Optimization of surgical technique has been an important component in reducing the morbidity and mortality associated with the procedure in the postoperative period. Even though minimally invasive techniques for adrenalectomy have been employed in many surgical centres, there is a need of surgeons and trainees to be confident with open adrenalectomy. Patients with large adrenocortical tumors (>6-8 cm) and those with CT suspicion of being locally invasive with adrenocortical cancers should undergo surgery with an open approach. Adequate exposure for a large right adrenal tumour is always challenging. On many occasions, the tumour may be adherent to the vena cava, involve the right liver segments or may be functional/ highly vascular. In such situations, the traditional liver mobilization entails a high risk of bleeding, tumour rupture, liver laceration, or uncontrolled hypertension due to handling of the tumour. The appropriate approach in these could be an anterior hepatectomy approach with liver hanging manoeuvre.

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