An Irish Experience of Robotic Adrenalectomy: Transitioning from Open to Robotic Surgery

An Irish Experience of Robotic Adrenalectomy: Transitioning from Open to Robotic Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Irish Experience of Robotic Adrenalectomy: Transitioning from Open to Robotic Surgery Ross Walsh, Jamie Walsh, Niall Hardy, Tim Harding, Adithya Pathanki, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7992533/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Minimally invasive techniques have become the gold-standard for the surgical management of the majority adrenal pathologies. No consensus exists over the benefit of robotic over laparoscopic adrenalectomy. The aim of the study was to analyse the authors’ experience of adrenalectomy with emphasis on its transition to robotic approaches. Methods : Retrospective data were collated from a prospectively maintained database of all consecutive adult patients undergoing adrenalectomy at the study centre between 1 st January 2015 to 1 st June 2025. Results : A total of 61 adrenalectomies were included in the study at a median patient age of 54 years (IQR43-67). 34% of these were for phaeochromocytoma. Open cases were more prevalent at the start of the study but over half the cases were performed robotically in the current series. Mean operative time reduced over the study period from 264 minutes in 2015 to 108 minutes in 2025. Median length of stay was 5 days (IQR4-7). Conclusion : This case series reflects a change in approach to adrenalectomy. The 10-year period demonstrated a marked transition to robotic adrenalectomy, paralleled by rising case volumes and significant improvements in length of stay, operative time, and blood loss demonstrating the safety and feasibility of robotic adrenalectomy. General Surgery Hepatobiliary & Transplant Surgery Adrenalectomy Robotic surgery Minimally invasive surgery Perioperative outcomes Surgical transition Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Adrenalectomy has evolved significantly since its inception as an open procedure by Sargent in 1912 [ 1 ]. The introduction of laparoscopic adrenalectomy by Gagner in 1992 marked a shift toward minimally invasive techniques, offering reduced morbidity and faster recovery [ 2 ]. Further advancement came with robotic adrenalectomy, first described by Desai in 2002, leveraging enhanced dexterity, 3D visualization, and precision provided by systems like the Da Vinci Xi [ 3 ]. These developments have been supported by substantial evidence demonstrating the safety and efficacy of laparoscopic and robotic approaches over traditional open surgery, particularly for benign and smaller lesions [ 4 – 6 ]. In Ireland, adrenal surgery is performed across various centres, with increasing incidentalomas detected due to advanced imaging [ 7 ]. At The Mater Misericordiae University Hospital (MMUH), a tertiary referral centre, the Hepatobiliary and Pancreatic (HPB) service has transitioned from open to minimally invasive methods, incorporating robotic technology. This study retrospectively reviews a 10-year experience (January 2015 to June 2025) to evaluate changes in surgical practice, case volumes, and key perioperative outcomes, providing insights into the practical implementation of robotic adrenalectomy in an Irish context. The findings were presented at the 16th Biennial Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) 2025 in Dublin, June 10–12. Methods Study Design and Population This was a retrospective cohort study of all adrenalectomies performed by the HPB service at MMUH over a 10-year period from January 2015 to June 2025. Inclusion criteria encompassed all procedures in patients aged > 18 years. Exclusion criteria included combined cases (e.g., adrenalectomy with concurrent major procedures) and paediatric cases. Data was extracted from electronic medical records and the hospital's surgical database. Data Collection Variables collected included patient demographics (age, gender, lesion laterality), histological diagnosis, lesion size, surgical approach (open, laparoscopic, or robotic using Da Vinci Xi), operative time (minutes), estimated blood loss (mL), and length of hospital stay (LOS, days). Annual case volumes and trends in surgical approaches were analysed to assess practice evolution. Statistical Analysis Continuous variables were reported as medians or means with ranges, and categorical variables as frequencies with