A bilateral pheochromocitoma in a 50 year old man with von Recklinghausen syndrome and previous splenectomy was treated by a two-step procedure. Non symptoms of pheochromocitoma were reported and the adrenal masses were detected at control CT scan performed to complete the assessment of the familial neurofibromatosis.

Mass size was 5 cm on both sides, since the right adrenal had a disomogeneous pattern, its laparoscopic removal was first performed. With the patient laying in a left lateral Gagner position, 4 ports are introduced. The adrenal vein is first searched with great care during dissection in order to avoid haemodynamic intra-operative complications. After the vein is clipped and divided, the dissection of the gland is completed by ultrasonic shears. Small oozing is controlled and the specimen extracted with a retrieval bag. One month later the patient underwent a left adrenalectomy through a posterior endoscopic approach. The patient lays in prone position. Three ports are inserted below the 11th and 12th ribs and the main landmarks, left kidney superior pole and spine are searched. Dissection by harmonic shears is continued upward till the mass is found. The adrenal vein is clipped and divided. Careful dissection of the gland is then accomplished. At the end, the specimen is withdrawn with a retrieval bag.

Histology showed a malignant pheochromocitoma on the right side, a benign pheochromocitoma on the left. Patient was discharged on postoperative day 3 after the first surgery and postoperative day 2 after the last operation. Postoperative courses were uneventful.

The endoscopic posterior approach to adrenalectomy is advised in patients with previous splenectomy or surgery on the upper left quadrant.