Laparoscopic adrenalectomy approaches: a 15-year experience in the search for a tailored procedure.

Aim. This study reports single-institution experience with anterior, flank lateral and submesocolic approaches in laparoscopic adrenalectomy (LA). Methods. The study population was 267 patients who underwent LA from 1994 to 2008 at our institution. The choice of surgical route (anterior, anterior submesocolic or flank lateral) was based on patient characteristics (body-mass index, previous abdominal surgery) and lesion features (size, side, secreting mass, pheochromocytoma, suspected malignancy). The submesocolic approach, as described in 2005, was used for left-sided lesions ≤7-8 cm and in non-obese patients; the flank lateral approach was used in obese or previously operated patients. Of a total of 267 patients, 116 underwent right LA by the anterior and 4 by the flank lateral approach; 88 underwent left LA by the anterior, 37 by the submesocolic, and 22 by the flank lateral approach. Results. The mean operating time was: 80.1 min (range, 65-125) for right anterior and 93 min (range, 96-145) for right flank lateral LA; 108 min (range, 80-305) for left anterior, 56.2 min (range, 38-105) for submesocolic, and 80.5 min (range, 54-125) for flank lateral LA. Major intraoperative complications requiring conversion to open surgery occurred in 7 patients: bleeding (5); splenic colonic flexure tear (1); and hypertension with severe arrhythmia in pheochromocytoma removal (1). There were no significant statistically differences in length of hospital stay or analgesic medications after anterior, flank lateral or submesocolic LA; the mean operating time was significantly shorter with use of the anterior and submesocolic approaches. Conclusion. In the authors' experience, tailoring the LA approach according to patient and lesion characteristics is both safe and effective. In selected cases, the operating time is shorter by the submesocolic appraoch.