2D versus 3D Laparoscopic Adrenalectomy: A Single-Centre Experience

By Cemil Yuksel¹, Huseyin Pulat¹, Cuneyt Akyuz¹, Serdar Gumus¹, Deniz Oztasan¹, Emel Senol²

Affiliations

1. Department of Surgical Oncology, Mersin City Training and Research Hospital, Mersin, Turkiye
2. Department of Endocrinology, Mersin City Training and Research Hospital, Mersin, Turkiye

doi: 10.29271/jcpsp.2026.08.990

ABSTRACT
Objective: To compare operative performance and perioperative outcomes between two-dimensional (2D) and three-dimensional (3D) laparoscopic systems in minimally invasive adrenalectomy.
Study Design: An observational study.
Place and Duration of the Study: Department of Surgical Oncology, Mersin City Training and Research Hospital, Mersin, Turkiye, from January 2023 to November 2025.
Methodology: Patients who underwent laparoscopic adrenalectomy performed by a single surgeon were retrospectively evaluated. The 2D and 3D laparoscopic systems were compared in operative time, estimated blood loss, tumour size, postoperative complications, conversion to open surgery, and length of hospital stay. Continuous variables were analysed using the independent samples t-test or the Mann–Whitney U test according to the data distribution. Categorical variables were compared using the chi-square or Fisher’s exact test. A p-value of <0.05 was considered statistically significant.
Results: A total of 41 patients were included (3D: n = 22; 2D: n = 19). The 3D group demonstrated significantly shorter operative time [62.5 (60–75) vs. 100 (85–120) minutes; p <0.001], lower intraoperative blood loss [20 (18–20) vs. 200 (100–300) mL; p <0.001], and shorter hospital stay [2 (2–3) vs. 4 (3–7) days; p <0.001]. Tumour size was smaller in the 3D group, although the difference was not statistically significant [40.5 (32–47) vs. 50 (39–70) mm; p = 0.069]. Postoperative complication rates were similar between groups.
Conclusion: 3D laparoscopic adrenalectomy may improve operative performance and perioperative outcomes compared with conventional 2D laparoscopy. However, the retrospective design and relatively small sample size require cautious interpretation of the findings, and larger prospective studies are needed.

Key Words: Laparoscopic adrenalectomy, Three-dimensional laparoscopy, Adrenal tumours, Minimally invasive surgery, Surgical outcomes.

INTRODUCTION

Advances in imaging technologies have led to an increase in the number of incidentally detected adrenal masses. Adrenal masses vary, including functional and non-functional benign and malignant tumours. Functional masses can lead to serious clinical conditions such as Cushing's syndrome, pheochromo- cytoma, and hypertension.¹ Functional adenomas or malignant lesions are treated surgically, while nonfunctional incidenta- lomas are generally managed conservatively. Computed tomo- graphy (CT) or magnetic resonance imaging (MRI) is commonly used to visualise and evaluate adrenal gland masses.

 

While the rate of increase in the United States has reached 40%, an increase in the number of adrenalectomies due to adrenal gland disorders has been reported worldwide in recent years.² The first minimally invasive adrenalectomy was performed in 1992,³ and today, laparoscopic adrenalectomy has become the gold standard, with some exceptions. Minimally invasive adrenal surgery results in less postoperative pain, shorter hospital stays, less blood loss, and a faster return to routine life. However, it is known that the procedure is highly challenging and that performing it without sufficient experience may increase the risk of serious complications.⁴ During open surgery, the surgeon has a three-dimensional (3D) view, while in conventional laparoscopy, the surgeon works with a two-dimensional (2D) image. This situation can cause disorientation and decreased depth perception, increasing the risk of errors (especially bleeding and prolonged operative time).⁵ 3D laparoscopy systems enable us to see anatomical structures more clearly and improve the safety of challenging cases. They achieve this by preserving depth perception, providing higher resolution, and enhancing micro-image clarity.⁶ 3D laparo- scopic systems may improve spatial orientation and operative precision during minimally invasive adrenal surgery.

