Anesthetic Management for Laparoscopic Adrenalectomy of Pheochromocytoma

Abstract

Phaeochromocytoma is a rare endocrine catecholamine-secreting tumor that usually arises from chromaffin cells in the adrenal gland medulla. This tumor accounts for less than 0.1% of all cases of hypertension seen clinically. Surgical excision is the definitive treatment for phaeochromocytoma. Until recently, open laparotomy has been used for resection of phaeochromocytoma because manual exploration of the abdomen was necessary to exclude accessory tumor deposits. But currently available imaging techniques allow the use of a more selective surgical approach to the tumor, such as laparoscopy. Laparoscopic adrenalectomy is recently considered a safe and efficient technique for removal of phaeochromocytoma in terms of intra and postoperative morbidity, with a low complication rate. From the surgical point of view, in experienced hands and with careful selection of patients, laparoscopic surgery for solitary and multiple phaeochromocytoma and also paragangliomas does not increase the specific risks associated with phaeochromocytoma surgery. However, from the anesthetic point of view, the use of laparoscopy raises some concerns due to the creation of pneumoperitoneum, which further complicates the anesthetic management for resection of phaeochromocytoma. Pre and intraoperative pharmacological blood pressure control used for conventional adrenalectomy is found to be also imperative and effective for the laparoscopic approach. There is till a debate, about the drugs used to control hypertension preoperatively, but the use of alpha blockade is still highly recommended by the majority of anesthesiologists. Also, it should be noted that there is never an emergency in adrenal surgery, and waiting till medical therapy has optimized the patient’s condition before surgery is not time consuming. Although several anesthetic techniques have been used successfully for resection of phaeochromocytoma, only anesthetics known for their hemodynamic stability are preferred. All anesthetic possibilities should be used carefully directed with two aims: First minimize indirect release of catecholamines through effective damping and prevention of stress. Second to support therapy of hemodynamic changes that occur during pneumoperitoneum and adrenal gland manipulation through ingenious use of effects and side effects of the anesthetic drugs. Nowadays, the calcium channel blocker Nicardipine is considered the intraoperative antihypertensive agent of choice during this procedure. Monitoring of the arterial blood pressure done by an intra-arterial catheter is recommended due to the occurrence of significant hemodynamic changes during the laparoscopic approach. Also, monitoring of the volume status is essential during surgery and postoperatively. A laparoscopic approach offers several advantages compared with an open laparotomy; namely, laparoscopic adrenalectomy decreases fluid shifts that may accompany an open procedure, potentially decreases the surgical stress imposed on the patient, decreases the need for postoperative analgesia, shortens postoperative convalescence-including an intensive care unit stay, and decreases overall hospital stay. Finally, experiences and excellent cooperation between surgeons, endocrinologists and anesthesiologists are essential for successful prevention of perioperative complications associated with phaeochromocytoma surgery.