Minimally Invasive Surgery and Selection in ACC

Localized Disease Management

Minimally invasive surgery (MIS) in adrenocortical carcinoma (ACC) refers primarily to laparoscopic, retroperitoneoscopic, or robotic adrenalectomy used for adrenal tumors that are known or suspected to be ACC. Within localized ACC care, the central question is whether these approaches can achieve the same oncologic goals as open adrenalectomy: complete en bloc removal, negative margins, avoidance of capsular disruption, and prevention of local or peritoneal tumor dissemination.¹² Because ACC is rare, often aggressive, and has limited effective salvage treatment after local failure, operative approach is judged mainly by oncologic adequacy rather than perioperative recovery alone.¹³

The evidence base is limited and consists largely of retrospective institutional series, registry analyses, and systematic reviews of heterogeneous cohorts.⁴³⁵ Selection bias is a major limitation: patients undergoing MIS usually have smaller and less invasive-appearing tumors, whereas open surgery is more often chosen for masses with suspected adjacent organ invasion, venous involvement, nodal disease, or greater technical complexity.⁶⁷ As a result, shorter hospitalization or reduced postoperative morbidity after MIS does not establish equivalent cancer control.

Current reviews and guideline-oriented sources therefore continue to regard open adrenalectomy as the reference approach for known or strongly suspected resectable ACC.¹²⁸ MIS may be considered in a narrow subgroup of patients with apparently localized, noninvasive tumors, particularly in high-volume centers with substantial adrenal and oncologic expertise, but long-term oncologic safety remains uncertain.⁶⁵

Diagnostic and Surgical Context

The operative objective in localized ACC is complete resection without tumor rupture, because local tumor-bed recurrence and peritoneal seeding may compromise the possibility of cure.⁹¹⁰ This distinguishes ACC from most benign adrenal disorders, for which minimally invasive adrenalectomy became standard largely because of lower postoperative pain, fewer complications, and faster recovery.¹¹ In ACC, those perioperative advantages remain relevant but are secondary to margin control and specimen integrity.¹²

Technical experience from benign adrenal surgery therefore has only partial applicability to ACC. Reports describing laparoscopic, retroperitoneoscopic, partial, or device-assisted adrenalectomy show that these methods are feasible across many adrenal lesions, but they do not demonstrate oncologic equivalence for suspected ACC.¹²¹³¹⁴ What is relatively reliable is that MIS platforms are mature in adrenal surgery overall; what is not reliable is the assumption that technical feasibility in benign disease translates into safe oncologic practice for ACC. Clinically, suspected ACC raises the threshold for using MIS even when a center has broad adrenal MIS experience.

Selection for Minimally Invasive Surgery

Patient selection is the main determinant of whether MIS is considered. Across reviews and operative series, the most consistent candidates are patients with apparently localized tumors and no radiographic evidence of adjacent organ invasion, venous tumor thrombus, bulky nodal disease, or distant metastasis.⁶¹⁵ Larger tumors are generally viewed as less suitable for MIS because increasing size is associated with more difficult dissection, higher conversion risk, and greater likelihood of occult invasive disease.⁶⁷

Preoperative uncertainty complicates this decision. Some adrenal masses resected as indeterminate or presumed benign lesions are later found to be ACC, whereas tumors already considered likely to be ACC are more often managed with open surgery from the outset.⁹¹⁰ This distinction is clinically important: inadvertent MIS for occult ACC may occur, but intentional MIS for a lesion strongly suspected to be ACC remains controversial. The practical implication is that increasing preoperative suspicion should generally favor an open oncologic approach rather than a modified minimally invasive one.

Center and surgeon experience probably influence outcomes, although the supporting evidence is indirect and retrospective.⁶⁵ Experienced teams may be better able to select appropriate cases and convert early when oncologic principles are threatened, but no precise volume threshold has been validated. In practice, any use of MIS for ACC is usually framed as a specialized strategy for centers that can also provide prompt open resection when needed.

