Though laparoscopic adrenalectomy is considered standard care for most adrenal pathologies requiring surgery, it is still an uncommon procedure. General and urologic surgery residents perform relatively few adrenal cases during their training and unless practicing in a tertiary care center, many surgeons will rarely see such pathology. A survey of general surgery residents showed they performed on average 1.5 laparoscopic adrenalectomies during their training.9
A survey of urology residents showed only about one-third of responders performed 1 to 5 cases during the year prior to responding to the survey.10
This relative unfamiliarity with adrenal surgery might explain some of the apprehension to attempt laparoscopic adrenalectomy in general.
Maccabee et al8
stated that extra training is needed to overcome the learning curve of this advanced procedure, while Reynolds et al11
felt differently, stating that an experienced laparoscopic surgeon could be taught a variety of complex procedures including laparoscopic adrenalectomy with minimal extra training. This might hold especially true for the modern trained urologic surgeon who is familiar with the anatomy and the similar dissection between laparoscopic adrenalectomy and laparoscopic nephrectomy. All surgeons in the current study were experienced laparoscopists, and we have shown that this diverse group of surgeons can perform this procedure with low complication and open conversion rates.
We saw no difference in outcomes based on the size of the adrenal mass, pathology, or BMI regardless of laterality. Similar to our findings, Ramacciato12
did not show a negative correlation between outcomes and tumor size. This is contrary to Shen et al13
who showed that size >5cm, BMI>25, and pheochromocytoma were all significant independent risk factors associated with complication and conversion rates. Rosoff stated in a recent review that for experienced surgeons, size, suspicion of malignancy, or invasive disease should not be considered an absolute contraindication to laparoscopic adrenalectomy.5
We also saw no difference in outcome for right or left adrenalectomy in patients with previous abdominal surgery. Morris et al14
showed a trend for longer operative times in patients with previous surgery, but this difference was not significant.
Surgery on the right adrenal gland has been thought to be more difficult than the surgery on the left. This belief is anecdotal and mainly based on the retrocaval location of the right adrenal gland and short adrenal vein coming directly off of the vena cava. However, this study shows that right-sided operative time is significantly less difficult, and there was a trend towards less EBL for the right side as well. Several plausible explanations exist for these findings. It is important to remember that the left side can also be difficult because of the close proximity to the tail of the pancreas, the splenic vasculature, and the unforgiving nature of the spleen itself. Varkarakis et al15
reported an 8% rate of distal pancreatic injury with laparoscopic adrenalectomy. The left side also requires dissection of the left renal hilum to gain vascular control of the adrenal vein, which potentially increases the complexity of the left-sided procedure. This may explain one of the reasons we found increased time needed to perform left-sided versus right-sided laparoscopic adrenalectomy. Another explanation for increased time to perform left-sided adrenalectomy is that on the left side the splenic flexure requires more mobilization than the right colon. The liver reflection often only requires simple retraction. Lezoche16
also observed faster times for right adrenalectomy versus left (80 versus 109 minutes), but this difference was not statistically significant.
One shortcoming this study suffers from, based on its retrospective design, is selection bias. We could not account for the experience of each individual surgeon. However, in a pool of 27 surgeons, it was assumed that the difference of experience between the 2 cohorts would be minimal. We note that our surgeons performed twice as many left-sided adrenalectomies as right-sided. It is unclear whether this finding represented a difference in management of other right-sided adrenal pathology that was either observed, treated medically, or for which patients underwent open right-sided adrenalectomy. Some surgeons likely preferentially performed open right-sided adrenalectomy for large tumors or pheochromocytomas based on previous biases. We did not search or compare rates of open adrenalectomy in our hospitals for the same time period since the focus of our study was to specifically address the perceived belief that laparoscopic right adrenalectomy is more difficult than left. The question of whether to approach certain adrenal pathologies by open or laparoscopic procedures was beyond the scope of this study. Including the open data in our cohorts may, in fact, have introduced results that would not have addressed our original question.