Laparoscopic adrenalectomy for malignant lesions: surgical principles to improve oncologic outcomes

Laparoscopic adrenalectomy (LA) is the treatment of choice for benign adrenal lesions. Size of the lesion and radiologic features define the risk for malignancy. In lesions at high risk of malignancy, the experience with the laparoscopic approach is limited and therefore controversial. The purpose of this study was to determine the feasibility and oncological safety of LA for malignant disease.

Retrospective analysis of prospectively collected database. All LA performed in our department from 2003 to 2011 were reviewed and demographic, perioperative, and follow-up data for those who had malignancy in the final histological report was analyzed. Data are presented as mean ± standard deviation or median (range).

Of 121 LA, we identified 20 patients with 21 malignant adrenal pathologies: 11 primary tumors, 5 adrenocortical carcinoma, 5 large B cell lymphoma, and 1 leiomyosarcoma. Ten metastatic lesions included 5 malignant melanoma (1 patient, both sides), 4 adenocarcinoma, and 1 renal cell carcinoma. There was no conversion to laparotomy. Tumor size was 4.5 (1-9.5) cm, operative duration was 79 (42-262) min, and estimated blood loss was 40 (0-250) ml. All patients resumed regular diet on postoperative day 1, and the median length of stay was 2 days after surgery. Two patients died at 6 and 24 months postoperatively. Three patients were lost to follow-up. All the rest of the patients were disease-free at a follow-up of 58 (7-96) months.

LA for primary or metastatic malignant lesions is feasible and seems oncologically safe. Surgical principles should be the same for all LA: en bloc resection of all epinephric fat, minimal touch technique, and low threshold for conversion. Size of the lesion alone should not be an indication for open surgery.