Operative Approaches

Laparoscopic transabdominal adrenalectomy is the most commonly described MIS approach in ACC. Retrospective data suggest that it can be completed in selected localized tumors, but concerns persist regarding limited exposure for locally advanced disease, adequacy of margins, extent of nodal assessment, and the risk of tumor spillage or peritoneal dissemination.⁹⁴ The most reliable conclusion is that laparoscopy may offer perioperative advantages in selected cases, but these advantages are not dependable surrogates for oncologic quality.²⁷

Retroperitoneoscopic adrenalectomy provides a different route of access and may reduce intra-abdominal manipulation, but ACC-specific evidence is sparse.¹⁶¹⁵ Its restricted working space may be problematic when intact specimen removal is difficult or when unrecognized local invasion is present. The practical implication is that retroperitoneoscopic surgery remains less well supported than transabdominal laparoscopy for suspected ACC.

Robotic adrenalectomy has expanded in adrenal surgery and may reduce conversion rates compared with conventional laparoscopy in selected malignant adrenal cases.⁸ Reviews also suggest improved dexterity and visualization, but long-term ACC-specific oncologic evidence remains limited and costs are higher.⁵ Adjuncts such as fluorescence guidance may improve tissue-plane visualization, but they have not resolved the core ACC question of oncologic adequacy.¹⁷ At present, the most defensible conclusion is technical feasibility rather than proven oncologic equivalence.

Oncologic Outcomes and Patterns of Failure

The main comparative issue is whether MIS preserves local control and survival to the same extent as open adrenalectomy. Retrospective studies and systematic reviews generally support caution, with signals toward higher positive-margin rates, less thorough nodal assessment, and more local or peritoneal recurrence in some minimally invasive cohorts, particularly in patients with more advanced local disease.⁴²³ Other datasets have not shown clear differences in margin status between intent-to-treat MIS and open groups, underscoring how strongly results may be shaped by case selection.⁷

Taken together, the evidence is mixed but does not establish broad equivalence between MIS and open surgery. The most consistent finding is that positive margins are strongly associated with worse outcomes and that tumors with T3 features or other signs of local advancement are poor candidates for MIS.⁴ Clinically, this supports preferring open resection whenever the risk of incomplete excision is more than minimal.

Patterns of failure reported after MIS reinforce these concerns. Case reports and small series describe port-site recurrence, peritoneal carcinomatosis, and local tumor-bed recurrence after laparoscopic resection of ACC.¹⁶¹⁰³ These events are too uncommon and selectively reported to define precise incidence, but they are clinically significant because they may reflect violation of oncologic technique during an operation intended to be curative. The practical implication is a low tolerance for maneuvers that risk capsular disruption, piecemeal removal, or difficult extraction.

Conversion, Pitfalls, and Limits of the Evidence

Conversion from MIS to open surgery is best understood as an oncologic safeguard rather than a procedural failure.⁶¹⁰ Database analyses associate conversion with higher margin positivity, longer hospitalization, and worse survival, but this likely reflects the adverse tumor biology and technical complexity that prompted conversion rather than harm from conversion itself.⁸ What is reliable is that a low threshold for conversion is appropriate when exposure, margin control, or specimen integrity becomes uncertain.

The overall literature has important constraints. ACC is rare, randomized trials are unlikely, and available studies often combine occult ACC, suspected ACC, and other adrenal malignancies across different eras and operative platforms.⁴⁵ Historical and indirect reports are useful for understanding how MIS became established in adrenal surgery and how newer tools may improve operative handling, but they do not answer the central oncologic question for ACC.¹¹¹²¹⁴ The practical implication is that current evidence supports selective use at most, not routine substitution of MIS for open adrenalectomy.

Role in Current Management and Research

In current management, open adrenalectomy remains the standard comparator and generally preferred approach for most patients with known or strongly suspected resectable ACC.¹²⁸ MIS may have a role in carefully selected patients with small, localized, noninvasive-appearing tumors when surgery is undertaken by teams experienced in both adrenal MIS and ACC-specific oncologic judgment.⁶⁵ Its principal potential benefit is reduced perioperative burden; its principal risk is compromise of a potentially curative resection.

