Abdominal Radiology

, Volume 44, Issue 1, pp 140–153 | Cite as

What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques

  • Steven P. Rowe
  • Carolina Lugo-Fagundo
  • Hannah Ahn
  • Elliot K. Fishman
  • Jason D. PrescottEmail author


Adrenalectomy is the standard of care for management of many adrenal tumor types and, in the United States alone, approximately 6000 adrenal surgeries are performed annually. Two general approaches to adrenalectomy have been described; (1) the open approach, in which a diseased adrenal is removed through a large (10–20 cm) abdominal wall incision, and (2) the minimally invasive approach, in which laparoscopy is used to excise the gland through incisions generally no longer than 1–2 cm. Given these disparate technique options, clear preoperative characterization of those specific disease features that inform selection of adrenalectomy approach is critically important to the surgeon. Because most of these features are directly assessed via preoperative abdominal imaging, in particular computed tomography (CT) scanning, a clear mutual understanding among surgeons and radiologists of those adrenal tumor features impacting operative approach selection is vital for planning adrenal surgery. In this context, we review the preoperative CT imaging features that specifically inform adrenalectomy approach selection, provide illustrative examples from our institution’s imaging and surgical archives, and provide a stepwise guide to both the open and laparoscopic adrenalectomy approaches.


Laparoscopy Adrenal Adrenalectomy Computed tomography Adrenocortical carcinoma 


Compliance with ethical standards


None/not applicable.

Conflict of interest

All authors declare that they have no conflict of interest.

