited in this regard due to the increased technical challenges involved [9].

Minimally invasive surgery should not be defined merely by the small size of incisions, but rather by its capacity to optimise tissue handling. The lateral decubitus position provides gravity‐assisted retraction, reducing the need for additional instruments and allowing for gentler, more precise manipulation of critical structures. Avoiding direct traction on the fragile adrenal glands minimises the risk of injury, preventing significant bleeding, tumour cell dissemination and hormonal release.

In our experience, tumour size—even when greater than 6 cm—did not represent a contraindication to laparoscopy. Interestingly, the two cases requiring conversion to open surgery involved smaller tumours (37 and 35 mm), both associated with positive IDRFs on preoperative CT scan. Conversely, three IDRF‐positive patients underwent successful laparoscopic resection without complications and with favourable oncological results. These findings highlight the importance of carefully assessing each IDRF individually, as not all confer the same level of intraoperative risk.

From a purely technical point of view, right adrenalectomy is often regarded as less demanding than the left in the hands of experienced laparoscopic surgeons, primarily due to the presence of well‐defined anatomical landmarks such as the IVC, which facilitates rapid localisation of the adrenal gland. However, despite the clearer identification of anatomical landmarks, right adrenalectomy poses specific technical challenges. Dissection of the middle adrenal vein can be difficult. This vein is short and located deep beneath the liver. Its division always requires great caution and technical expertise, as it carries a considerable risk of bleeding [12], as observed in one of our cases. A further advantage of the lateral laparoscopic approach is the anterior displacement of the adrenal vein compared to its anatomical orientation in the horizontal plane.

The use of indocyanine green fluorescence imaging may further enhance the identification of vascular landmarks and represents a potentially valuable adjunct to a compartment‐oriented approach. In adult patients, its use has been reported with favourable outcomes, providing intraoperative support for the identification of tumour margins and vascular structures and potentially contributing to improved procedural safety [13, 14].

In the paediatric setting, current evidence regarding the use of indocyanine green fluorescence imaging for adrenal neoplasms remains limited, and further studies are warranted to clarify its role. Nevertheless, this technique may represent a promising option for future paediatric surgical applications.

This study has inherent limitations, including its monocentric design, small sample size and relatively short follow‐up, which preclude definitive conclusions regarding long‐term oncological outcomes. Consequently, the oncological validity of the laparoscopic approach cannot be fully assessed based on this series alone.

In conclusion, findings from our case series support the safety of laparoscopic adrenal compartment resection for paediatric adrenal neoplasms, demonstrating favourable surgical and oncological outcomes in carefully selected patients managed in a multidisciplinary setting. An approach centred on the adrenal compartment, rather than direct tumour manipulation, extends the applicability of minimally invasive techniques even to selected cases of IDRF‐positive NB and to tumours of larger size.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Video S1: ejh70158‐sup‐0001‐VideoS1.mp4.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.