Patients who undergo a bilateral adrenalectomy need of a lifelong challenging steroid replacement. Cortical-sparing surgery allows to avoid this condition, it can be adopted in hereditary adrenal lesions with low risk of malignancy, like in Von Hippel Lindau, MEN type 2 and Neurofibromatosis type 1 syndromes. The robotic technology associated with intraoperative ultrasound and indocyanine green angiography makes this procedure applicable in more patients.

We present a patient affected by MEN2A syndrome with a history of right total adrenalectomy, total thyroidectomy and subtotal parathyroidectomy. After 20 years, during follow up, a hypersecreting pheochromocytoma of the left adrenal gland was found. Therefore, the patient was discussed in a multidisciplinary setting where a partial left adrenalectomy was indicated and the patient was prepared adequately before the surgery.

Partial adrenalectomy was performed with Da Vinci Robotic Surgical System (Intuitive Surgical), no intraoperative complications occurred. Intraoperative ultrasonography was performed to localize tumor and guide dissection planes. Furthermore, to show the correct identification and post resection vascular preservation of the cortical residue, indocyanine green angiography was used. The patient was discharged on the fourth post-operative day. At follow up good cortical function was observed.

Partial adrenalectomy, when indicated, represents a safe and feasible procedure for hereditary pheochromocytomas with low risk of malignancy, with the aim of improving patient's quality of life while preserving the adrenal cortex function. Patients should be closely followed up and managed in referral centers, which can offer optimal treatment option to preserve adrenal function and control oncologic progression.