Pregnancy is a relative contraindication for laparoscopic adrenalectomy, and the procedure is best deferred until after delivery when possible, especially if the adrenal lesion is diagnosed in the third trimester. However, clinical circumstances may mandate surgery during pregnancy. Shalhav et al. (48) summarized the important points of performing laparoscopic adrenalectomy during pregnancy as follows:

■ Perform surgery during the second trimester, because surgery in the first trimester carries a risk of spontaneous abortion and congenital abnormalities, while surgery in the third trimester carries a higher risk of premature labor.

■ Open access is preferred to avoid insufflation of the uterus with resultant CO2 embolism. As an alternative, closed pneumoperitoneum can be created with the subcostal passage of a Veress needle.

■ The pneumoperitoneum should be <12 mmHg.

■ Fetal monitoring should be performed throughout the procedure.

Obesity may make laparoscopic surgery more challenging; however, the obese patient has much to gain from a laparoscopic approach. In obese patients, laparoscopic adrenalectomy has been shown to be more effective than open surgery because it offers significant benefits in terms of postoperative recovery and convalescence (49).

Extensive previous intra-abdominal surgery may preclude a transperitoneal laparoscopic approach; however, the retroperitoneal route may be used (8). Conversely, a transperitoneal approach may be preferable in cases of previous retroperitoneal surgery. In rare cases of extensive previous surgery in both the peritoneal cavity and the retroperitoneum, a transthoracic approach has been described as an option (8). The issue of primary and metastatic adrenal disease is controversial as discussed in the preceding section. Similarly, the upper limit for safe resection with respect to size is also debatable. A maximum of 6 cm was previously recommended (35,50). However, lesions of up to 15 cm have been resected (22,38).

The upper size limit that may be safely resected is not an absolute, arbitrarily defined number, but rather relates to the surgeon's experience, size of the lesion, patient body habitus, surrounding anatomy, and, because right-sided tumors may be intimately associated with the inferior vena cava, the side of the lesion (45).

Gill recommends that laparoscopic adrenalectomy may not be advisable for lesions greater than 10 to 12 cm in diameter (8). At least initially, it would not be unreasonable to use 6 cm as an upper limit for resectability because larger lesions are technically more demanding (34). Age per se is not a contraindication. Laparoscopic adrenalectomy has been well described in pediatric patients via both transperitoneal and retroperitoneal approaches, although the transperitoneal approach may be preferable because of the smaller working space in children (24,51).

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