The anterior transperitoneal route is used with the patient is supine position [17]. This technique can present few advantages, including easy positioning of the patient on the operative table, clear evidence of anatomical landmarks, wider exposure of the adrenal gland, early ligature of the main adrenal vein before gland manipulation, the possibility to perform a bilateral procedure, easy immediate conversion to open in the case of major bleeding.

A 2.5-cm vertical incision is made within the umbilical ring, through which a SILS™ port (Covidien, New Haven, CT, USA). In alternative, other commercially available multi-channel ports can be used, such as the Triport™ (Olympus, Tokyo, Japan) or standard trocars placed within the same skin incision but through different fascial incisions (in this case a 5-mm nonbladed trocar can be placed side-by-side with the camera trocar). Besides the umbilical site, a 3-mm or a 5-mm nonbladed trocar is then placed along the anterior axillary line. This access site is used for the left or the right hand depending on the site of the surgery. A variety of instruments can be used depending on surgeon’s preference, including vessel-sealing devices such as Ligasure™ (Covidien) or Harmonic™ scalpel (Ethicon, Cincinnati, OH, USA).

The surgical strategy follows a conventional transperitoneal adrenalectomy. Once the white line of Toldt’s fascia is incised, the junction of the colonic mesentery and Gerota’s fascia is identified. This plane is then dissected to the renal vein. The adrenal veins are identified, clipped with 5-mm Hem-O-Lok clips (Teleflex Medical, Research Triangle Park, NC, USA), and divided. A vessel-sealing device can be used to complete the adrenal dissection. The specimen is extracted by removing the 10-mm bag through the enlarged paraumbilical trocar site.

Adrenalectomy with the patient in the prone position (and with moderately bent hip joints) has been detailed for both standard retroperitoneoscopy [18] and single-site retroperitoneoscopy [19]. The same principles are used for the RPLS technique. Regardless the technique, besides the number of access points, the procedure remains the same.

Initially, a 1.5 cm transverse incision just below the tip of the 12th rib is performed. After having prepared the subcutaneous and muscle layer by sharp and blunt dissection, the retroperitoneal space was easily accessible by digital perforation of the dorsolumbar fascia. A small cavity is prepared digitally for balloon dilatation with a special distension balloon trocar, which is insufflated under endoscopic control for a few minutes. After removing the distension trocar, a 5-mm standard trocar is introduced with internal finger guidance 4–5 cm laterally (medioaxillary line) to the initial incision site. Thus safe trocar placement is possible without visual control. Finally, a blunt trocar with an inflatable balloon and an adjustable sleeve is introduced into the initial incision site and blocked. Pneumoretroperitoneum is created by high (20 mmHg) CO₂ pressure. Retroperitoneoscopy is performed by a 10-mm 30° endoscope which is introduced into the port. The endoscope itself can eventually allow a step-by-step creation of the retroperitoneal space by disruption of the Gerota’s fascia and by pushing the retroperitoneal fatty tissue bluntly downwards. Thereby, the area of the adrenal gland and the upper renal pole are exposed.