**4. Laparoscopic technique**

*Pheochromocytoma, Paraganglioma and Neuroblastoma*

with an under 2% rate of death.

dominal or posterior surgical approaches.

open surgery if necessary for exceptional cases [15].

insufficient learning curve and lack of tactile feedback.

disease rate, the open approach is prefered [16].

other organs injuries.

rupture.

procedures [14].

surgical technique.

surgery technique [9].

with cardiac events such as arrhythmia, myocardial dysfunction, pulmonary embolism and sepsis. Mortality for adrenalectomy has improved in the last decade,

Firstly, the main critical point in adrenalectomy in pheochromocytoma is the minimal manipulation of the tumor to avoid seeding the tumor in adjacent tissues and in order to prevent a hypertensive crisis during the operation (it is said that adrenalectomy should be performed by dissecting away the body from the gland, not the gland from the body). Secondly, another crucial step during the surgical procedure is the control of vascular supply together with the complete tumor resection. All of these can be provided by adequate surgical exposure in order to prevent

Minimally invasive techniques can be done laparoscopically or robotically. The aim of minimally invasive procedures and open surgical approach is the minimal manipulation of the tumor, in order to prevent catecholamine release as mentioned above; if this is not respected, it can result in hemodynamic instability and tumor

Also, to diminish the risk of releasing large amounts of hormones, it is indicated to early ligature the adrenal vein. This step can be performed through the transab-

Furthermore, the surgical approach is dependent on surgeon choise, experience and familiarity with the specific techniques. However, some factors may influence the decision of surgical approach: body mass index, tumor size and location, and patient's personal pathological history of abdominal or retroperitoneal surgical

Our paper will focus mainly on the minimally invasive laparoscopic approach, being the surgical procedure of choice for adrenal tumors, due to its advantages of

The laparoscopic approach includes normal anatomy and easy conversion to

Although the retroperitoneal approach can directly access the adrenal gland and would require less effort to dissect and mobilize nearby visceral organs, this technique is not easy for general surgeons due to lack of familiarity with it. In addition, the contraindications for the retroperitoneal surgical approach include tumors bigger than seven to eight cm due to the narrow working space and an increased body mass index with increased retroperitoneal fat. Simultaneously, a tumor lying around the inferior vena cava (on the right side) or close to the aorta (on the left side) can lead to a complex surgical resection by retroperitoneal access [13]. Retrospective studies from literature have shown that robotic and laparoscopic resection of pheochromocytomas are equivalent in terms of operative time, blood loss volumes, intraoperative hemodynamic events, rates of morbidity and mortality, and rates of conversion from minimally invasive approach to open

Furthermore, the main advantages of robotic adrenalectomy include: the three

When invasive malignant pheochromocytoma is suspected or concerned clinically, open approach is the first choice. Open treatment may benefit from a greater risk of tumor rupture, which may lead to pheochromocytoma disease. For patients with confirmed SDHB mutations, that are associated with a higher metastatic

For patients with pheochromocytoma associated with different syndromes, minimally invasive or open surgical methods can also be used for cortical sparing

dimensional acces, improved wrist mobilization for the surgeon, and a stable camera port. Disadvantages of robotic adrenal surgery include increased cost,

**50**
