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EDITORIALS |
From the Division of General Surgery, Weill Medical College of Cornell University, New York, New York.
Correspondence: Address correspondence to: Dennis L. Fowler, MD, Division of General Surgery, Weill Medical College of Cornell University, 525 East 68th Street, F-763, New York, NY 10021; Fax: 212-746-5774; E-mail: dlf2001{at}med.cornell.edu
When we first heard that a surgeon had removed the adrenal gland laparoscopically,1 many of us had the following questions: Could it really be done? Should it be done? How could you possibly even see the adrenal gland laparoscopically? Over the next several years, numerous reports of successful series of laparoscopic adrenalectomy cases documented that laparoscopic adrenalectomy was technically possible and that, perhaps, it should be done. Now, in this issue of the Annals of Surgical Oncology, Zeh and Udelsman2 provide us with the results of their series and a comprehensive review of the reported experience with laparoscopic adrenalectomy. Little doubt now remains that we not only can do laparoscopic adrenalectomy, but that we should do laparoscopic adrenalectomy (and even that we can see the adrenal gland laparoscopically).
The authors report their series of 100 patients who had an attempted laparoscopic adrenalectomy and the results are stellar. The postoperative morbidity was 6%, and most of the morbidity was minor. No 30-day postoperative mortality occurred. The recovery of these patients was superior. More than 60% of the patients went home on the first postoperative day. Despite the lack of class I data and, further, despite that the open adrenalectomy controls in their report suffered from an adverse selection bias, it is impossible to dispute their recommendation: "Laparoscopic adrenalectomy is the procedure of choice for the removal of most benign lesions of the adrenal gland." They support that recommendation not only with their own results, but also with a comprehensive review of the previously reported series of significance. Their results confirm and enhance the earlier reports and, in total, provide compelling support that adrenalectomy for benign lesions should be completed laparoscopically.
The authors addressed not only the clinical outcomes, but also the issue of cost. In the comparison of laparoscopic and open adrenalectomy at their institution, they identified a significant cost saving for the institution and society with laparoscopic adrenalectomy. Additionally, they compared the cost at their institution for all types of adrenalectomy with the cost of adrenalectomy reported from other sites in the state of Maryland and documented that the cost at their institution was less than the average reported cost in the rest of the state. They implied that their cost profile was better because their series had a high percentage of laparoscopic adrenalectomies.
Although most of their patients were treated for typically benign lesions, the authors discussed several other aspects of the treatment of adrenal lesions, including indications for laparoscopic treatment of nonfunctioning adrenal masses and the use of laparoscopic adrenalectomy for cancer. They provide good evidence that nonfunctioning adrenal masses <4 cm in size have little risk of harboring cancer and need not be removed. For lesions >4 cm, they recommend resection; however, if no other findings are suggestive of cancer, they recommend laparoscopic adrenalectomy.
Finally, the authors addressed the issue of laparoscopic adrenalectomy for cancer. They admit that no significant studies have examined the outcome of laparoscopic adrenalectomy for primary adrenal cancers. Despite that, they make an aggressive recommendation that known primary adrenal cancers should be resected with open surgery. This is certainly traditional surgical wisdom, yet growing evidence that other types of malignancy may be better treated with minimal access surgery than open surgery3,4 beg the question of why not laparoscopic adrenalectomy for primary adrenocortical cancer, if technically possible. Obviously, more information will be required to answer that question. On the contrary, the authors did support the use of laparoscopic adrenalectomy for the treatment of isolated metastatic disease in the adrenal gland. Again, few data on this topic exist, but their recommendation seems reasonable if the gland can be technically removed laparoscopically.
The biggest remaining issue regarding the use of laparoscopic adrenalectomy is not whether to do it, but who should do it. Should all surgeons do it? Should only endocrine surgeons do it? Should only surgeons with advanced laparoscopic training do it? We know that experienced laparoscopic surgeons reported all of the studies reviewed in this manuscript. The fact that they reported a relatively large number of cases in each series is a testament to that fact. Thus, the results of these series, including the current one, are from surgeons with real expertise in laparoscopic adrenalectomy. We do not know what criteria should be used to determine who should do laparoscopic adrenalectomy, but from my perspective, a surgeon who performs laparoscopic adrenalectomy should have both advanced laparoscopic skills and a good knowledge of adrenal anatomy and pathophysiology.
Because the volume of adrenalectomy cases is not great, this suggests that the surgeon who sees only an occasional patient in need of an adrenalectomy and who does no other advanced laparoscopy should probably not do laparoscopic adrenalectomy. Surgeons who routinely do advanced laparoscopic cases and are knowledgeable about adrenal anatomy and pathophysiology, however, should offer their adrenalectomy patients the laparoscopic approach. Additionally, surgeons who see many patients for adrenalectomy, even if they do not otherwise perform advanced laparoscopy, should learn to perform laparoscopic adrenalectomy. Many laparoscopic adrenalectomy cases are not technically difficult, although they do require two-handed laparoscopic skills. An example of a case that is usually not difficult is laparoscopic adrenalectomy for Conn’s syndrome. Because of undistorted anatomy and a low risk hormonal environment in which to do laparoscopic adrenalectomy, these cases often are routine.
In summary, it now seems clear to me that, although every surgeon should probably not do laparoscopic adrenalectomy, most patients with benign adrenal lesions should have their adrenalectomy completed laparoscopically. This report by Zeh and Udelsman should eliminate open adrenalectomy for most benign lesions.
Received for publication September 3, 2003. Accepted for publication September 23, 2003.
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