percentages. Comparisons between groups (e.g., open vs. robotic) used Student's t-test or Mann-Whitney U test for continuous data, and chi-square test for categorical data. Trends over time were visualized using line and bar graphs. Statistical significance was set at p < 0.05. Analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY). Ethical approval was received from institutional research board. Results A total of 61 adrenalectomies were performed during the study period. Baseline characteristics included a median age of 54 years (IQR43-67), with 29 males (48%) and 32 females (52%). Lesion laterality was left in 23 cases (38%), right in 34 (56%), bilateral in 1 case (2%), and para-aortic in 3 cases (5%). Changes in Surgical Approaches and Case Volumes Surgical approaches evolved markedly over the 10 years. Initially, open procedures dominated, accounting for all cases in 2015 (n = 3) and 2016 (n = 3). Laparoscopic adrenalectomy was introduced in 2017 (n = 2) and peaked in 2018 (n = 3). Robotic adrenalectomy began in 2019 (n = 1) and rapidly increased, becoming the predominant approach by 2021 (n = 3) and reaching highs of 10 cases in 2023, 8 in 2024, and 7 in 2025 (up to June). Overall, 2. Of the 47 minimally invasive cases, there was a single conversion from laparoscopic to open for intra-operative blood loss Case volumes increased substantially, from 3 per year in 2015 to a peak of 10 in 2023, reflecting service expansion and greater adoption of minimally invasive techniques (Fig. 1 ). Histology and Lesion Size Histological diagnoses included pheochromocytoma/paraganglioma (n = 21, 34%), adenoma (n = 17, 28%), metastasis (n = 9, 15%), primary malignancy (n = 3, 5%), other (n = 7, 11%), and myelolipoma (n = 4, 7%). Median lesion size was 4cm overall, with larger lesions in open cases (6.5cm) compared to minimally invasive (4cm), consistent with selective use of open approaches for complex pathology (Fig. 2 ). Perioperative Outcomes Median LOS was 4 days for robotic cases, significantly shorter than 6 days for both open and laparoscopic (p < 0.001 vs. open; p < 0.031 vs. laparoscopic; p = 0.591 open vs. laparoscopic) (Fig. 3 ). Mean operative time decreased annually from approximately 250 minutes in 2015 to 120 minutes in 2025, indicative of a learning curve. By approach, mean times were 183 minutes for open, 129 minutes for laparoscopic, and 122 minutes for robotic, with robotic significantly shorter than open (p < 0.006) and comparable to laparoscopic (Fig. 4 ). Median blood loss was 80 mL for robotic, 100 mL for laparoscopic, and 400 mL for open. Minimally invasive approaches showed significantly less blood loss than open (p < 0.001), with robotic outperforming laparoscopic (p < 0.05) (Fig. 5 ). Discussion This 10-year review at MMUH demonstrates a profound shift in adrenalectomy practice, from reliance on open surgery to predominant use of robotic techniques. Early years were characterized by low volumes and open approaches, likely due to established practices and limited access to robotic platforms. The introduction of robotic surgery post-2018 coincided with increased case volumes, driven by growing referrals, surgeon training, and institutional investment in the Da Vinci Xi system. By 2025, robotic adrenalectomy accounted for the majority of cases, aligning with global trends toward minimally invasive surgery for improved precision and ergonomics [ 4 , 5 ]. Perioperative outcomes improved significantly with this transition. Reduced LOS in robotic cases (4 days vs. 6 days) reflects faster recovery, consistent with literature showing benefits in pain control and mobilization [ 6 ]. Operative times decreased over time, suggesting a learning curve effect, with robotic times comparable to laparoscopic but shorter than open, without compromising safety [8]. Blood loss was markedly lower in robotic procedures, potentially due to enhanced visualization and instrument control, reducing transfusion needs and complications [9]. Larger lesions were appropriately managed openly, highlighting selective case allocation to optimize outcomes. Limitations include the retrospective design, small sample size (n = 61), and single-centre focus, which may limit generalizability. Long term outcomes (e.g., recurrence, endocrine function) were not fully captured, warranting future prospective studies. Despite these, the data underscore the feasibility and benefits of robotic adoption in an Irish setting, where adrenal surgery