Abstract
<title>Abstract</title> <p>Background Exposure during retroperitoneal laparoscopic adrenalectomy (RLA) can be limited by a confined working space, adherent perinephric fat, and loss of orientation after peritoneal breach. We developed a standardized four-plane technique using the renal capsule and renal fascia as sequential landmarks. This study describes the operative sequence and reports technical completion and in-hospital outcomes. Methods This single-center retrospective case series included 102 patients with selected unilateral adrenal tumors smaller than 6 cm who underwent four-plane RLA at Kaifeng Central Hospital between January 2018 and December 2024. Four surgically defined relatively avascular interfaces were developed after opening the lateroconal fascia. The primary endpoint was completion of the planned four-plane exposure and intended laparoscopic adrenalectomy without open conversion. Secondary endpoints included major injury, intraoperative adverse events, operative time, estimated blood loss, in-hospital postoperative complications, and recovery variables. Outcomes were summarized descriptively, with exact 95% confidence intervals for selected proportions. Results All 102 procedures were completed laparoscopically (100%; 95% CI, 96.4–100), with no open conversion or major visceral or vascular injury (each 0%; 95% CI, 0–3.6). Mean operative time was 48.3 ± 6.5 min and mean estimated blood loss was 10.8 ± 5.4 mL. Six intraoperative adverse events occurred: two peritoneal breaches and four superficial renal capsule lacerations; all were managed laparoscopically. Eight patients developed mild postoperative subcutaneous emphysema that resolved without intervention (Clavien–Dindo grade I); no grade II or higher in-hospital postoperative complication was recorded. Median time to oral intake was 12 h and median postoperative hospital stay was 4 days. Follow-up was available for 97 patients; no recurrence was documented over a median 24 months, although surveillance was not uniform. Conclusions In this selected single-center cohort, the anatomical four-plane technique achieved complete laparoscopic exposure and adrenalectomy without open conversion. These uncontrolled findings support technical feasibility and describe the in-hospital safety profile, but do not establish superiority over conventional RLA. Prospective comparative studies are required to define optimal indications, learning curve, and reproducibility. Trial registration: Not applicable.</p>