Future progress will likely depend on multicenter registries and more granular comparative datasets that separate occult ACC from intentionally selected MIS cases and better account for tumor stage, invasion pattern, and surgeon selection.⁷⁵ Until stronger evidence emerges, the prevailing interpretation is that oncologic completeness should take precedence over minimally invasive recovery benefits, and that MIS in ACC should remain a highly selective rather than routine operative strategy.²³

Included Articles

• PMID 18043254: This review states that when adrenocortical carcinoma is suspected, laparoscopic adrenalectomy is not the standard approach; instead, open adrenalectomy with en-bloc excision is presented as the mainstay for both primary and recurrent disease because effective adjuvant therapy is lacking.¹

• PMID 19216698: In a single-center laparoscopic adrenalectomy series, the small ACC subset showed a more difficult intraoperative course than other adrenal lesions, with longer operative times, greater blood loss, larger tumors, and longer postoperative stays despite laparoscopic completion.¹⁸

• PMID 23414734: In this single-center series of malignant adrenal tumors, laparoscopic adrenalectomy was rarely completed for primary adrenocortical carcinoma and was judged inappropriate for known or suspected ACC because of frequent conversion, concern for inadequate margins, and risk of peritoneal dissemination. Open surgery was favored when imaging suggested local invasion or large tumor burden.⁹

• PMID 24062770: In a Cushing syndrome cohort that included seven adrenocortical carcinomas, one ACC measuring 3.3 cm developed retroperitoneal and peritoneal seeding after laparoscopic adrenalectomy. The report also notes shorter hospitalization with retroperitoneoscopic adrenalectomy versus transabdominal surgery, but raises concern about laparoscopic tumor spillage in ACC.¹⁶

• PMID 24761076: For large adrenal tumors, minimally invasive adrenalectomy was associated with higher bleeding, conversion, and postoperative complication rates than for tumors 6 cm or smaller, but was considered feasible in experienced high-volume hands. The article emphasizes preserving oncologic principles, converting to open surgery when they cannot be maintained, and reserving conventional adrenalectomy for clear radiologic invasion or metastases.⁶

• PMID 27238874: A National Cancer Data Base analysis of ENSAT stage I to III ACC found that laparoscopic adrenalectomy was associated with very limited nodal assessment and, in T3 tumors, higher margin positivity; in stage II disease it was linked to worse overall survival, while positive margins were the strongest mortality predictor.⁴

• PMID 27431446: This systematic review states that for known or suspected adrenocortical carcinoma, open adrenalectomy remains the gold standard. Laparoscopic resection may be feasible only in carefully selected ACC cases without adjacent organ involvement, given retrospective signals of higher positive margins, local recurrence, and peritoneal carcinomatosis.²

• PMID 28043080: This operative review describes laparoscopic retroperitoneal adrenalectomy, including indications that list adrenocortical carcinoma, technical steps for lateral and posterior retroperitoneal approaches, and contraindications such as venous tumor thrombus, extensive local invasion, and large masses over 10 to 12 cm as a relative contraindication.¹⁵

• PMID 29022106: A national database study of localized ACC found increasing use of minimally invasive adrenalectomy from 2010 to 2014, including growth in robotic cases. Tumor size greater than 5 cm was the only significant predictor of conversion to open surgery, while margin status did not differ between minimally invasive and open intent-to-treat groups.⁷

• PMID 29283086: This case report highlights port-site recurrence with occult peritoneal carcinomatosis after laparoscopic adrenalectomy for localized ACC. It supports open adrenalectomy as the preferred approach when ACC is suspected, with minimally invasive surgery reserved for carefully selected cases at experienced centers and a low threshold for conversion.¹⁰

• PMID 29606881: This retrospective single-center study of 42 patients with stage I–III ACC found that open adrenalectomy was associated with longer disease-free survival and better 2-year disease-free survival than laparoscopic adrenalectomy, despite less favorable perioperative metrics. First recurrence after laparoscopy was uniformly local tumor-bed recurrence in this cohort.³

