In the laparoscopic retroperitoneal technique, the patient is positioned prone (i.e. lying face down) and the adrenal gland is approach through the back. Three small incisions are made beneath the ribcage. This cavity is then inflated, with carbon dioxide gas. The top of the kidney is identified and the adrenal vein is tied off. As with the anterior technique the gland is placed into a bag but usually the tumor does not need to be morcellated and the incisions do not need to be made bigger in order to remove the adrenal gland.
The major benefit of the retroperitoneal approach is that the surgeon does not need to move any other organs out of the way (i.e. spleen, liver, pancreas, colon, etc.) because the adrenal gland lies right against the ribcage in the back. This technique means that it may be performed faster than the traditional transabdominal approach. In addition, this may be a better technique for patients having both adrenal glands removed (because the patient does not need to be "flipped over" in order to get to the other side) and for those with extensive scar tissue in their abdomen from previous surgery. In addition, some surgeons feel that patients have less post-operative pain. This approach is not recommended for tumors over 6 cm in size and for morbidly obese patients.