Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach

Table 1 Indications and relative contraindications for each surgical approach

Indications	Relative contraindications
OS-A
Adrenocortical carcinoma with radiographic evidence of extra-adrenal extension (stage III-IV)	Amenable to minimally-invasive approach
Extension of adrenal vein tumor thrombus into IVC
Size larger than 10-12 cm	Size < 10 cm
Concomitant open procedure
Paraganglioma
Multiple prior abdominal surgeries
MI-A
Non-functioning and functioning adrenal tumors, including pheochromocytoma	Locally-advanced tumors (stage III-IV)
Isolated adrenal metastases	Known, relatively large adrenocortical carcinoma (complete resection is essential for cure)
Size < 10 cm	Size larger than 10-12 cm
Adrenocortical carcinoma, consider only if stage I-II and < 10 cm	Multiple prior abdominal surgeries (or discussion of possibility of conversion)
BMI ≥ 30 kg/m2
LESS-A
For patients who consider cosmesis to be of great importance	Surgeon inexperience with LESS-A
Size < 4-5 cm	Size > 5 cm
Non-functioning and functioning adrenal tumors, including pheochromocytoma	Adrenocortical carcinoma
Isolated adrenal metastases	Multiple prior abdominal surgeries
BMI < 30 kg/m2

OS-A: Open surgical adrenalectomy; MI-A: Minimally-invasive adrenalectomy; LESS-A: Laparoendoscopic single-site adrenalectomy; BMI: Body mass index.

Table 2 Outcomes from select studies comparing minimally-invasive adrenalectomy to open surgical adrenalectomy

Ref.	N	Mean tumor size (cm)	ACC or MET (%)1	OT (min)	EBL (mL)	LOS (d)	Conversion (%)	Complications (%)
Assalia et al[116]	581 MI-A	2.8	0.9	184	154	2.9	-	10.9
	753 OS-A	4.1	5.8	162	309	7.2	-	35.8
Lee et al[59]	358 MI-A	-	13.6	174	-	4.1	-	3.6
	311 OS-A	-	44.5	234	-	9.4	-	17.4
Eichhorn-Wharry et al[119]	1980 MI-A	-	4.1	146	-	2.8	-	1.8
	592 OS-A	-	18.4	186	-	6.7	-	7.6
Lombardi et al[120]	30 MI-A	7.7	100	135	-	5.3	0	3.4
	126 OS-A	9	100	129	-	9.3	-	5.6
Mir et al[121]	18 MI-A	7	100	298	1500	4	24	5.0
	26 OS-A	13	100	273	1100	6	-	20.0
Donatini et al[79]	13 MI-A	5.5	100	-	-	7	0	8.0
	21 OS-A	6.8	100	-	-	9	-	14.0
Bittner et al[122]	356 MI-A	3.2	5.9	159	-	2.5	6.2	11.0
	46 OS-A	8.5	28.2	197	-	9.1	-	50.0

¹Preoperative indication of ACC or isolated adrenal metastasis. ACC: Adrenocortical carcinoma; MET: Metastasis to adrenal gland; OT: Operative time; EBL: Estimated blood loss; LOS: Length of hospital stay; OS-A: Open surgical adrenalectomy; MI-A: Minimally-invasive adrenalectomy.

Table 3 Summary of the most recent meta-analyses comparing laparoscopic techniques for adrenalectomy

Ref.	RAL-A vs MI-A	TL-A vs RL-A	LESS-A vs MI-A
	Brandao et al[30]	Nigri et al[27]	Wang et al[41]
n	600	1205	443
Mean tumor size (cm)	3.86, 3.78	4.0, 3.3	2.7, 3.43
(Odds ratio, CI)	NA	0.48 (-0.21-1.18)	- 0.69 (-1.11--0.26)
P-value	NS	0.17	0.002
Mean operating time (min)	175, 148	132, 136	113.1, 92.7
(Estimate, CI)	5.88 (-6.02-17.79)	-11.07 (-41.38-19.24)	14.97 (4.69-25.24)
P-value	0.33	0.47	0.004
Mean EBL (mL)	44, 69	115, 85	74.2, 79.7
(Estimate, CI)	-18.21 (-29.11--7.32)	29.7 (-10.32-69.72)	-1.4 (-9.72-6.91)
P-value	< 0.0001	0.15	0.74
Mean LOS	3.78, 3.17	6.4, 5.5	3.82, 4.38
(Estimate, CI)	-0.43 (-0.56--0.30)	0.66 (-0.11-1.43)	-0.5(-1.02-0.02)
P-value	< 0.0001	0.09	0.06
Mean % conversion rate	4.4, 7.1	7.23, 7.74	7.8, 1.2
(Odds ratio, CI)	0.82 (0.39-1.75)	NA	4.66 (0.88-24.64)
P-value	0.61	NA	0.07
Mean % complication rate	3.6, 6.8	8, 6	14.2, 10.1
(Odds ratio, CI)	-0.04 (-0.07--0.00)	0.923 (0.58-1.46)	1.83 (0.88-3.81)
P-value	0.05	0.73	0.1

RAL-A: Robot-assisted laparoscopic adrenalectomy; MI-A: Minimally-invasive adrenalectomy; TL-A: Transpeitoneal laparoscopic adrenalectomy; RL-A: Retroperitoneal laparoscopic adrenalectomy; LESS-A: Laparoendoscopic single-site adrenalectomy; EBL: Estimated blood loss; LOS: Length of hospital stay.

Table 4 Laparoendoscopic single-site adrenalectomy vs minimally-invasive adrenalectomy: Overview of the outcomes from available comparative studies (adapted from Rane et al[8] and Wang et al[41])

Ref.	N	Mean tumor size (cm)	ACC or MET (%)1	OT (min)	EBL (mL)	LOS (d)	Conversion (%)	Complications (%)
Jeong et al[36]	9 TLESS-A	2.9	0	169	178	3.2	11 (1 to MI-A)	11
	17 MI-A	4.3	0	145	205	3.5	5.8 (1 to OS-A)	5.8
Walz et al[40]	47 RLESS-A	2.3	2.1	56	< 10	2.4	8.5 (to TLESS-A)	8.5
	47 TLESS-A	2.6	0	40	< 10	3.1	0	6.4
Ishida et al[39]	10 TLESS-A	2.8	0	125	12	5.2	0	0
	10 MI-A	4.5	0	120	15	6.9	0	0
Shi et al[38]	19 RLESS-A	2.1	0	55	30	6	0	11
	38 MI-A	2.4	0	42	18	6	0	7.9
Kwak et al[123]	10 TLESS-A	3.3	0	127	-	4.5	0	10
	12 MI-A	3	8	113	-	4.1	0	-
Vidal et al[124]	20 TLESS-A	3	0	95	Min	3.0	0	0
	20 TL-A	3	0	80	Min	2.5	0	0
Wang et al[125]	13 TLESS-A	2	7.7	149	79	5.2	0	31
	26 TL-A	2.4	0	113	93	6.3	0	12
Tunca et al[126]	22 TLESS-A	3.3	0	64	48	2.45	-	0
	74 TL-A	4.7	4.1	68	38	3	-	0
Lin et al[127]	21 RLESS-A	-	0	145	Min	2	0	0
	28 MI-A	-	0	95	50	4	0	3.6

¹Preoperative indication of ACC or isolated adrenal metastasis. ACC: Adrenocortical carcinoma; MET: Metastasis to adrenal gland; OT: Operative time; EBL: Estimated blood loss; LOS: Length of hospital stay; TLESS-A: Transperitoneal LESS-A; RLESS-A: Retroperitoneal LESS-A.