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.