• PMID 31038857: In a mixed adrenalectomy cohort, adrenocortical carcinoma was associated with higher postoperative complication risk and mortality, while larger tumors and higher BMI predicted intraoperative complications. The study also notes laparoscopic adrenalectomy is generally preferred, with exceptions for suspected malignancy and large tumors.¹⁹

• PMID 34724582: In a national cohort of planned minimally invasive adrenalectomy for adrenal malignancies, including many ACC cases, robotic surgery was associated with lower conversion-to-open rates than laparoscopy, while conversion correlated with higher margin positivity, longer hospitalization, and worse overall survival. The excerpt also reiterates that current guidelines still favor open adrenalectomy for most resectable ACC.⁸

• PMID 41042457: This review summarizes robotic adrenalectomy as a minimally invasive option for selected malignant adrenal tumors, reporting high R0 resection rates in well-selected localized cases and low perioperative morbidity. It emphasizes use in experienced, high-volume centers while noting limited long-term oncologic evidence and higher costs.⁵

• PMID 33512630: A retrospective robotic adrenalectomy study found that indocyanine green fluorescence improved quantified visual distinction between adrenocortical tumors and surrounding tissue compared with conventional view. Because ACC and other malignant tumors were excluded, the findings are best interpreted as an indirect technical adjunct relevant mainly to robotic dissection rather than evidence for ACC-specific oncologic safety.¹⁷

• PMID 10367872: A retrospective comparison in primary hyperaldosteronism found fewer postoperative complications with laparoscopic than open adrenalectomy and comparable blood pressure and potassium outcomes, illustrating why MIS became established in benign adrenal surgery. Its relevance to ACC is indirect, as oncologic adequacy for ACC was not studied and only one open-case patient had ACC.¹¹

• PMID 15379930: A 2004 clinical series described single-incision, gasless, portless retroperitoneal endoscopic adrenalectomy as a feasible minimally invasive technique with favorable perioperative results in mixed adrenal tumors. Its ACC relevance is limited because only one patient had adrenocortical carcinoma and no ACC-specific oncologic outcomes were reported.¹²

• PMID 15517476: A large single-center series of posterior retroperitoneoscopic adrenalectomy reported comparable perioperative results for partial and total adrenalectomy in predominantly benign primary adrenal tumors, with long-term functional preservation after partial resection in selected bilateral cases. Because the cohort was not focused on ACC and included only isolated malignant pathology, its relevance is mainly as background on technical scope rather than evidence supporting MIS or partial adrenalectomy for ACC.¹³

• PMID 18986311: A veterinary case series reported technical feasibility of laparoscopic adrenalectomy for selected unilateral adrenocortical carcinomas without vena caval invasion, but its relevance to human ACC is indirect. The described need for capsular opening, aspiration, and piecemeal removal reinforces rather than resolves concerns about specimen integrity and tumor spillage in ACC surgery.²⁰

• PMID 20393338: A 2010 series described clipless, sutureless transperitoneal laparoscopic adrenalectomy using LigaSure, with low blood loss and no conversions in a mixed adrenal-mass cohort. Because the study did not include ACC-specific analysis, it mainly adds a technical note on hemostatic methods rather than supporting MIS oncologic adequacy in ACC.¹⁴

• PMID 27438168: A prospective patient-reported outcomes study found that recovery after laparoscopic adrenalectomy was not immediate: quality-of-life measures were most impaired at 2 weeks and generally returned to baseline by around 4 weeks. Its ACC relevance is indirect because the cohort was mostly benign and included only one ACC case, so it informs convalescence rather than cancer control.²¹

References

Footnotes

1. Current management of adrenal tumors.. Curr Opin Oncol. 2008. PMID: 18043254. Local full text: 18043254.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

2. International Consultation on Urological Diseases and European Association of Urology International Consultation on Minimally Invasive Surgery in Urology: laparoscopic and robotic adrenalectomy.. BJU Int. 2017. PMID: 27431446. Local full text: 27431446.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