volumes are modest compared to international high-volume centres [ 7 ]. Conclusion Over a decade, MMUH's HPB service transitioned successfully to robotic adrenalectomy, accompanied by rising case volumes and substantial improvements in LOS, operative time, and blood loss. This evolution enhances patient care and supports continued investment in robotic technology for adrenal surgery. Declarations The study was approved by the Mater Misericordiae University Hospital Research Ethics Committee (Reference: 1/378/2456, dated 12 March 2025) under the category of clinical audit and service evaluation. As the research involved analysis of fully anonymized, routinely collected clinical data with no direct patient contact, no identifiable information included in the dataset, and no intervention beyond standard clinical care, informed consent was waived by the ethics committee in accordance with Irish health research regulations and the Declaration of Helsinki. All data was handled in compliance with the General Data Protection Regulation (GDPR) (EU) 2016/679 and local data protection policies. Patient confidentiality was strictly maintained throughout the study. Funding None. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgements We thank the HPB team at MMUH for their contributions to patient care and data collection. This work was presented at the 16 th Biennial Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) 2025 in Dublin, June 10-12. References Heger P, Probst P, Hüttner FJ, Gooßen K, Proctor T, Müller-Stich BP, Strobel O, Büchler MW, Diener MK. Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis. World J Surg. 2017 Nov;41(11):2746-2757. doi: 10.1007/s00268-017-4095-3. PMID: 28634842. Shen ZJ, Chen SW, Wang S, Jin XD, Chen J, Zhu Y, Zhang RM. Predictive factors for open conversion of laparoscopic adrenalectomy: a 13-year review of 456 cases. J Endourol. 2007 Nov;21(11):1333-7. doi: 10.1089/end.2006.450. PMID: 18042025. Gaujoux S, Mihai R; joint working group of ESES and ENSAT. European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg. 2017 Mar;104(4):358-376. doi: 10.1002/bjs.10414. PMID: 28199015. Arezzo A, Bullano A, Cochetti G, Cirocchi R, Randolph J, Mearini E, Evangelista A, Ciccone G, Bonjer HJ, Morino M. Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults. Cochrane Database Syst Rev. 2018 Dec 30;12(12):CD011668. doi: 10.1002/14651858.CD011668.pub2. PMID: 30595004; PMCID: PMC6517116. Economopoulos KP, Mylonas KS, Stamou AA, Theocharidis V, Sergentanis TN, Psaltopoulou T, Richards ML. Laparoscopic versus robotic adrenalectomy: A comprehensive meta-analysis. Int J Surg. 2017 Feb;38:95-104. doi: 10.1016/j.ijsu.2016.12.118. Epub 2016 Dec 30. PMID: 28043926. Vatansever S, Nordenström E, Raffaelli M, Brunaud L, Makay Ö; EUROCRINE Council. Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry. Surgery. 2022 May;171(5):1224-1230. doi: 10.1016/j.surg.2021.12.003. Epub 2022 Jan 10. PMID: 35027208. Ma W, Mao Y, Zhuo R, Dai J, Fang C, Wang C, Zhao J, He W, Zhu Y, Xu D, Sun F. Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma. Eur J Surg Oncol. 2020 Oct;46(10 Pt A):1843-1847. doi: 10.1016/j.ejso.2020.04.001. Epub 2020 May 23. PMID: 32723609. Tables Table 1: Baseline Characteristics Characteristic Value Median age (years) 54 Male/Female 29/32 Laterality (Left/Right/Bilateral/Para-aortic) 23/34/1/3 Approach (Open/Laparoscopic/Robotic) 14/13/34 Table 2: Histology and Lesion Size Histology n (%) Mean Size (cm) PPGL 20 (33) 4.50 Adenoma/Other benign 24 (39) 3.45 Metastasis 7 (11) 5.50 Primary malignancy 6 (10) 18.33 Myelolipoma 3 (5) 7 Other 1 (2) 3 Overall - 6.27 Open - 9.02 Minimally Invasive - 3.74 PPGL: Pheochromocytoma/paraganglioma Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":33919,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart of histological diagnoses (pheochromocytoma/paraganglioma 34%, adenoma 28%, metastasis 15%, primary malignancy 5%, other 11%, myelolipoma 7%).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7992533/v1/59a71b7cf61545ee3f94060f.png"},{"id":95224641,"identity":"eda8b1bf-31e4-4a01-80ba-0faad1f0ff71","added_by":"auto","created_at":"2025-11-05 16:24:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":80484,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel diagram illustrating median LOS by approach (open 6 days, laparoscopic 6 days, robotic 4 days).