The indications for laparoscopic adrenalectomy are basically the same as those for open adrenalectomy, with few exceptions. These indications include the following:

1. Functional adrenal cortical masses: (1) Cushing's syndrome caused by benign cortisol-producing adenoma; (2) Cushing's disease after failed pituitary surgery or after failure to control or find an ectopic adrenocorticotropic hormone (ACTH)-producing tumor; (3) aldosterone-producing adenoma (Conn's syndrome); and (4) rare virilizing/feminizing secreting tumors

2. Functional medullary adrenal masses: benign adrenal pheochromocytoma

3. Nonfunctional adrenal tumors: (1) benign-looking incidentalomas (nonfunctioning adenomas) confined to the adrenal glands and meeting accepted criteria for adrenalectomy (>4 cm at presentation or growth during follow-up); (2) benign symptomatic lesions; and (3) rare entities such as cyst and myelolipoma

Laparoscopic adrenalectomy has been reported for several other conditions10"12 but is not currently considered standard. These include neuroblastoma and congenital adrenal hyperplasia in children and isolated adrenal metastases.

General contraindications for laparoscopy include unacceptable cardiopulmonary risk and uncorrectable/untreated coagulopathy. Additional relative contraindications for laparoscopic approach include previous surgery or trauma in the direct vicinity of the adrenal gland, diaphragmatic hernia, and surgeon's inexperience.3 Obesity and previous major abdominal surgery are no longer contraindications for laparoscopic adrenalectomy.

Currently, in experienced hands, the only specific absolute contraindications to laparoscopic adrenalectomy are known large adrenocortical carcinoma with frank tumor invasion to adjacent structures and metastatic pheochromocytoma to periaortic nodes. In these cases, an open procedure is preferred to allow an en bloc resection and node dissection to be performed.

Although controversy exists over the maximum acceptable tumor size for laparoscopic adrenalectomy, laparoscopy may not be generally advisable for adrenal tumors larger than 12 to 14 cm because of the technical difficulties associated with such surgery and the malignant potential of these large tumors. Nevertheless, the indications and contraindications of laparoscopic adrenalectomy are currently dictated mainly by the experience of the individual laparoscopic surgeon.

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