However, data specifically evaluating the impact of 3D visualisation on adrenalectomy outcomes remain limited. Therefore, this study aimed to compare the operative performance and perioperative outcomes between 2D and 3D laparoscopic adrenalectomy systems.

METHODOLOGY

This retrospective study included a total of 41 patients who underwent laparoscopic adrenalectomy for various adrenal disorders, including Conn syndrome, pheochromocytoma, malignant or benign tumours, and non-functional large adrenal masses, at the Department of Surgical Oncology, Mersin City Training and Research Hospital, Mersin, Turkiye, from January 2023 to November 2025. A single surgeon performed all procedures. During the early study period, procedures were performed using a conventional 2D laparoscopic system. Following the introduction of the 3D visualisation system to this institution, subsequent laparoscopic adrenalectomies were preferentially performed using the 3D platform. Patient data were retrieved from the hospital’s electronic medical records. The study protocol was approved by the Institutional Ethics Committee (Approval No. 48/2025; dated: 20 November 2025) and conducted in accordance with the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent was waived by the institutional ethics committee. Inclusion criteria were adult patients (≥18 years) with adrenal masses identified on imaging studies who were evaluated by the Department of Endocrinology or Medical Oncology, had complete documentation covering both preoperative and postoperative periods and had no history of open surgical procedures. Exclusion criteria were patients <18 years, those who underwent primary open adrenalectomy, patients with metastatic adrenal tumours and cases with incomplete clinical or perioperative data.

For each patient, data collection encompassed demographic characteristics (age and gender), clinical presentation, radiologic findings, type of laparoscopic approach, operative duration, estimated blood loss, need for conversion to open surgery, tumour laterality, indication for surgery, postoperative complications classified according to the Clavien–Dindo system, length of hospitalisation, histopathological results and mortality. Postoperative complications were classified according to the Clavien-Dindo classification system. For statis-tical analysis, complications were evaluated both as a categorical variable according to grade and as a binary variable (presence or absence of any complication). Major complications were defined as Clavien-Dindo grade ≥III. All patients were consulted with the preoperative endocrinology clinic. Estimated blood loss was calculated using a gravimetric method. The preoperative and postoperative weights of the gauze pads were measured, and the amount of blood collected in the suction canister was added to determine the total estimated blood loss.⁷

To obtain anaesthesia clearance for all patients, complete blood count, biochemistry, coagulation profile, ELISAs, urine sampling, and tumour marker tests were performed. Electrocardiography (ECG) and chest X-ray were performed. All patients were consulted with the Endocrinology Clinic for functional assessment. CT or MRI was performed to determine the tumour location. For patients with suspected malignancy, the final decision was made by a tumour board.

A transabdominal approach was used in all patients. Four ports, one of which was a camera, were used in both right and left adrenalectomies. In left adrenalectomy, liver retraction and dissection were performed using laparoscopic instruments inserted through the right port because a Nathanson retractor was not available in the clinic. All patients were placed in the lateral decubitus position. The lateral position was used to utilise gravity.⁸ Port placements are similar for both sides. A Veress needle was inserted just below the costal arch (arcus costarum) to establish a 12 mmHg pneumoperitoneum. Subsequently, a line was drawn between the costal arch and the umbilicus and divided into three equal sections. A 10-mm camera trocar was then inserted through the area closest to the umbilicus (the distal section).

Following this, the other trocars were placed 5 cm to the right and 5 cm to the left of the camera trocar site, immediately below the costal arch. Dissection was performed using LigaSure™, and the adrenal vein was ligated with a metal clip, while the adrenal arteries were ligated with LigaSure™. Full mobilisation was achieved by opening the hepatorenal connections on the right and the splenorenal connections on the left. All specimens were removed from the abdomen using an Endobag to prevent contamination. One Hemovac drain was used for each patient.