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7992533/v1/2cc5ffa73abd55eda8d0a9fa.png"},{"id":95119480,"identity":"a8dc4725-743f-4192-bf91-3ff034928563","added_by":"auto","created_at":"2025-11-04 13:42:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35420,"visible":true,"origin":"","legend":"\u003cp\u003eLine graph of mean operative time per year (decreasing trend) and bar graph by approach (open 183 min, laparoscopic 129 min, robotic 122 min).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7992533/v1/cb68b00a387d34f482ee6a67.png"},{"id":95119485,"identity":"fd8b9a19-2b77-44b4-a7a2-d0c78324be32","added_by":"auto","created_at":"2025-11-04 13:42:04","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":15941,"visible":true,"origin":"","legend":"\u003cp\u003eBar graph of median blood loss by approach (open 400 mL, laparoscopic 175 mL, robotic 80 mL).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7992533/v1/b796a92b9590ae45c6d83486.png"},{"id":95230315,"identity":"c1000ced-818f-4854-86b6-50ef2eae38aa","added_by":"auto","created_at":"2025-11-05 16:37:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":595485,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7992533/v1/9a967e6a-72d6-4bfa-925b-25ad3cb1091e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAn Irish Experience of Robotic Adrenalectomy: Transitioning from Open to Robotic Surgery\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdrenalectomy has evolved significantly since its inception as an open procedure by Sargent in 1912 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The introduction of laparoscopic adrenalectomy by Gagner in 1992 marked a shift toward minimally invasive techniques, offering reduced morbidity and faster recovery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Further advancement came with robotic adrenalectomy, first described by Desai in 2002, leveraging enhanced dexterity, 3D visualization, and precision provided by systems like the Da Vinci Xi [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These developments have been supported by substantial evidence demonstrating the safety and efficacy of laparoscopic and robotic approaches over traditional open surgery, particularly for benign and smaller lesions [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Ireland, adrenal surgery is performed across various centres, with increasing incidentalomas detected due to advanced imaging [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. At The Mater Misericordiae University Hospital (MMUH), a tertiary referral centre, the Hepatobiliary and Pancreatic (HPB) service has transitioned from open to minimally invasive methods, incorporating robotic technology. This study retrospectively reviews a 10-year experience (January 2015 to June 2025) to evaluate changes in surgical practice, case volumes, and key perioperative outcomes, providing insights into the practical implementation of robotic adrenalectomy in an Irish context. The findings were presented at the 16th Biennial Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) 2025 in Dublin, June 10\u0026ndash;12.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Population\u003c/h2\u003e\u003cp\u003eThis was a retrospective cohort study of all adrenalectomies performed by the HPB service at MMUH over a 10-year period from January 2015 to June 2025. Inclusion criteria encompassed all procedures in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years. Exclusion criteria included combined cases (e.g., adrenalectomy with concurrent major procedures) and paediatric cases. Data was extracted from electronic medical records and the hospital's surgical database.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eVariables collected included patient demographics (age, gender, lesion laterality), histological diagnosis, lesion size, surgical approach (open, laparoscopic, or robotic using Da Vinci Xi), operative time (minutes), estimated blood loss (mL), and length of hospital stay (LOS, days). Annual case volumes and trends in surgical approaches were analysed to assess practice evolution.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eContinuous variables were reported as medians or means with ranges, and categorical variables as frequencies with percentages. Comparisons between groups (e.g., open vs. robotic) used Student's t-test or Mann-Whitney U test for continuous data, and chi-square test for categorical data. Trends over time were visualized using line and bar graphs. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY). Ethical approval was received from institutional research board.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 61 adrenalectomies were performed during the study period. Baseline characteristics included a median age of 54 years (IQR43-67), with 29 males (48%) and 32 females (52%). Lesion laterality was left in 23 cases (38%), right in 34 (56%), bilateral in 1 case (2%), and para-aortic in 3 cases (5%).\u003c/p\u003e\n\u003ch3\u003eChanges in Surgical Approaches and Case Volumes\u003c/h3\u003e\n\u003cp\u003eSurgical approaches evolved markedly over the 10 years. Initially, open procedures dominated, accounting for all cases in 2015 (n\u0026thinsp;=\u0026thinsp;3) and 2016 (n\u0026thinsp;=\u0026thinsp;3). Laparoscopic adrenalectomy was introduced in 2017 (n\u0026thinsp;=\u0026thinsp;2) and peaked in 2018 (n\u0026thinsp;=\u0026thinsp;3). Robotic adrenalectomy began in 2019 (n\u0026thinsp;=\u0026thinsp;1) and rapidly increased, becoming the predominant approach by 2021 (n\u0026thinsp;=\u0026thinsp;3) and reaching highs of 10 cases in 2023, 8 in 2024, and 7 in 2025 (up to June). Overall, 2.\u003c/p\u003e\u003cp\u003eOf the 47 minimally invasive cases, there was a single conversion from laparoscopic to open for intra-operative blood loss\u003c/p\u003e\u003cp\u003eCase volumes increased substantially, from 3 per year in 2015 to a peak of 10 in 2023, reflecting service expansion and greater adoption of minimally invasive techniques (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eHistology and Lesion Size\u003c/h2\u003e\u003cp\u003eHistological diagnoses included pheochromocytoma/paraganglioma (n\u0026thinsp;=\u0026thinsp;21, 34%), adenoma (n\u0026thinsp;=\u0026thinsp;17, 28%), metastasis (n\u0026thinsp;=\u0026thinsp;9, 15%), primary malignancy (n\u0026thinsp;=\u0026thinsp;3, 5%), other (n\u0026thinsp;=\u0026thinsp;7, 11%), and myelolipoma (n\u0026thinsp;=\u0026thinsp;4, 7%). Median lesion size was 4cm overall, with larger lesions in open cases (6.5cm) compared to minimally invasive (4cm), consistent with selective use of open approaches for complex pathology (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerioperative Outcomes\u003c/h3\u003e\n\u003cp\u003eMedian LOS was 4 days for robotic cases, significantly shorter than 6 days for both open and laparoscopic (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 vs. open; p\u0026thinsp;\u0026lt;\u0026thinsp;0.031 vs. laparoscopic; p\u0026thinsp;=\u0026thinsp;0.591 open vs. laparoscopic) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMean operative time decreased annually from approximately 250 minutes in 2015 to 120 minutes in 2025, indicative of a learning curve. By approach, mean times were 183 minutes for open, 129 minutes for laparoscopic, and 122 minutes for robotic, with robotic significantly shorter than open (p\u0026thinsp;\u0026lt;\u0026thinsp;0.006) and comparable to laparoscopic (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMedian blood loss was 80 mL for robotic, 100 mL for laparoscopic, and 400 mL for open. Minimally invasive approaches showed significantly less blood loss than open (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with robotic outperforming laparoscopic (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis 10-year review at MMUH demonstrates a profound shift in adrenalectomy practice, from reliance on open surgery to predominant use of robotic techniques. Early years were characterized by low volumes and open approaches, likely due to established practices and limited access to robotic platforms. The introduction of robotic surgery post-2018 coincided with increased case volumes, driven by growing referrals, surgeon training, and institutional investment in the Da Vinci Xi system. By 2025, robotic adrenalectomy accounted for the majority of cases, aligning with global trends toward minimally invasive surgery for improved precision and ergonomics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePerioperative outcomes improved significantly with this transition. Reduced LOS in robotic cases (4 days vs. 6 days) reflects faster recovery, consistent with literature showing benefits in pain control and mobilization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Operative times decreased over time, suggesting a learning curve effect, with robotic times comparable to laparoscopic but shorter than open, without compromising safety [8]. Blood loss was markedly lower in robotic procedures, potentially due to enhanced visualization and instrument control, reducing transfusion needs and complications [9]. Larger lesions were appropriately managed openly, highlighting selective case allocation to optimize outcomes.