This paper outlines the indications and techniques of laparoscopic surgery for malignant adrenal
tumors. Laparoscopic surgery is not indicated for adrenal
tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. When laparoscopic surgery is performed for a
tumor without invasion that has a maximum diameter of more than 6 cm or a
tumor that is considered potentially malignant from preoperative imaging or endocrine studies, it is important to inform the patient and family that the
tumor may be malignant and that
conversion to open surgery may be necessary. The transperitoneal approach is appropriate for primary adrenal
malignancies. For metastatic
cancer, the transperitoneal approach is suitable for radical surgery and the extraperitoneal approach for histological diagnosis by partial resection or
tumor biopsy. In either case, it is important for the surgeon to have a sufficiently wide working space, to remove the
tumor and surrounding fat en bloc, to never grasp the
tumor or adrenal tissue, and to carefully handle the ultrasonically activated scalpel or ultrasonic aspirator so that it does not touch the
tumor surface due to the risk of
tumor cell dissemination. It is also essential not to unreasonably persist with laparoscopic procedures, but to immediately switch to open surgery when laparoscopic surgery becomes difficult.