The data obtained in the study were analysed using IBM SPSS Statistics software (version 25.0, IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as mean ± standard deviation (SD) for numerical variables, and as number and percentage (%) for categorical variables. The data distribution was evaluated using the Shapiro–Wilk test, and non-parametric tests were employed for variables that did not exhibit a normal distribution. The Mann–Whitney U test was used for comparing continuous variables between the two groups (2D and 3D), while Fisher’s exact test or the chi-square test (χ²) was used, as appropriate, for comparing categorical variables. Effect size (r) was calculated for non- parametric comparisons using the formula: r = Z/√N, where Z represents the standardised test statistic and N the total sample size. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 41 patients were included in the study. Of these, 78% of the patients were female (n = 32), and 22% were male (n = 9). The mean age of the patients was 50.4 ± 11.5 years (25–73 years). Twenty- two patients (54%) underwent surgery with a 3D system, and 19 (46%) with a 2D system. The number of patients who underwent right adrenalectomy was 24 (61.5%), and left adrenalectomy was 17 (38.5%; Table I).

The most common indications for surgery were enlargement (n = 12), pheochromocytoma (n = 12), Cushing's syndrome (n = 10), and Conn's syndrome (n = 7). Pathology results revealed adrenal adenoma (58.5%) as the most common tumour, followed by pheochromocytoma (24.4%), adrenocortical carcinoma (14.6%), and oncocytic neoplasm (2.4%). No significant difference was observed between the groups in age (2D: 50.7 ± 14.2 years vs. 3D: 52.6 ± 13.7 years; p = 0.754). However, operative time, intraoperative blood loss, and length of hospital stay were significantly lower in the 3D group (all p <0.001), with large effect sizes (r = 0.75, r = 0.81, and r = 0.64, respectively). Although tumour size was smaller in the 3D group, the difference did not reach statistical significance [40.5 (32–47) vs. 50 (39–70) mm; p = 0.069; Table II].

Additional multivariable linear regression analyses were performed to evaluate the independent effect of the visualisation system after adjustment for tumour size. In the adjusted model, use of the 3D laparoscopic system remained independently associated with shorter operative time (β = -37.48, 95% CI: -51.49 to -23.47; p <0.001). Similarly, 3D laparoscopy remained independently associated with lower intraoperative blood loss (β = -174.01, 95% CI: -242.03 to -105.99; p <0.001) after adjustment for tumour size.

Table I: Patients’ demographic and clinical characteristics.

Demographic Characteristics	Categories	Values
Age	—	50.4 ± 11.5 (25–73)
Gender	Female	32 (78%)
	Male	9 (22%)
Side	Right	24 (61.5%)
	Left	17 (38.5%)
Visualisation system	3D	22 (53.7%)
	2D	19 (46.3%)
Conversion to open surgery	Yes	2 (4.9%)
	No	39 (95.1%)
Complication (Clavien–Dindo)	Grade I	1 (2.4%)
	Grade II	2 (4.8%)
	Grade IIIA	1 (2.4%)
	Grade IIIB	1 (2.4%)
Indication	Non-functional adrenal mass enlargement	12 (29.3%)
	Pheochromocytoma	12 (29.3%)
	Cushing’s syndrome	10 (24.4%)
	Conn syndrome	7 (17.0%)
Pathology	Adenoma	24 (58.5%)
	Pheochromocytoma	10 (24.4%)
	Adrenocortical carcinoma	6 (14.6%)
	Oncocytic neoplasm	1 (2.4%)

Table II: Comparison of 2D-3D laparoscopic adrenalectomies.

Variables	2D (median [IQR] or mean ± SD)	3D (median [IQR] or mean ± SD)	p-values	Effect size (r)
Age (years)	50.74 ± 14.20	52.59 ± 13.73	0.754	—
Operative time (min)	100 (85–120)	62.5 (60–75)	<0.001	0.75
Intraoperative blood loss (mL)	200 (100–300)	20 (18–20)	<0.001	0.81
Tumour size (mm)	50 (39–70)	40.5 (32–47)	0.069	0.28
Length of hospital stay (days)	4 (3–7)	2 (2–3)	<0.001	0.64
Variables are presented as mean ± SD for normally distributed variables and median (interquartile range, IQR) for non-normally distributed variables. Continuous variables were compared using the Independent Samples t-test or Mann–Whitney U test, as appropriate. Effect size (r) was calculated for non-parametric comparisons using the formula r = Z/√N.

