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Posterior retroperitoneoscopic approach | CION Cancer Clinics
A posterior retroperitoneoscopic adrenalectomy is keyhole surgery that removes the adrenal gland from the back. You lie face down, the surgeon makes a few small cuts below the ribs and reaches the gland directly, without entering the abdomen. It suits small and medium tumours that look benign, and is not used for large or suspected cancers. This page explains what happens, who it suits and what to ask. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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On this page
- What is a posterior retroperitoneoscopic adrenalectomy?
- What actually happens during the operation
- Who is this route right for, and who is it not?
- Keyhole from the back and keyhole from the front, compared
- Four things families ask us, and what is actually true
- What this page cannot tell you
- Common questions about the posterior approach
The short answer
What is a posterior retroperitoneoscopic adrenalectomy?
It is keyhole surgery to remove the adrenal gland from the back. You lie face down, the surgeon makes a few small cuts just below the ribs, and reaches the gland directly through the fat behind the abdomen without ever entering the abdominal cavity. The name is long, but the idea is simple: the shortest route to the gland is from behind.
Why go in from the back at all
The adrenal glands sit high up behind the abdomen, close to the back wall. Reaching them from the front means moving the bowel, the liver or the spleen out of the way. From the back there is nothing in between, so other organs are left alone, the gut is less disturbed, and old scarring inside the abdomen does not get in the way.
Why it is not used for everyone
The working space behind the abdomen is small, and it is created by gently inflating the fat with gas. That space limits the size of tumour that can be removed this way, and it gives the surgeon a narrower view if something unexpected is found. Large tumours, tumours that look like a cancer, and tumours growing into the kidney are removed by the front route or by open surgery instead.
You may see this written on your notes as "PRA" or "posterior approach". All three names mean the same operation.On the day
What actually happens during the operation
Going to sleep, then turning over
The anaesthetic is given while you lie on your back. Once you are asleep and the breathing tube and lines are in, the team turns you carefully face down onto padded supports, with your hips and chest cushioned so nothing presses on your belly.
Small cuts below the ribs
Usually three, on the side of the back just under the lowest rib. A camera goes through one and the instruments through the others.
Making the space
Gas is used to open up a pocket in the fat behind the kidney. This is the space the surgeon works in. It is small, but the gland is right there, so nothing else has to be moved.
Freeing the gland
The gland is separated from the top of the kidney and the tissue around it. The adrenal vein is sealed, and for a hormone-producing tumour the anaesthetist is warned before that moment so they can adjust your blood pressure.
Out in a bag, and closing
The gland is placed in a small bag and lifted out through one of the cuts, which may be widened slightly. The cuts are closed with a few stitches or glue. You are turned onto your back before you wake.
Not sure whether this applies to you?
Ask an oncologistWho it suits
Who is this route right for, and who is it not?
The surgeon weighs the tumour first, then the person. Ask which group you fall into.
Suits well
Small and medium tumours that look benign on the scan, including most aldosterone- and cortisol-producing tumours and smaller phaeochromocytomas.
Particularly useful when
- You have had abdominal surgery before
- Both adrenal glands need removing in one sitting
Suits with care
People who carry a lot of weight around the back, because the distance from skin to gland is longer and the space is harder to make. Experienced surgeons still use it here, but they may choose otherwise.
Not suited
Large tumours, tumours that look like an adrenal cancer, and any tumour growing into the kidney or nearby vessels. The narrow space gives no room to remove surrounding tissue safely.
For these, the front keyhole route or open surgery is chosen from the start.Depends on your surgeon
This route needs specific training and a surgeon who does it often. A centre that does not offer it is not wrong to use the front route instead; the results depend more on the surgeon's familiarity than on the route.
Worth asking
- How many of these they do each year
- What would make them switch route
Side by side
Keyhole from the back and keyhole from the front, compared
From the back (retroperitoneoscopic)
From the front (laparoscopic)
Lie face down; the abdominal cavity is never entered
Lie on your side; bowel, liver or spleen moved aside
Small working space, suits smaller tumours
Wider view, suits larger tumours
Old abdominal scarring does not get in the way
Previous abdominal surgery can make it harder
Bowel is undisturbed, so eating often restarts sooner
Gut may take a little longer to settle
Fewer surgeons trained in it
The route most surgeons learned first
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Commonly believed
Four things families ask us, and what is actually true
"Going in from the back must be riskier than from the front."
In trained hands the safety of the two keyhole routes is similar, and the back route avoids handling the bowel and other organs altogether. What raises risk is using either route for a tumour it does not suit, or a surgeon unfamiliar with it.