Institutional Review Board (IRB) approval

Not required

Ethical approval

This article does not contain any studies with animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Brunt ML, Salles A (2017) Adrenal Incidentaloma. In: Cameron JL, Cameron AM (eds) Current surgical therapy. Philadelphia: Elsevier, pp 749–755Google Scholar
  2. 2.
    Fergany AF (2016) Adrenal masses: a urological perspective. Arab J Urol 14:248–255CrossRefGoogle Scholar
  3. 3.
    Guazzoni G, Cestari A, Montorsi F, et al. (2001) Current role of laparoscopic adrenalectomy. Eur Urol 40:8–16CrossRefGoogle Scholar
  4. 4.
    Elfenbein DM, Scarborough JE, Speicher PJ, Scheri RP (2013) Comparison of laparoscopic versus open adrenalectomy: results from American College of Surgeons-National Surgery Quality Improvement Project. J Surg Res 184:216–220CrossRefGoogle Scholar
  5. 5.
    Lachenmayer A, Cupisti K, Wolf A, et al. (2012) Trends in adrenal surgery: institutional review of 528 consecutive adrenalectomies. Langenbecks Arch Surg 397(7):1099–1107CrossRefGoogle Scholar
  6. 6.
    Janetschek G (1999) Surgical options in adrenalectomy: laparoscopic versus open surgery. Curr Opin Urol 9:213–218CrossRefGoogle Scholar
  7. 7.
    Gill IS (2001) The case for laparoscopic adrenalectomy. J Urol 166:429–436CrossRefGoogle Scholar
  8. 8.
    Porpiglia F, Miller BS, Manfredi M, Fiori C, Doherty GM (2011) A debate on laparoscopic versus open adrenalectomy for adrenocortical carcinoma. Horm Cancer 2:372–377CrossRefGoogle Scholar
  9. 9.
    Feo CV, Portinari M, Maestroni U, et al. (2016) Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients. Surg Endosc 30:3532–3540CrossRefGoogle Scholar
  10. 10.
    Miller BS, Gauger PG, Hammer GD, Doherty GM (2012) Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy. Surgery 152:1150–1157CrossRefGoogle Scholar
  11. 11.
    Cooper AB, Habra MA, Grubbs EG, et al. (2013) Does laparoscopic adrenalectomy jeopardize oncologic outcomes for patients with adrenocortical carcinoma? Surg Endosc 27:4026–4032CrossRefGoogle Scholar
  12. 12.
    Autorino R, Bove P, De Sio M, et al. (2016) Open versus laparoscopic adrenalectomy for adrenocortical carcinoma: a meta-analysis of surgical and oncological outcomes. Ann Surg Oncol 23:1195–1202CrossRefGoogle Scholar
  13. 13.
    Payabyab EC, Balasubramaniam S, Edgerly M, et al. (2016) Adrenocortical cancer: a molecularly complex disease where surgery matters. Clin Cancer Res 22:4989–5000CrossRefGoogle Scholar
  14. 14.
    Natkaniec M, Pedziwiatr M, Wierdak M, et al. (2016) Laparoscopic transperitoneal lateral adrenalectomy for large adrenal tumors. Urol Int 97:165–172CrossRefGoogle Scholar
  15. 15.
    Warda MH, Shehata SM, Zaiton F (2016) Chemical-shift MRI versus washout CT for characterizing adrenal incidentalomas. Clin Imaging. 40(4):780–787CrossRefGoogle Scholar
  16. 16.
    Seo JM, Park BK, Park SY, Kim CK (2014) Characterization of lipid-poor adrenal adenoma: chemical-shift MRI and washout CT. AJR Am J Roentgenol 202(5):1043–1050CrossRefGoogle Scholar
  17. 17.
    Panda A, Das CJ, Dhamija E, Kumar R, Gupta AK (2015) Adrenal imaging (Part 1): imaging techniques and primary cortical lesions. Indian J Endocrinol Metab 19(1):8–15CrossRefGoogle Scholar
  18. 18.
    Williams AR, Hammer GD, Else T (2014) Transcutaneous biopsy of adrenocortical carcinoma is rarely helpful in diagnosis, potentially harmful, but does not affect patient outcome. Eur J Endocrinol 170(6):829–835CrossRefGoogle Scholar
  19. 19.
    Vanderveen KA, Thompson SM, Callstrom MR, et al. (2009) Biopsy of pheochromocytomas and paragangliomas: potential for disaster. Surgery 146(6):1158–1166CrossRefGoogle Scholar
  20. 20.
    Mazzaglia PJ, Monchik JM (2009) Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: a decade of experience. Arch Surg 144(5):465–470CrossRefGoogle Scholar
  21. 21.
    Kumar R, Dey P (2016) Fine-needle aspiration cytology of non-neoplastic adrenal pathology. Diagn Cytopathol 44(6):472–476CrossRefGoogle Scholar
  22. 22.
    National Institute of Health (2002) NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci Statements 19:1–25Google Scholar
  23. 23.
    Hobart MG, Gill IS, Schweizer D, Sung GT, Bravo EL (2000) Laparoscopic adrenalectomy for large-volume (≥ 5 cm) adrenal masses. J Endourol 14:149–154CrossRefGoogle Scholar
  24. 24.
    Aksakal N, Agcaoglu O, Barbaros U, et al. (2015) Safety and feasibility of laparoscopic adrenalectomy: what is the role of tumour size? A single institution experience. J Minim Access Surg 11:184–186CrossRefGoogle Scholar
  25. 25.
    Serji B, Souadka A, Benkabbou A, et al. (2016) Feasibility and safety of laparoscopic adrenalectomy for large tumours. Arab J Urol 14:143–146CrossRefGoogle Scholar
  26. 26.
    Rao N, Ramachandran R, Tandon N, Singh P, Kumar R (2016) Laparoscopic adrenalectomy for pheochromocytoma-does size matter? A single surgeon comparative study. Transl Androl Urol 5:780–783CrossRefGoogle Scholar
  27. 27.
    Schteingart DE, Doherty GM, Gauger PG, et al. (2005) Management of patients with adrenal cancer: recommendations of an international consensus conference. Endocr Relat Cancer 12:667–680CrossRefGoogle Scholar
  28. 28.
    Huynh KT, Lee DY, Lau BJ, et al. (2016) Impact of laparoscopic adrenalectomy on overall survival in patients with nonmetastatic adrenocortical carcinoma. J Am Coll Surg 223:485–492CrossRefGoogle Scholar
  29. 29.
    Donatini G, Caiazzo R, Do Cao C, et al. (2014) Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach. Ann Surg Oncol 21:284–291CrossRefGoogle Scholar
  30. 30.
    Wajchenberg BL, Albergaria Pereira MA, Medonca BB, et al. (2000) Adrenocortical carcinoma: clinical and laboratory observations. Cancer 88:711–773CrossRefGoogle Scholar
  31. 31.
    Azoury SC, Nagarajan N, Young A, et al. (2017) Computed tomography in the management of adrenal tumors: does size still matter? J Comput Assist Tomogr 41(4):628–632CrossRefGoogle Scholar
  32. 32.
    Fishman EK, Deutch BM, Hartman DS, et al. (1987) Primary adrenocortical carcinoma: CT evaluation with clinical correlation. AJR Am J Roentgenol 148:531–535CrossRefGoogle Scholar
  33. 33.
    Johnson PT, Horton KM, Fishman EK (2009) Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls. Radiographics 29:1333–1351CrossRefGoogle Scholar
  34. 34.
    Rowe SP, Hawasli H, Fishman EK, Johnson PT (2016) Advances in the treatment of oligometastatic disease: what the radiologist needs to know to guide patient management. Acad Radiol 23:326–328CrossRefGoogle Scholar
  35. 35.
    Adler JT, Mack E, Chen H (2007) Equal oncologic results for laparoscopic and open resection of adrenal metastases. J Surg Res 140:159–164CrossRefGoogle Scholar
  36. 36.
    Uberoi J, Munver R (2009) Surgical management of metastases to the adrenal gland: open, laparoscopic, and ablative approaches. Curr Urol Rep 10:67–72CrossRefGoogle Scholar
  37. 37.
    Mazeh H, Froyshteter AB, Wang TS, et al. (2012) Is previous same quadrant surgery a contraindication to laparoscopic adrenalectomy? Surgery 152:1211–1217CrossRefGoogle Scholar
  38. 38.
    Agha A, Iesalnieks I, Hornung M, et al. (2014) Laparoscopic trans- and retroperitoneal adrenal surgery for large tumors. J Minim Access Surg 10:57–61CrossRefGoogle Scholar
  39. 39.
    Agrusa A, Romano G, Frazzetta G, et al. (2014) Laparoscopic adrenalectomy for large adrenal masses: single team experience. Int J Surg 12(Suppl 1):S72–S74CrossRefGoogle Scholar
  40. 40.
    Sameh WM, Kotb AF (2015) Open adrenalectomy for medium sized adrenocortical tumour: how I do it? Can Urol Assoc J 9(5–6):E291–E293CrossRefGoogle Scholar
  41. 41.
    Miller BS, Else T (2017) AACE Adrenal Scientific Committee. Personalized care of patients with adrenocortical carcinoma: a comprehensive approach. Endocr Pract 23(6):705–715CrossRefGoogle Scholar
  42. 42.
    Bittner JGT, Brunt LM (2012) Evaluation and management of adrenal incidentaloma. J Surg Oncol 106:557–564CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Steven P. Rowe
    • 1
  • Carolina Lugo-Fagundo
    • 1
  • Hannah Ahn
    • 1
  • Elliot K. Fishman
    • 1
  • Jason D. Prescott
    • 2
    Email author
  1. 1.The Russell H. Morgan Department of Radiology and Radiological ScienceJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of SurgeryJohns Hopkins University School of MedicineBaltimoreUSA

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