Although tumour size was smaller in the 3D group, the difference did not reach significance (p = 0.069). Among the categorical variables, two patients (10.5%) in the 2D group required conversion to open surgery, while no conversions occurred in the 3D group; however, the difference was not statistically significant (p = 0.21). There were no conversions to open surgery in surgeries performed for adrenal cancer; however, the reasons for conversions were pheochromocytoma and Cushing's syndrome. When complication rates were evaluated according to the Clavien–Dindo classification, no major complications were observed in the 3D group, while one Grade IIIA and one Grade IIIB complication were detected in the 2D group. This difference did not reach statistical significance (p = 0.086). Overall, procedures performed with the 3D laparoscopic system were associated with a significant reduction in operative duration, intraoperative blood loss, and hospital stay, as well as a numerically lower postoperative complication rate.

DISCUSSION

This study analysed surgical outcomes in 41 patients who underwent minimally invasive adrenalectomy at the institution between 2023 and 2025 with a particular focus on assessing the effect of 3D laparoscopic technology on operative performance. All adrenal pathologies were included, except metastatic adrenal tumours. Functional adrenal lesions constituted 70.7% of cases, and pheochromocytoma was the most frequently observed diagnosis (29.3%), consistent with previously published reports.⁹ The results indicate that the use of 3D laparoscopic systems may improve operative ergonomics and perioperative outcomes by decreasing operative duration and length of hospitalisation, as well as by markedly lowering intraoperative blood loss. In contrast, no statistically significant difference was observed between the two groups regarding postoperative complication rates.

Numerous studies have consistently highlighted the safety and efficacy of laparoscopic adrenalectomy. Since Gagner et al.³ first reported the laparoscopic approach to adrenalectomy, minimally invasive techniques have rapidly been adopted as the standard of care. More recently, robotic-assisted adrenalectomy has also emerged as an alternative minimally invasive option.¹⁰ Compared with open adrenalectomy, the laparoscopic approach provides well-established benefits, including reduced postoperative pain, shorter hospitalisation, and more rapid recovery.^11,12 Nevertheless, the lack of depth perception inherent to 2D visualisation may impair spatial orientation, particularly during adrenal vein ligation. Consequently, advanced surgical expertise is required, especially in critical steps such as haemorrhage control, vascular dissection, and venous clipping.¹³

3D laparoscopic technology enhances spatial orientation by maintaining depth perception, enabling more precise evaluation of tissue planes and improving visualisation of the operative field. This feature is especially valuable in anatomically complex regions characterised by dense vascularisation and restricted working space, such as the adrenal gland.^14,15 In the present study, procedures performed using the 3D system were associated with a significantly shorter operative time [62.5 (60–75) vs. 100 (85–120) minutes; p <0.001]. These findings are in agreement with previous reports by Storz et al. and Curro et al.^5,6, which showed that 3D visualisation enhances surgical efficiency, largely through improved hand–eye coordination. With 2D laparoscopic systems, surgeons with limited surgical experience have been shown to have difficulty identifying anatomical structures and accurately assessing the distance between tissues.¹⁶ Some studies have also shown that 3D laparoscopy reduces these errors.¹⁷ The European Association of Endoscopic Surgery (EAES) even advocates that 3D systems reduce operating time.¹⁸ Experimental studies have shown 3D laparoscopy to be superior, which supports the results of this study.¹⁹ Given the technical complexity and relatively low procedural volume of adrenalectomy, improved depth perception provided by 3D systems may facilitate the learning process for minimally invasive adrenal surgery.²⁰