\u003c/p\u003e\u003cp\u003eLimitations include the retrospective design, small sample size (n\u0026thinsp;=\u0026thinsp;61), and single-centre focus, which may limit generalizability. Long term outcomes (e.g., recurrence, endocrine function) were not fully captured, warranting future prospective studies. Despite these, the data underscore the feasibility and benefits of robotic adoption in an Irish setting, where adrenal surgery volumes are modest compared to international high-volume centres [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOver a decade, MMUH's HPB service transitioned successfully to robotic adrenalectomy, accompanied by rising case volumes and substantial improvements in LOS, operative time, and blood loss. This evolution enhances patient care and supports continued investment in robotic technology for adrenal surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThe study was approved by the Mater Misericordiae University Hospital Research Ethics Committee (Reference: 1/378/2456, dated 12 March 2025) under the category of clinical audit and service evaluation. As the research involved analysis of fully anonymized, routinely collected clinical data with no direct patient contact, no identifiable information included in the dataset, and no intervention beyond standard clinical care, informed consent was waived by the ethics committee in accordance with Irish health research regulations and the Declaration of Helsinki. All data was handled in compliance with the General Data Protection Regulation (GDPR) (EU) 2016/679 and local data protection policies. Patient confidentiality was strictly maintained throughout the study.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the HPB team at MMUH for their contributions to patient care and data collection. This work was presented at the 16\u003csup\u003eth\u003c/sup\u003e Biennial Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) 2025 in Dublin, June 10-12.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eHeger P, Probst P, H\u0026uuml;ttner FJ, Goo\u0026szlig;en K, Proctor T, M\u0026uuml;ller-Stich BP, Strobel O, B\u0026uuml;chler MW, Diener MK. Evaluation of Open and Minimally Invasive Adrenalectomy: A Systematic Review and Network Meta-analysis. World J Surg. 2017 Nov;41(11):2746-2757. doi: 10.1007/s00268-017-4095-3. PMID: 28634842.\u003c/li\u003e\n \u003cli\u003eShen ZJ, Chen SW, Wang S, Jin XD, Chen J, Zhu Y, Zhang RM. Predictive factors for open conversion of laparoscopic adrenalectomy: a 13-year review of 456 cases. J Endourol. 2007 Nov;21(11):1333-7. doi: 10.1089/end.2006.450. PMID: 18042025.\u003c/li\u003e\n \u003cli\u003eGaujoux S, Mihai R; joint working group of ESES and ENSAT. European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg. 2017 Mar;104(4):358-376. doi: 10.1002/bjs.10414. PMID: 28199015.\u003c/li\u003e\n \u003cli\u003eArezzo A, Bullano A, Cochetti G, Cirocchi R, Randolph J, Mearini E, Evangelista A, Ciccone G, Bonjer HJ, Morino M. Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults. Cochrane Database Syst Rev. 2018 Dec 30;12(12):CD011668. doi: 10.1002/14651858.CD011668.pub2. PMID: 30595004; PMCID: PMC6517116.\u003c/li\u003e\n \u003cli\u003eEconomopoulos KP, Mylonas KS, Stamou AA, Theocharidis V, Sergentanis TN, Psaltopoulou T, Richards ML. Laparoscopic versus robotic adrenalectomy: A comprehensive meta-analysis. Int J Surg. 2017 Feb;38:95-104. doi: 10.1016/j.ijsu.2016.12.118. Epub 2016 Dec 30. PMID: 28043926.\u003c/li\u003e\n \u003cli\u003eVatansever S, Nordenstr\u0026ouml;m E, Raffaelli M, Brunaud L, Makay \u0026Ouml;; EUROCRINE Council. Robot-assisted versus conventional laparoscopic adrenalectomy: Results from the EUROCRINE Surgical Registry. Surgery. 2022 May;171(5):1224-1230. doi: 10.1016/j.surg.2021.12.003. Epub 2022 Jan 10. PMID: 35027208.\u003c/li\u003e\n \u003cli\u003eMa W, Mao Y, Zhuo R, Dai J, Fang C, Wang C, Zhao J, He W, Zhu Y, Xu D, Sun F. Surgical outcomes of a randomized controlled trial compared robotic versus laparoscopic adrenalectomy for pheochromocytoma. Eur J Surg Oncol. 2020 Oct;46(10 Pt A):1843-1847. doi: 10.1016/j.ejso.2020.04.001. Epub 2020 May 23. PMID: 32723609.