Precision Surgery for a Gland You Never Knew You Had
The tiny adrenal gland, no larger than a fortune cookie, holds immense power over your health. Removing it requires the steady hands of a surgeon and, increasingly, the precision of a robot.
Nestled above your kidneys lie two small but remarkably powerful organs—the adrenal glands. Though each weighs merely four to five grams, these triangular-shaped endocrine factories regulate essential bodily functions, including stress response, fluid balance, and blood pressure through hormone production 1 .
For decades, the preferred method was open surgery, requiring a large incision and leading to a prolonged recovery. The 1990s introduced laparoscopic adrenalectomy, a minimally invasive technique that reduced pain and shortened hospital stays 6 .
Today, a new era has dawned with robotic adrenalectomy, an advanced minimally invasive procedure that is rapidly transforming patient outcomes and expanding the possibilities of adrenal surgery 2 .
Robotic adrenalectomy is not performed by an autonomous robot but by a surgeon who controls a sophisticated robotic platform from a console within the operating room. The system enhances human capability with groundbreaking technology 2 .
The robotic system provides several key advantages that are particularly beneficial in the confined and delicate space around the adrenal gland 2 6 :
The surgeon sees a magnified, three-dimensional view of the surgical field, offering incredible depth perception and detail far superior to the 2D view of standard laparoscopy 6 .
The robotic instruments have "wrists" that can rotate and bend with a greater range of motion than the human hand or rigid laparoscopic tools. This allows for delicate maneuvers in tight spaces 1 .
The system filters out any natural hand tremors from the surgeon, enabling exceptionally steady and precise movements during dissection 7 .
Seated comfortably at the console, the surgeon can operate with reduced physical strain, which may enhance focus during complex procedures 1 .
These technological advancements translate into tangible surgical benefits. A 2025 meta-analysis that synthesized data from 28 studies concluded that robotic adrenalectomy resulted in less blood loss, a lower rate of conversion to open surgery, and a slightly shorter hospital stay compared to the laparoscopic approach 7 .
The theoretical advantages of robotics are being confirmed by a growing body of clinical evidence from institutions worldwide.
A 2024 study from a single tertiary institution in Korea, which reviewed 122 consecutive robotic adrenalectomy cases, provides strong evidence for the procedure's safety. The study reported no perioperative complications and identified noteworthy trends, such as shorter operation times for female patients and those with smaller tumors 3 .
Consecutive Cases
Perioperative Complications
Shorter Times for Smaller Tumors
While overall outcomes between robotic and laparoscopic adrenalectomy are often similar, the robotic approach demonstrates superior performance in specific, high-risk scenarios 2 . The largest and most recent meta-analysis on the topic reveals a nuanced picture 7 :
| Outcome Measure | Advantage | Statistical Significance |
|---|---|---|
| Intraoperative Blood Loss | Robotic | Slightly less 7 |
| Conversion to Open Surgery | Robotic | Slightly lower rate 7 |
| Length of Hospital Stay | Robotic | Slightly shorter 7 |
| Operation Time | Comparable | No significant difference 7 |
| Complication Rates | Comparable | No significant difference 7 |
| Postoperative Recovery | Robotic | Faster gastrointestinal recovery 8 |
The robotic platform's strengths become most apparent in difficult situations 1 2 :
For large tumors (>6 cm) or suspected adrenocortical carcinoma, robotic adrenalectomy has been associated with fewer positive tumor margins and lower conversion rates to open surgery compared to laparoscopy 2 .
Patients with a high Body Mass Index (BMI) often have more retroperitoneal fat, making dissection challenging. The improved visualization and dexterity of the robot are advantageous in these cases 2 .
The need for minimal tumor manipulation and precise, early control of the adrenal vein is critical in preventing hypertensive crises during surgery for pheochromocytoma. Robotic instrumentation is ideally suited for this task 4 .
To understand the practical application of this technology, let's examine how a robotic adrenalectomy is typically performed. The procedure can be done via two main approaches, each with distinct advantages.
This is the most common approach. The patient is placed on their side, and the surgeon accesses the adrenal gland through the abdominal cavity. It offers a familiar anatomy and a larger working space, making it preferred for larger tumors or obese patients 2 3 .
Here, the patient is placed in a prone (face-down) position, and the surgeon accesses the gland directly through the back, entering the retroperitoneal space without going through the abdomen. This approach is ideal for patients who have had prior abdominal surgery and allows for faster recovery with minimal pain 2 5 6 .
A 2025 study from the Hospital Clínic of Barcelona successfully performed this approach on 10 patients using the Hugo™ robotic platform, reporting a median hospital stay of just one day and no postoperative complications, demonstrating its feasibility and effectiveness 5 .
While techniques vary, a typical robotic adrenalectomy follows a logical sequence 4 :
The patient is carefully positioned (lateral for LTA, prone for PRA). Small incisions (usually 8-12 mm) are made for the robotic ports and camera.
The abdominal cavity or retroperitoneal space is gently inflated with carbon dioxide gas to create a working space. The robotic arms are then docked to the ports.
The surgeon at the console carefully identifies key anatomical landmarks—the kidney's upper pole, the inferior vena cava (on the right), or the renal vein (on the left).
A critical step involves meticulously dissecting, clipping, and sealing the main adrenal vein to prevent bleeding. In pheochromocytoma, this step is performed as early as possible.
The adrenal gland is delicately freed from its surrounding attachments and fatty tissue using a combination of blunt dissection and advanced energy devices that seal small blood vessels as they cut.
The freed gland is placed into a protective bag and removed through one of the small incisions. The robotic system is undocked, and the tiny incisions are closed with sutures.
The successful execution of this procedure relies on a suite of specialized tools that work in concert.
| Tool | Function in Robotic Adrenalectomy |
|---|---|
| Da Vinci or Hugo™ Robotic Platform | The core system providing 3D visualization, tremor filtration, and control of articulated instruments 2 5 . |
| Articulated Sealing Device | An advanced energy instrument that cuts and seals blood vessels simultaneously, crucial for controlling the gland's multiple small arteries 2 . |
| 30° Endoscope | A high-definition camera that can be angled to provide a panoramic view of the confined surgical field, revealing anatomy hidden from a straight-on view 2 5 . |
| Weck® Hem-o-lok® Clips | Non-absorbable polymer clips used to securely ligate (tie off) the adrenal vein before it is cut, preventing severe hemorrhage 4 . |
| Indocyanine Green (ICG) | A fluorescent dye that can be injected intravenously. When activated by a special light on the camera, it can help visualize the adrenal gland and its blood supply, aiding in identification and ensuring complete resection 9 . |
The innovation in robotic adrenalectomy continues at a rapid pace. The latest advancement is Single-Port Robotic Posterior Retroperitoneoscopic Adrenalectomy (SP-PRA). This state-of-the-art technique allows the entire procedure to be performed through a single small incision in the back, further minimizing tissue trauma and offering the best possible cosmetic outcome with hidden scars 6 .
From the large incisions of open surgery to the precision of robotic instruments, the journey of adrenalectomy reflects the broader trajectory of modern medicine toward minimizing invasiveness while maximizing patient recovery and outcomes. Robotic adrenalectomy represents a significant milestone in adrenal surgery, combining the benefits of minimally invasive techniques with superior visualization and unparalleled dexterity 1 .
While not without its challenges, this technology has proven to be a safe and effective alternative, particularly for complex cases that would have previously required open surgery. As technology continues to evolve and surgeons gain more experience, the promise of robotic adrenalectomy—to provide the best possible care with the least amount of physical disruption—is being realized, one tiny gland at a time.