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Invited Critique
March 16, 2009

Effect of Laparoscopy on the Indications for Adrenalectomy—Invited Critique

Arch Surg. 2009;144(3):259. doi:10.1001/archsurg.2008.552

The indications for adrenalectomy were developed before the introduction of laparoscopy. Tumors larger than 5 cm, tumors between 3 and 5 cm with worrisome features or in young patients who would require prolonged follow-up, and functioning tumors are generally accepted reasons to recommend adrenalectomy. In this article, Henneman and others reviewed their 20-year experience with adrenal surgery to determine whether the indications for operation have changed with the introduction of LA at their center. They conclude that the indications for surgery have remained constant during the study period. However, the authors note a dramatic increase in the number of adrenalectomies performed, from 66 cases to 203 cases after the introduction of LA. The laparoscopic era was further divided into 5-year intervals. An increase from 81 cases in the first 5-year period to 122 cases in the latter period was noted. The authors state that the recruitment of an endocrine surgeon with experience in LA might explain the increase in the latter 5 years. They also note that increased imaging, which has identified more adrenal incidentalomas, and greater emphasis placed on endocrine disease at their center are other possible reasons for the growth.

The data the authors present seem to suggest to us that the indications for adrenalectomy may have broadened somewhat during the study. First, the large increase in the number of operations during the study period is not completely explained by the factors that the authors suggest are causative. Second, the mean tumor size decreased significantly in the laparoscopic era from 5.6 cm in the first 5 years to 4.4 cm in the second 5 years. The ASA classification also changed between the pre- and post-LA eras, with 9% of patients in the first 10 years being in class III, while 22% were in class III in the second period. Both of these latter findings suggest a trend toward recommending operations to patients who might have previously been observed.

The indications for adrenalectomy have served patients well, with the most benefit being provided to those who really need an operation and a major risk being avoided by those who do not need an operation. Broadening the indications for adrenalectomy because of the minimally invasive nature of laparoscopy will not increase overall benefit to patients but will only subject more to unnecessary risk.

Correspondence: Dr Prinz, Department of General Surgery, Rush University Medical Center, 1653 W Congress Pkwy, 785 Jelke, Chicago, IL 60612 (rprinz@rush.edu).

Financial Disclosure: None reported.