Most studies show that the results of laparoscopic adrenalectomy for cancer are similar to those of open adrenalectomy, without the morbidity of an open approach. It is important to note, however, that: (1) the diagnosis of ACC was often made retrospectively without clinical recognition of a malignant tumor preoperatively; (2) most of the tumors removed laparoscopically showed no suspicious features of ACC preoperatively, and thus may represent earlier stage or less biologically aggressive tumors; and (3) small, retrospective cohort series do not establish equivalency between techniques. Although concerns have been raised regarding the risks of peritoneal carcinomatosis, local recurrence, and port-site metastases following laparoscopic adrenalectomy , most larger cohort series have not observed an increased frequency of these events [11,31,46,98,99,100]. Furthermore, in larger cohort studies or prospective nonrandomized studies, laparoscopic resection of other more common primary intra-abdominal malignancies (colon and renal cell) have not demonstrated an increased risk of local recurrence, peritoneal dissemination, or port site recurrence [99,104109]. In our view, a laparoscopic approach is contraindicated for known malignant primary adrenal tumors, or those tumors with local or vascular invasion (see Fig. 1). A laparoscopic approach can be used for most incidentalomas, because the risk of a primary malignant adrenal tumor is low [14,15]. A primary malignant adrenal tumor is more likely if the following findings are present: (1) large size; (2) hypersecretion of multiple hormones, and imaging studies demonstrating local or vascular invasion; (3) adjacent lymphadenopathy; or (4) the presence of metastases [13,16,28,31]. Imaging features such as irregular margins, heterogeneity, and attenuation coefficients >10 HU on noncontrast CT have also been cited to be more common in malignancy , but may also be seen in benign lesions . Laparoscopic resection is appropriate in selected patients with solitary metastases to the adrenal gland from cancers of the lung, kidney, colon, breast, and melanoma, and the indications for laparoscopic metastasectomy should be the same as for an open approach.
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