Posterior Retroperitoneoscopic Adrenalectomy (PRA) provides the best access to the adrenals. However, and due to the limited operative space, there have been concerns about its feasibility in specific cases such as in the resection of large or giant masses/specimens, in primary carcinoma and in extreme obesity. We aim to present our "Retroperitoneal Space Augmentation" techniques in order to expand the indications of PRA.

We present tips and tricks and video-material from selected extreme cases treated with the PRA. These include resection of 1) >8cm adenoma in a superobese patient (BMI>57) 2) >6cm adrenal primary carcinoma with an intact 15x8.5cm specimen 3) 8.7cm rare adrenal malignancy (composite hemangioendothelioma) 4) >10cm Adenoma 5) 12cm Dopaminoma 6) >9cm renal carcinoma and simultaneous resection of 7.5 adrenal adenoma (specimen >20cm). The Retroperitoneal Space Augmentation Techniques (RSAT) were categorized as A) External (patient positioning with contralateral bending of legs and torso, skin tapes to decrease subcutaneous tissue depth, liberal trocar positioning) B) Internal (kidney partial- or total-mobilization, medial-first dissection, ambidextrous surgery, steep patient tilting).

There was no complication. The patients were discharged within 24 hours from surgery, except from the simultaneous kidney/adrenal resection (48 hours). All resections were R0. Post-discharge analgesic use was minimal to none.

This technical presentation provides a description of PRA modifications in order to address extreme cases in adrenal surgery such as extreme obesity, giant tumors or very large intact specimens, large primary cancer. The RSAT do increase the surgical field enhancing the feasibility of the PRA in challenging cases.