Current status of laparoscopic adrenalectomy and future directions

The technique of laparoscopic adrenalectomy has been standardised over recent decades and is now favoured over open surgery for most indications, due to the established short-term benefits associated with laparoscopic surgery. The aim of this series, which is focussed on laparoscopic adrenalectomy, was to elaborate on the technical aspects of adrenalectomy, and to explore more controversial topics, such as the roles of laparoscopic adrenalectomy for large adrenal tumours and partial adrenalectomy. Key issues of patient selection, preoperative work-up and operative technique for both transperitoneal and retroperitoneal laparoscopic adrenalectomy have been elegantly summarised in two articles by Stechman and McCoy et al. (1,2). The retroperitoneal approach is less widely adopted but appears to have an acceptable learning curve when undertaken by experienced laparoscopic surgeons, and may have advantages over a transperitoneal approach, particularly for small or bilateral lesions. The importance of mentorship on reducing the learning curve for retroperitoneal adrenalectomy has been emphasised in the article by van Uitert et al. (3). Although a transperitoneal approach may be more familiar to laparoscopic surgeons, the impact of surgeon experience and volume on postoperative outcomes after transperitoneal adrenalectomy has also been highlighted by Stechman.

With increasing experience, surgeons invariably test the limits of what may be achievable laparoscopically, and the systematic review by Varghese et al. (4) evaluated the feasibility of laparoscopic adrenalectomy for large tumours. In the absence of any high-quality prospective data, they found that a laparoscopic approach was feasible for large tumours (over 6 cm), although tumour size was associated with an increased risk of conversion to open surgery, particularly for phaeochromocytoma. The authors have highlighted the importance of surgeon experience in selecting patients with large tumours for a laparoscopic approach and have advised caution in patients with suspected adrenal cancer. Maintaining oncological principles of achieving an R0 resection without capsular breach is essential and should be prioritised over any potential short-term advantages of laparoscopic surgery. In experienced hands, however, a laparoscopic approach may be considered for selected patients with adrenal cancer, providing that the quality of the oncological resection can be preserved, with a low threshold for conversion to open surgery, especially in the presence of adjacent organ involvement.

On the other end of the spectrum, adrenalectomy is frequently performed for patients with small, benign lesions, which are ideally suited for a laparoscopic approach. A subset of these patients is susceptible to developing bilateral lesions, and there has been a growing interest in the role of partial (or cortical-sparing) adrenalectomy to preserve adrenal function in these patients in order to prevent or delay the onset of adrenal insufficiency that would follow bilateral adrenalectomy. Onuma et al. (5) have undertaken a comprehensive review of the literature on the topic of partial adrenalectomy, including a detailed description of the technical aspects of the procedure. They have also introduced the topic of intraoperative near-infrared imaging after systemic injection of indocyanine green as a potentially useful adjunct during surgery, and merits further study.

It is clear that patient recovery is faster after laparoscopic adrenalectomy, and this is reflected by shorter hospitalization compared to open surgery. Day-case (or outpatient) surgery is a natural progression and has proven to be safe and cost-effective for common procedures such as laparoscopic cholecystectomy. Michelakos et al. (6) performed a scoping review on the topic of outpatient minimally invasive adrenalectomy and found that hospital discharge within 24 hours after surgery was feasible after both transperitoneal and retroperitoneal approaches, and that outpatient adrenalectomy could potentially be applied to a wide spectrum of patients, with the possible exception of phaeochromocytoma. They identified several factors that were associated with failure to discharge patients within 24 hours, such as American Society of Anesthesiologists (ASA) class and body mass index. However, they noted that outpatient adrenalectomy is not widely practised at present and in the absence of prospective studies, it is not possible to clearly define the target group who are most likely to benefit from this approach.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Laparoscopic Surgery for the series “Laparoscopic Adrenalectomy”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-23-8/coif). The series “Laparoscopic Adrenalectomy” was commissioned by the editorial office without any funding or sponsorship. RPS served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Laparoscopic Surgery from February 2022 to January 2024. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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