Since 1992 LA has become the standard treatment in patients with small benign adrenal masses [
1]. When comparing with open technique, LA offered better clinical outcomes, reduced surgical trauma, lower perioperative morbidity and mortality, shorten hospitalization and better cosmetic results [
2]. In order to reduce surgical trauma and improvement clinical postoperative outcome several authors developed posterior retroperitoneoscopic adrenalectomy (PRA). A randomized clinical trial by Barczynski et al. [
18] showed excellent results of both techniques, anterior and posterior, in unilateral small tumors with statistically significant advantage of PRA in operative time, blood loss and postoperative course. However, the retroperitoneal approach reduced its benefits in the case of larger adrenal masses, so this approach could be preferred for bilateral small lesions and for patients with multiple past abdominal surgery that increased the risk of intraoperative complications and rate of conversion to the open surgery [
19]. Laparoscopic surgery was also more difficult to learn than open surgery because required different psychomotor skills. Robotic adrenalectomy (RA) presented multiple advantages with three-dimensional vision and increased degrees of freedom of the surgical instruments. A recent meta-analysis [
20] that included 798 patients compared operative parameters and clinical outcomes between RA and LA. The authors concluded that RA was a safe and feasible technique with reduced blood loss and shorter hospital stay than LA. Laparoscopic approach seemed to be a more rapid technique when comparing to RA. On the other hand, some authors considered the use of 3D laparoscopic technology with a traditional transperitoneal approach so as to combine the advantages of a standardized and diffused surgical procedure with an improved vision [
21]. These authors analyzed LA for particular deep location of adrenal loggia with theoretical maximum advantage of a 3D system. The results showed the better visualization in depth perception with effect on surgical precision but without significant differences in term of operative time and intraoperative complications [
22,
23]. In our study we registered pre-operative data like ASA score, radiological features and hormonal tests. In literature age and ASA score were direct related to increased of length of hospital stay and postoperative complications [
24]. Radiological features and tumor size appeared as a very important predictive parameter of outcome. The results showed the large adrenal masses (> 6 cm) were associated with duration of surgery and with an increased risk of intraoperative incident. Many author reported lesion diameter over 5–6 cm as independent predictive factors for conversion [
25,
26]. Functioning masses and in particular pheochromocytomas required longer operative time to identify the adrenal vein but these differences were no statistically significant. From analysis of partial operative time we also demonstrated that in large adrenal masses significantly increased the time necessary to approach the adrenal loggia. First exposure of adrenal gland by section of triangular and coronary liver ligament on the right side and splenocolic and splenophrenic ligament on the left side must be performed carefully in order not to damage diaphragm, spleen and pancreatic tail. Bleeding was the main intraoperative complications and injuries of the vena cava, renal vein or hepatic vein represented a real dangerous situation with increased conversion rate [
27].We did not report conversion to open surgery. In case of intraoperative complications we performed a conservative laparoscopic management of vascular, splenic and diaphragmatic injuries. The conversion instead was mandatory in case of intraoperative evidences of malignancy like periadrenal tissue infiltration or vascular invasion. We considered capsular disruption as an intraoperative complication too. Literature data suggested that the main limitation during laparoscopic dissection for large and potentially malign adrenal tumors was incomplete resection and capsular disruption with increased risk of local recurrence and intra-abdominal neoplastic dissemination [
28], but the tumor size per se could not be considered as an absolute controindication to LA. A correct preoperative patients selection and a meticulous surgical technique could limit that risk. Postoperative complication rate was 5% with one blood transfusion and three respiratory diseases. According to Dindo-Clavien scale rate we considered medical or surgical complications with grade ≥ 2 for statistical analysis with no significant correlation between mean tumor size, histological type and postoperative outcome (
p value > 0.05). Coste T. et al. [
24] reported that postoperative medical complications were mainly respiratory diseases and various infections.