The significantly lower intraoperative blood loss observed in the 3D group may be related to improved depth perception and more precise dissection provided by 3D visualisation systems. Enhanced spatial orientation may facilitate safer vascular control during adrenal vein dissection and reduce inadvertent tissue injury. Similar findings have been reported in previous studies evaluating 3D laparoscopic adrenal surgery.²¹ Although the absolute difference in blood loss between the groups may have limited direct clinical impact in routine adrenalectomy cases, reduced bleeding may still contribute to improved operative field visibility and technical confidence, particularly in anatomically complex procedures or during the learning phase of minimally invasive adrenal surgery. In the present study, lower blood loss in the 3D group was also accompanied by shorter operative time and reduced hospital stay.¹⁶ Moreover, additional multivariable analyses adjusted for tumour size demonstrated that the association between 3D laparoscopy and improved operative outcomes remained statistically significant, suggesting that the observed differences were not solely attributable to differences in tumour size between the groups. Complication rates were generally low. One patient (2.4%) experienced Clavien–Dindo grade I, grade IIIA, and grade IIIB complications, while two patients (4.8%) experienced grade II complications. The absence of major complications in the 3D group, although not statistically significant, is clinically significant. Complication rates reported in the literature generally range from 5% to 15%,²² and the present results, at 12.1%, are consistent with this range. Two patients had adrenal insufficiency, and one patient had both adrenal insufficiency and an abscess, which was drained with an external catheter. Another patient developed postrenal acute kidney injury, and the last patient developed a pancreatic leak, which resolved with medical treatment. Furthermore, the conversion rate to open surgery in this study was 4.9%, which is similar to rates ranging from 3% to 7% reported in previous large series.^23,24 This finding suggests that minimally invasive adrenal surgery can be performed safely in experienced hands.

Although several studies have reported technical advantages associated with 3D laparoscopy, certain limitations should also be considered. Some authors have described visual discomfort, eye fatigue, nausea, diplopia, and difficulties related to depth adaptation during prolonged procedures using 3D systems,²⁵ In addition, the higher cost of 3D imaging platforms and the potential influence of the learning curve may limit their widespread implementation, particularly in low-volume centres. Furthermore, although statistically significant, some perioperative advantages observed with 3D systems may have limited direct clinical impact in routine adrenalectomy cases.

This study has several limitations that should be acknow- ledged. First, its retrospective single-centre design may have introduced selection bias and limited the generalisability of the findings. Second, the relatively small sample size reduced the statistical power of subgroup analyses and may have affected the interpretation of perioperative outcomes. Because of the retrospective design of the study, a formal pre-study sample size calculation was not performed.

In addition, tumour size differences between the 2D and 3D groups may have acted as a confounding factor influencing operative time and intraoperative blood loss. In addition, the impact of the learning curve associated with the transition from 2D to 3D laparoscopy was not specifically evaluated and may also have influenced perioperative outcomes.

Furthermore, the cost analysis of the 3D system was beyond the scope of the present study. Nevertheless, all procedures were performed by a single experienced surgeon using a standardised surgical technique, which reduced technical variability between cases. Larger prospective multicentre studies are required to validate these findings.
 

CONCLUSION

3D laparoscopic adrenalectomy may improve operative performance and perioperative outcomes compared with conventional 2D laparoscopy, particularly with respect to operative time, intraoperative blood loss, and length of hospital stay. However, the retrospective design, limited sample size, and potential selection bias require cautious interpretation of these findings. Larger prospective multicentre studies are needed to further validate the clinical advantages of 3D laparoscopic systems in adrenal surgery.

ETHICAL APPROVAL:
The study was approved by the Non-Interventional Clinical Research Ethics Committee of Mersin City Training and Research Hospital, Mersin, Turkiye (Approval No. 2025/48; dated: 20 November 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki.

PATIENTS’ CONSENT:
Due to the retrospective nature of the study and the use of anonymised patient data, the requirement for informed consent was waived.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTIONS:
CY: Study design, data collection, surgical supervision, statistical analysis, and manuscript writing.
HP, CA, DO: Data collection and revision.
SG: Manuscript review.
ES: Endocrine evaluation and clinical data review.
All authors approved the final version of the manuscript to be published.

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