DR. ANAND ARUMUGAM K , DR.MADHUSUDHANAN R , DR JAGAN GOVINDASAMY
DOI: https://doi.org/Background: Due to the minimally invasive technique, improved visualization, and rapid recovery, laparoscopic adrenalectomy has established itself as the gold standard for the surgical management of adrenal tumors. Yet, perioperative anaesthetic management of adrenal tumors can be challenging due to the varied functional characteristics of adrenal lesions, from non-secreting incidentalomas to hormonally active tumors, such as pheochromocytomas, Cushing’s adenomas, and aldosterone-producing adenomas. Each variant will have specific hemodynamic effects, biochemical derangements, and associated perioperative risks, which require careful preoperative assessment, vigilant monitoring intraoperatively, and precise pharmacologic approach.
Aim: The aim of this paper is to address the multi-faceted considerations and management protocols associated with the anesthetic care of laparoscopic adrenalectomy across endocrine pathologies, including differential diagnostic challenges, optimization concepts and evidence-informed perioperative management of hemodynamic instability.
Materials and Methods: A retrospective analysis was conducted on patients undergoing laparoscopic adrenalectomy for a variety of adrenal pathologies at a tertiary care teaching hospital. The records of demographic characteristics, clinical presentation, pre-operative hormonal work-up, radiological studies, anaesthetic methods, intra-operative hemodynamic fluctuations, pharmacological therapies, and post-operative outcomes were scrutinized. Pre-operative optimization included a combination of alpha- and beta-blockade in the management of pheochromocytoma, steroid suppression in Cushing's syndrome, and volumetric correction in Conn's syndrome. General anaesthesia data included the standard provision of balanced volatile agents, continuous invasive arterial blood pressure monitoring, and goal-directed fluid therapy. Data analysis included descriptive statistics and comparative measures between diagnostic entities.
TPM Vol. xx, No. x, March 20yy – 5-23 – doi: 10.4473/TPM31.1.1 – © 2024 Cises
Green Open Access under CC BY-NC-ND 4.0 International License
Results: Ultimately, there were 42 patients included in the overall analysis: 16 with pheochromocytoma, 12 with cortisol-secreting adenomas, 8 with Conn’s syndrome, and 6 with non-functioning adrenal masses. Preoperative optimization achieved at baseline hemodynamics in 88% of the patients prior to induction. The intraoperative period was characterized by transient hypertensive crises in 10 patients (23.8%) and hypotensive episodes following adrenal vein ligation in 8 patients (19%). Pheochromocytoma cases exhibited the greatest hemodynamic variability requiring vasoactive support, while cortisol and aldosterone secreting tumors fluctuated mildly and were managed with
interventions. There were no major perioperative morbidity or mortality. The mean recovery time of 2.8 ± 0.9 days was shorter with quicker ambulation and a shorter hospital length of stay than patients who underwent open adrenalectomy at the studied institution.
Conclusion: Effective anaesthetic management of laparoscopic adrenalectomy requires a clear preoperative diagnosis, multidisciplinary collaboration, and careful monitoring of the patient intraoperatively. Knowledge of the endocrine changes that can occur with each adrenal pathology can facilitate early intervention in troublesome hemodynamic shifts. An anaesthetic plan developed around the unique patient physiology and comorbidities can help reduce complications, improve recovery, and optimize overall perioperative outcomes despite the inherent diagnostic complexities associated with adrenal pathology.
