Laparoscopic
adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal
tumors, but it is not indicated for
tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic
adrenalectomy for metastatic adrenal
malignancy is a feasible procedure, in the case of primary adrenal
malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal
tumors >6 cm or for
tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the
tumors may be malignant and that
conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the
tumor and surrounding fat en bloc, and never grasp the
tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the
tumor surface because this will create a risk of
tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.