Myelolipomas of the adrenal gland are rare benign neoplasms made up of adipose and myeloid tissue. It was first described in 1905 by Gierke, owing its name to Oberling [1] .

Clinically, they are asymptomatic and are usually diagnosed incidentally. When there is any clinical manifestation, the most common is pain, either abdominal or lumbar [2] . The size is usually less than 5 cm, although myelolipomas have been described as giants up to 34 cm and almost 6 kg in weight [3] .

Right laterality is more common in 75% of cases and may even be bilateral in 3.7% of cases. The average age of presentation is between 37 and 65 years, with the male-female ratio being 1 to 1.1 [4] . The size is usually less than 5 cm, although myelolipomas have been described as giants up to 34 cm [5] .

Surgical resection is recommended for lesions larger than 4 or 5 cm due to the risk of hemorrhage. Currently, the preferred approach is the laparoscopic route, which offers advantages over open surgery such as shorter hospital stay, faster recovery, less blood loss, and less postoperative pain [6] .

Adrenal myelolipomas are usually an incidental finding and are mostly diagnosed at the time of work-up for other suspected diseases [6] . The diagnosis also emerged incidentally in the current case series.

Medical literature reveals the prevalence of a tumor in the right adrenal gland, as seen in Table 1 [7] . This was not our case; three of them were in the left adrenal gland and three on the right.

Another intriguing observation from this case series is that, as mentioned in the literature, these tumors are small [8] .

However, in the present case series, 4 of 6 tumors were larger and measured about 8 cm. Figure 7 shows the size of the specimens in our case series.

Although a greater size poses a threat for malignant transformation, in the present study, all the cases were benign.

Furthermore, the greater the size, the greater the probability of spontaneous rupture; in all our cases, none of them presented as a spontaneous retroperitoneal bleeding [9] .

In all cases, the management was a laparoscopic adrenalectomy with a transperitoneal approach. Table 2 shows the intraoperative outcomes of our case series. Several retrospective and comparative studies have addressed the advantages of minimally invasive adrenalectomy, specifically in terms of less postoperative pain, improved patient satisfaction, shorter hospital stay, and recovery time when compared to open adrenalectomy [10] .

The laparoscopic transabdominal lateral adrenalectomy is currently the most widely used approach [11] .

This technique effectively managed all our cases. In our cases, the first peritoneal access is made 2 cm below the right or left costal margin in the midclavicular line with CO₂ is at a pressure of 15 mmHg. Optical access Place a 10- to 12-mm trocar for the endoscope in the pararectal line, 5cm above the umbilicus. Under direct vision, position the second 10 - 12 mm trocar medially next to the first one. The third trocar (5 mm) is inserted 3 cm above the anterior superior iliac spine in the anterior axillary line. The fourth trocar (5 mm) is inserted at the subcostal angle. The key factor for adequate exposure is effective dissection of the Toldt fascia. We ligate the vascular structures with Hem-O-Lock and then use ultrasonic energy to dissect the adrenal gland. We extract the adrenal through a Gibson-type incision, leaving a Penrose drain in all cases, which we remove upon the patient’s discharge.

Surgical treatment for adrenal masses is usually warranted when the lesions are clinically significant, hormonally active, or of considerable size. The likelihood of cancer increases notably for tumors larger than 6 cm, which is recognized as the threshold for surgery. Small, non-functioning tumors can be safely monitored with yearly imaging, whereas those greater than 7 cm typically require removal due to a higher risk of malignancy [12] .

Giant myelolipomas (over 10 cm) are frequently linked to complications during surgery, such as bleeding, capsule rupture, and increased chances of local recurrence. Open radical adrenalectomy remains the standard procedure in cases of large myelolipomas or emergencies involving bleeding or rupture [13] . The largest recorded myelolipoma excised was 31 × 24.5 × 11.5 cm in size and weighed 6 kg, completed via open surgery by Akamatsu [14] .

The minimally invasive approach, first described by Gagner in 1992, has become increasingly favored. It offers advantages like less postoperative pain, shorter hospital stays, and faster recovery, making laparoscopic adrenalectomy the preferred option for smaller, benign lesions such as adrenal myelolipomas [15] .

Several studies in the literature have examined the use of laparoscopic techniques for the removal of giant adrenal myelolipomas. Adrenal myelolipomas with diameters greater than 10 cm have been successfully approached using transperitoneal laparoscopy. Notably, none of the cases reviewed required conversion to open surgery, which underscores the feasibility of laparoscopic management for such large tumors [16] .

Minimally invasive procedures offer clear advantages over traditional open surgery, including reduced pain, decreased blood loss, shorter hospital stays, quicker recovery times, and a lower risk of surgical site infections. In all cases reviewed, no complications related to laparoscopic techniques were observed [17] . The current series was effectively managed via a transperitoneal laparoscopic approach, with postoperative follow-up confirming an uncomplicated recovery.

In conclusion, adrenal myelolipoma is an asymptomatic, nonfunctional adrenal mass. Giant myelolipomas require surgical treatment and given their large diameter and potential for hemorrhagic rupture, open surgery may be an option in those cases. There are different advantages of the minimally invasive approach compared with the traditional approach: less pain, shorter hospitalization, and faster recovery, as reported in our study. Our cases suggest that >10 cm myelolipoma could be removed safely with a laparoscopic approach, without any intra- or postoperative complication, providing a better outcome to the patient.

Conceptualization, H.D. F and R.M.; methodology, H.D.F.; data curation, H.D.F.; writing—original draft preparation, H.D.F.; writing—review and editing, H.D. F and G.C.; supervision, H.D. F and R.S. All authors have read and agreed to the published version of the manuscript.

Consent for treatment and open access publication was obtained or waived by all participants in this study. Clinical Trials issued approval NCT06525467. Consent for treatment and open access publication was obtained or waived by all participants in this study. Mexican Institute of Social Security issued approval 98235522. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. The study was registered in ClinicalTrials.gov.

Consent for treatment and open access publication was obtained or waived by all participants in this study. PRS Clinical Trials issued approval NCT0625.

The original data presented in the study are openly available via e-mail at huber_576@hotmail.com .