The serendipitous detection of adrenal masses, known as adrenal incidentalomas, has been increasing in recent years, as a result of the growing use of radiological examinations. The prevalence of adrenal incidentalomas is up to 10%, and these numbers make it critical to define the best management to avoid wasting of resources. The most recent guidelines of the European Society of Endocrinology (ESE) and European Network for the Study of Adrenal Tumors (ENSAT) provide useful recommendations for the management of adrenal incidentalomas, also as regards surgical treatment. Hormonal assessment should always be performed before surgery, because hormonal excess is reported in 30–50% of cases and can influence the pre-, peri- and postoperative management. The risk of malignancy should be simultaneously evaluated, since malignant tumors are found in up to 8% of patients. A multidisciplinary approach should be implemented by an expert team, particularly in the event of indeterminate adrenal masses. As for surgery, a minimally invasive approach should be preferred when possible. Adrenalectomy should be performed in high-volume surgical centers, by expert surgeons.