Background. The low incidence rate of adrenocortical carcinoma (ACC) requires a multidisciplinary approach in which surgery plays an essential role because complete resection of the primary tumor is the only chance of cure. To improve patient care, insight into operative results within the ACC population is essential. In 2007, a Dutch Adrenal Network Registry was created covering care and outcome of patients treated for ACC in the Netherlands since 1965. Using this database, we performed a study ( I) to gain insight into surgical performance in the Netherlands and (2) to compare operative data with international literature. Methods. Data on patients treated from 1965 until January 2008 were studied. The following data were collected: age, gender; functionality of the tumor, stage at diagnosis, operative procedure, completeness of surgery, disease recurrence, adjuvant mitotane therapy, and recurrence-free and overall survival (OS). Results. A total of 175 patients were studied, of whom 149 underwent surgery. Patients with complete resection had significantly longer OS times than patients with incomplete resection (P = .010). Patients operated on in a Dutch Adrenal Network center had significantly longer duration of OS in both univariate (P = .011) and multivariate analysis (P = .014). A significantly greater OS was observed for operated stage IV patients compared with nonoperated patients (P = .002). Conclusion. Our data suggest the relevance of national cooperation and centralized surgery in ACC. For selected patients with stage IV disease, surgery can be beneficial in extending survival. On the basis of the retrospective analysis, operative ACC in the Netherlands can and will be improved. (Surgery 2012; 15 2: 50-6.