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Baseline Characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384px;\"\u003e\n \u003cp\u003eMedian age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384px;\"\u003e\n \u003cp\u003eMale/Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e29/32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384px;\"\u003e\n \u003cp\u003eLaterality (Left/Right/Bilateral/Para-aortic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e23/34/1/3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 384px;\"\u003e\n \u003cp\u003eApproach (Open/Laparoscopic/Robotic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e14/13/34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Histology and Lesion Size\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Size (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003ePPGL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e20 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003eAdenoma/Other benign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e24 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e3.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003eMetastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e7 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003ePrimary malignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e6 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e18.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003eMyelolipoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e6.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e9.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimally Invasive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 178px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 224px;\"\u003e\n \u003cp\u003e3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePPGL: Pheochromocytoma/paraganglioma\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Royal College of Surgeons in Ireland","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adrenalectomy, Robotic surgery, Minimally invasive surgery, Perioperative outcomes, Surgical transition","lastPublishedDoi":"10.21203/rs.3.rs-7992533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7992533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Minimally invasive techniques have become the gold-standard for the surgical management of the majority adrenal pathologies. No consensus exists over the benefit of robotic over laparoscopic adrenalectomy. The aim of the study was to analyse the authors’ experience of adrenalectomy with emphasis on its transition to robotic approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Retrospective data were collated from a prospectively maintained database of all consecutive adult patients undergoing adrenalectomy at the study centre between 1\u003csup\u003est\u003c/sup\u003e January 2015 to 1\u003csup\u003est\u003c/sup\u003e June 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 61 adrenalectomies were included in the study at a median patient age of 54 years (IQR43-67). 34% of these were for phaeochromocytoma. Open cases were more prevalent at the start of the study but over half the cases were performed robotically in the current series. Mean operative time reduced over the study period from 264 minutes in 2015 to 108 minutes in 2025. Median length of stay was 5 days (IQR4-7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This case series reflects a change in approach to adrenalectomy. The 10-year period demonstrated a marked transition to robotic adrenalectomy, paralleled by rising case volumes and significant improvements in length of stay, operative time, and blood loss demonstrating the safety and feasibility of robotic adrenalectomy.\u003c/p\u003e","manuscriptTitle":"An Irish Experience of Robotic Adrenalectomy: Transitioning from Open to Robotic Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 13:42:00","doi":"10.21203/rs.3.rs-7992533/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"83e0478a-54b6-4f4b-87df-bbe1c338d7ed","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57185225,"name":"General Surgery"},{"id":57185226,"name":"Hepatobiliary \u0026 Transplant Surgery"}],"tags":[],"updatedAt":"2025-11-04T13:42:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 13:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7992533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7992533","identity":"rs-7992533","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}