■ Thoracoscopic transdiaphragmatic technique is a novel minimally invasive procedure.

■ In patients with a surgically virgin abdomen, laparoscopic adrenalectomy done with the technically simpler transperitoneal or retroperitoneal approaches is recommended and preferred.

■ A thoracoscopic transdiaphragmatic approach through the virgin thoracic cavity may be reasonable in the rare patient with surgical adrenal pathology and prior major abdominal surgery precluding transperitoneal and retroperitoneal laparoscopy.

■ Necessary requirements for thoracoscopic transdiaphragmatic surgery include anatomical familiarity and considerable experience with thoracoscopic and transabdominal laparoscopy.

■ In the future, thoracoscopic and transabdominal laparoscopy could be combined to provide a minimally invasive alternative to open surgical thoracoabdominal incision in patients with larger adrenal (25) or upper pole renal masses.

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