We read with interest the article by Alesina et al.  and we congratulate the authors for their contribution to the of management of Cushing’s syndrome, which is frequently encountered by endocrine surgeons. Because of severe obesity and associated co-morbid conditions, surgical excision of tumor by the conventional transperitoneal procedure, via either the open or laparoscopic approach, has always been challenging. A direct approach leading to the tumor has always been desirable. To gain a full understanding of the study of Alesina et al., we would like to know how many of their patients were morbidly obese and what their experience was in the management of such patients . Second, because the chance of malignancy is much higher in patients with adrenal tumors C6 cm , and because of limited intraoperative exposure and inability to inspect the liver and peritoneal surfaces, the transperitoneal approach is preferred over the retroperitoneal approach in suspected adrenal malignancy [4, 5], we would like to know how many of their patients had tumors C6 cm on preoperative imaging, and what their strategy was in removing these tumors.