While laparoscopic adrenalectomy has become the treatment of choice for benign adrenal disorders, its role remains controversial for adrenocortical malignancies. A comparison between these surgical approaches is difficult and current practice is based mainly on retrospective studies and expert opinion. Many studies tried to demonstrate the non-inferiority of laparoscopic surgery compared to open surgery, while many others raise concern regarding the oncologic outcome after the laparoscopic approach. The results are inf by bias and not conclusive, mainly because only a minority of early-stage adrenocortical carcinomas (ACCs) are correctly recognized and staged before surgery; more often the diagnosis is formulated postoperatively by the pathologist. For this reason, the main guidelines of various institutions recommend a prudential use of the laparoscopic approach in the management of adrenal incidentalomas and ACCs.