3. Open adrenalectomy versus laparoscopic adrenalectomy for adrenocortical carcinoma: a retrospective comparative study on short-term oncologic prognosis.. Onco Targets Ther. 2018. PMID: 29606881. Local full text: 29606881.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

4. Impact of Laparoscopic Adrenalectomy on Overall Survival in Patients with Nonmetastatic Adrenocortical Carcinoma.. J Am Coll Surg. 2016. PMID: 27238874. Local full text: 27238874.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

5. Robotic adrenalectomy: a comprehensive review of perioperative outcomes, comparative efficacy, and technological advancements.. J Robot Surg. 2025. PMID: 41042457. Local full text: 41042457.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

6. Laparoscopic trans- and retroperitoneal adrenal surgery for large tumors.. J Minim Access Surg. 2014. PMID: 24761076. Local full text: 24761076.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

7. Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma: Five-Year Trends and Predictors of Conversion.. World J Surg. 2018. PMID: 29022106. Local full text: 29022106.md ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

8. A comparison of robotic and laparoscopic minimally invasive adrenalectomy for adrenal malignancies.. Surg Endosc. 2022. PMID: 34724582. Local full text: 34724582.md ↩ ↩² ↩³ ↩⁴ ↩⁵

9. Minimally invasive surgery for malignant adrenal tumors.. Surgeon. 2013. PMID: 23414734. Local full text: 23414734.md ↩ ↩² ↩³ ↩⁴

10. Images: Port site recurrence on followup imaging after adrenalectomy for adrenocortical carcinoma - first indicator of carcinomatosis.. Can Urol Assoc J. 2018. PMID: 29283086. Local full text: 29283086.md ↩ ↩² ↩³ ↩⁴ ↩⁵

11. Laparoscopic vs open adrenalectomy for the treatment of primary hyperaldosteronism.. Arch Surg. 1999. PMID: 10367872. Local full text: 10367872.md ↩ ↩² ↩³

12. Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: experience with initial 30 cases.. Int J Urol. 2004. PMID: 15379930. Local full text: 15379930.md ↩ ↩² ↩³

13. Partial versus total adrenalectomy by the posterior retroperitoneoscopic approach: early and long-term results of 325 consecutive procedures in primary adrenal neoplasias.. World J Surg. 2004. PMID: 15517476. Local full text: 15517476.md ↩ ↩²

14. Clipless and sutureless laparoscopic adrenalectomy carried out with the LigaSure device in 32 patients.. Surg Laparosc Endosc Percutan Tech. 2010. PMID: 20393338. Local full text: 20393338.md ↩ ↩² ↩³

15. [Not Available].. Aktuelle Urol. 2016. PMID: 28043080. Local full text: 28043080.md ↩ ↩² ↩³

16. Clinical Characteristics of Endogenous Cushing’s Syndrome at a Medical Center in Southern Taiwan.. Int J Endocrinol. 2013. PMID: 24062770. Local full text: 24062770.md ↩ ↩² ↩³

17. A visual quantification of tissue distinction in robotic transabdominal lateral adrenalectomy: comparison of indocyanine green and conventional views.. Surg Endosc. 2022. PMID: 33512630. Local full text: 33512630.md ↩ ↩²

18. Laparoscopic adrenalectomy: Norwegian single-center experience of 242 procedures.. J Laparoendosc Adv Surg Tech A. 2009. PMID: 19216698. Local full text: 19216698.md ↩

19. Predictors of complication after adrenalectomy.. Int Braz J Urol. 2019. PMID: 31038857. Local full text: 31038857.md ↩

20. Laparoscopic adrenalectomy for treatment of unilateral adrenocortical carcinomas: technique, complications, and results in seven dogs.. Vet Surg. 2008. PMID: 18986311. Local full text: 18986311.md ↩

21. How to Quantify Recovery After Laparoscopic Adrenalectomy: An Assessment of Patient-reported Health-related Quality of Life.. Surg Laparosc Endosc Percutan Tech. 2016. PMID: 27438168. Local full text: 27438168.md ↩