While there are nuances to the surgical technique to remove the adrenal gland, what makes adrenal surgery unique is not necessarily the procedural aspect of it, but rather the clinical work-up and preoperative preparation of the patient. Adrenal tumors are often hormonally active. Depending on the type of hormonal activity, the needs of the patient before, during, and after surgery vary greatly. Is volume in this study really more of a marker for the patients who underwent appropriate work-up and treatment before surgery, and not a marker of the technical demands of the operation? And this study does not take into consideration the surgeon skill in advanced laparoscopy, as while some of these surgeons may be performing one or two adrenal cases a year, they also perform laparoscopic colon, kidney, pancreas, spleen, liver, or stomach surgery. These are cases with just as much, if not more, technical demands in the operating room.
And what about how the gland is removed? There are at least nine different surgical approaches to the adrenal gland. Is it open or is it minimally invasive? Are you approaching it from the front, the back, or laterally? Are you using the robot? And does it really matter if you are only doing two cases a year? While super-high-volume centers (they do way more than just five cases a year) are publishing their outcomes with using the robot and approaching the adrenal gland from the back, they also allude to the learning curve of the various procedures, as well as the progression in surgical approach acquisition. But what has yet to be determined is when should that additional approach be attempted? At what clinical volume does having eight different ways to take out the adrenal gland matter? Shouldn’t the first step be having one way to take out the adrenal gland that results in good outcomes? And how often do you need to perform each approach to ensure that you as the surgeon are at your best? And what about the fact that the anatomy for a right is completely different from the left? The combinations quickly become endless.
While we can continue to publish research showing high volume is better, we have to acknowledge that not all Americans have access to a high-volume surgeon. The barriers to accessing this care are complex, and are due to both system and patient factors. It is not just as simple as ensuring that everyone has health insurance.
Sarah Oltmann, M.D., is clinical instructor of endocrine surgery at the University of Wisconsin, Madison.
