Laparoscopic resection is preferred for most adrenal tumors. From 1996 to 2007, 54 consecutive patients who underwent resection of an adrenal tumor or extraadrenal pheochromocytoma were reviewed to determine the outcome of laparoscopic resection and the rate of conversion and indications for open resection. Adrenalectomy was performed in 51 patients and resection of a pheochromocytoma of the organs of Zuckerkandl in three patients. Laparoscopic adrenalectomy was initiated in 42 patients, three (7.3%) of whom underwent conversion to an open approach because of bleeding from an accessory vein (one), tumor invasion (one), or adhesions (one) (median American Society of Anesthesiologists score = 2, estimated blood loss = 186 +/- 235 mL, size = 5 +/- 3 cm). Open resection was performed in 12 patients, six at the time of another procedure, three for pheochromocytoma of the organs of Zuckerkandl, two for bilateral adrenalectomy, and one for tumor invasion (median American Society of Anesthesiologists score = 3, estimated blood loss = 1525 +/- 978 mL, size = 8 +/- 4 cm). With proper patient selection, laparoscopic adrenalectomy can be successfully performed with a low conversion rate. When unrecognized, an accessory right adrenal vein may be a source of significant bleeding requiring conversion to an open approach. Open resection is indicated for tumor invasion, for extraadrenal pheochromocytoma, when laparoscopic resection cannot be performed safely, and for concomitant open procedures.