"Lying face down under anaesthetic sounds dangerous."
Face-down positioning is routine in spinal and kidney surgery. The anaesthetist secures the breathing tube and lines before you are turned, pads every pressure point, and checks your breathing in the new position before the operation starts.
"It is the newest technique, so it must be the one to ask for."
It is a good route for the right tumour, not a better operation in general. A surgeon who does hundreds of front-route operations and none from the back will serve you well with the front route. Ask about experience, not novelty.
"Smaller cuts mean the tumour was not serious."
The route is chosen on size and scan appearance. The pathology report after the operation is what tells you what the tumour was, and it is the same report whichever route was used.
Being straight with you
What this page cannot tell you
This page cannot tell you whether the back route is right for your tumour, or whether your surgeon offers it. Those depend on the size and appearance of the lump on your scan, your build, your previous operations and your surgeon's training.
What is the same whichever route is used
The preparation for a hormone-producing tumour, the blood pressure management during surgery, the possibility of steroid tablets afterwards and the pathology report are identical. The route changes the cuts, the position on the table and the pace of recovery. It does not change what the operation achieves.
Questions worth asking
Ask whether your centre offers this route and, if so, how often the surgeon uses it. Ask what about your tumour makes it suitable or not. Ask what would make them convert to another route during the operation, and whether you would then wake with different wounds from those you expected. If the route is not offered, ask what the front keyhole route would mean for you instead. A centre that does not offer the back route is not a reason to change centre on its own.
Bring your scan films or disc, not only the report. The surgeon needs to see the gland's position to judge the route.Questions we are asked
Common questions about the posterior approach
Is recovery really faster from the back route?
Often a little faster, mainly because the bowel is never touched, so eating and moving restart sooner and there is less of the bloating that follows front keyhole surgery. Most people go home within a day or two. The difference is modest, and a well-done front keyhole operation is also a quick recovery.
Will I have back pain afterwards?
Some soreness around the cuts below the ribs is usual for a few days and settles with ordinary painkillers. Because you lay face down during the operation, you may also feel stiff in the neck or shoulders on the first day. Tell the nurse if any pain is more than that.
Can both adrenal glands be removed this way at once?
Yes, and this is one of the route's advantages. Lying face down, the surgeon can reach both sides without turning you over, which the front route requires. Removing both glands means lifelong steroid tablets afterwards, so that decision is made separately and carefully.
What if the surgeon cannot finish from the back?
They convert, either to the front keyhole route or to an open cut, depending on what they have found. This is uncommon with a well-chosen tumour and is agreed with you in advance. It means you may wake with wounds in a different place from those you expected, and the team will explain why.
Is this route safe for a phaeochromocytoma?
For a smaller one, yes, provided the usual weeks of blocking tablets have been given and an anaesthetist experienced in these tumours is present. The blood pressure surge is managed the same way as with any other route. Larger adrenaline-producing tumours are usually removed from the front or by open surgery.
Where will the scars be?
On the side of the back, just below the lowest rib, usually three small marks. They are hidden by clothing and most fade to thin lines over a year. There is no scar on the front of the abdomen at all.
Why does my surgeon not offer this route?
It needs specific training, and many excellent adrenal surgeons use the front keyhole route for everything and get equally good results. A surgeon who is expert in one route and honest about it is a safer choice than one trying a route they rarely use. Ask about experience with adrenal surgery overall.
Is it covered by Aarogyasri or my insurance?
It is billed as a laparoscopic adrenalectomy, so cover usually follows the same rules as any keyhole adrenal operation. Aarogyasri, CGHS, ECHS and EHS are accepted, and most cashless insurers are empanelled. Call the helpline with your card details and the surgeon's plan to check before you fix a date.
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Sources
- Cancer Research UK — Surgery for adrenal gland cancer
- Cancer.Net (ASCO) — Adrenal Gland Tumor: Types of Treatment
- National Cancer Institute — Adrenocortical Carcinoma Treatment (PDQ) - Patient Version
- NHS — Phaeochromocytoma
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Laparoscopic vs Open AdrenalectomyHow the front keyhole route and open surgery compareAdrenalectomy: What the Operation InvolvesThe operation from admission to going homeLiving With One Adrenal GlandWhat changes, and what does not, after the gland is goneChoosing a Surgeon and a CentreHow to ask about experience with a specific routeAnaesthesia for Cancer SurgeryWhat the anaesthetist does, including positioning
Talk to us
Want to know which route suits your tumour?
Send us your scan and hormone reports or call the helpline. A surgical oncologist will explain what your tumour's size and position mean for the choice of route. One helpline serves every CION centre.