Factors affecting the surgical approach and timing of bilateral adrenalectomy Billy Y. Lan • Halit E. Taskin • Erol Aksoy • Onur Birsen • Cem Dural • Jamie Mitchell • Allan Siperstein • Eren Berber Received: 17 April 2014 / Accepted: 4 September 2014 Ó Springer Science+Business Media New York 2014 Abstract Background Laparoscopic adrenalectomy has gained widespread acceptance. However, the optimal surgical approach to laparoscopic bilateral adrenalectomy has not been clearly defined. The aim of this study is to analyze the patient and intraoperative factors affecting the feasibility and outcome of different surgical approaches to define an algorithm for bilateral adrenalectomy. Methods Between 2000 and 2013, all patients who underwent bilateral adrenalectomy at a single institution were selected for retrospective analysis. Patient factors, surgical approach, operative outcomes, and complications were analyzed. Results From 2000 to 2013, 28 patients underwent bilateral adrenalectomy. Patient diagnoses included Cush- ing’s disease (n = 19), pheochromocytoma (n = 7), and adrenal metastasis (n = 2). Of these 28 patients, successful laparoscopic adrenalectomy was performed in all but 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while three were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and patient body habitus in one. Of the adrenalectomies completed using the mini- mally invasive approach, a posterior retroperitoneal (PR) approach was performed in 17 patients and lateral trans- abdominal (LT) approach in 9 patients. Patients who underwent a LT approach had higher BMI, larger tumor size, and other concomitant intraabdominal pathology. Hospital stay for laparoscopic adrenalectomy was 3.5 days compared to 5 and 12 days for the two open cases. There were no 30-day hospital mortality and 5 patients had minor complications for the entire cohort. Conclusions A minimally invasive operation is feasible in 93 % of patients undergoing bilateral adrenalectomy with 65 % of adrenalectomies performed using the PR approach. Indications for the LT approach include morbid obesity, tumor size [ 6 cm, and other concomitant intra- abdominal pathology. Single-stage adrenalectomies are feasible in most patients, with prolonged operative time causing respiratory instability being the main indication for a staged approach. Keywords Adrenal Á Endocrinology Á Surgical Á Technical Bilateral adrenal tumors account for 10 % of all adrenal diseases [1]. Until recently, the surgical options for bilat- eral adrenalectomy were very morbid [2]. Over the past decade, a minimally invasive approach has gained uni- versal acceptance as the standard for bilateral adrenalec- tomy [3–5]. However, the optimal surgical approach to accessing the adrenal gland has not been well defined. Gagner et al. first described a laparoscopic transperitoneal adrenalectomy in 1992 that approached the adrenal gland with the patient in the lateral decubitus position [6]. Sub- sequently, Mercan et al. described a retroperitoneal Presented at the SAGES 2014Annual Meeting, April 2–5, 2014, Salt Lake City, Utah. B. Y. Lan (&) Á J. Mitchell Á A. Siperstein Á E. Berber Department of General Surgery, Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA e-mail: lanb@ccf.org E. Berber e-mail: berbere@ccf.org H. E. Taskin Á E. Aksoy Á O. Birsen Á C. Dural Á J. Mitchell Á A. Siperstein Á E. Berber Department of Endocrine Surgery, Endocrinology and Metabolism Institute, The Cleveland Clinic, 9500 Euclid Avenue F20, Cleveland, OH 44195, USA 123 Surg Endosc DOI 10.1007/s00464-014-3891-1 and Other Interventional Techniques