Consultant anesthesiologist

Anaesthesia department

Security Force Hospital, Riyadh, KSA.

Adnan B. Mofti MB. ChB. FRCS(Eng) FRCS(Glas)

Consultant Surgeon

Department of Surgery

Security Forces Hospital, Riyadh, K.S.A.

Souliman Al Muhaya MD. FRCP.

Consultant nephrologist

Department of Medicine

Security Forces Hospital, Riyadh

Adel Al-Zourkany MB.ChB.

Anaesthesia Registrar

Anaesthesia department

Security Force Hospital, Riyadh, KSA

Nader M. Hussein MB. ChB, FRCS(Ed)

Senior Registrar.

Department of Surgery

Security Forces Hospital, Riyadh, K.S.A

Hazem Al-Gamal MB. ChB. MRCP (UK)

Nephrologist

Department of Medicine

Security Forces Hospital, Riyadh.

Mohammad S.M. Takrouri MB. ChB. FFARCSI.

Locum Consultant Intenseve Care, Department of Anaesthesia SFH

Professor of Anaesthesia

King Khalid University Hospital, Medical college, King Saud University, Riyadh, K.S.A.

Address for correspondence: Safwan T Jandali,

Department of Anaesthesia, Security Forces Hospital,

P.O.Box 3643, Riyadh 11481, Kingdom of Saudi Arabia.

Tel 009661 4774480

Fax 009661 4764747

BACKGROUND: During the last two decades laparoscopic surgery has become a widely practiced procedures. Laparoscopic adrenalectomy for adrenal tumor excision is one of these new applications. The anesthesia implications are special in the presence of long standing essential hypertension and nephrotic syndrome with poly-phrmacy.

OBJECTIVES: To report on the first anesthesia for laparoscopic adrenalectomy in Security Forces Hospital (SFH) in Riyadh.

SETTING: Tertiary care SFH in Riyadh.

PATIENT: A 58 years old Saudi woman diagnosed to have essential hypertension, nephrotic syndrome, non insulin dependent diabetes milletus (NIDDM), and right adrenal tumor, with the provisional diagnosis of pheochromocytoma.

INTERVENTIONS: General anesthesia, thoracic epidural, control of hypertension with both alpha and beta blockers, and selective surgical intensivve care unit (SICU) admission for monitoring and pain relief.

MEASUREMENT AND THE MAIN RESULTS: Preoperative ultrasound and MRI, MIBG scan of the adrenals, catecholamines serum level, intraoperative direct cardiovascular pressure measurements using Swan-Ganz catheter and arterial line, . Pain control using epidural narcotics, measurement of blood glucose, blood gases, urea, creatinine and electrolytes. Adequesy of ventilation monitored by capnography and pulse oximetry . The surgical procedure included right adrenalectomy and cholecystectomy.

CONCLUSION: Anaesthesia for laparoscopic adrenalectomy has special problems to solve related to pneumoperitonium effect, polypharmacy and the current disease state. The use of modern anesthetic agents, cardiovascular monitoring, ventilation and proper analgesia make the hospital stay short, morbidity and mortality minimal.

KEY WARDS:

Major MeSH: Adrenalectomy [methods]; Laparoscopy; Anaesthesia. Pheochromcytoma, Cholecystectomy.

Minor MeSH: Adult; Female; Middle age; Pain relief; Monitoring; Investigation

Check Tag: Case Report, Human.

The wealth of experience in laparoscopy proved that this new technique is safe, less expensive with reduced incidence of severe pain and the patient resume his normal life in short time. Also it presented new special problems including the complications of insufflation of carbon dioxide and its resorption to the blood, embolization, and the cardiovascular effects which occur due to the increased intra-abdominal pressure. only one report to our knweledge reported removal of pheocromocytoma with a patient with long term hemodialysed patient appeared in the literature. We describ anaesthetic management of the first laparoscopic adrenalectomy in a nephrotic syndrome case suffering from diabetes and hypertension in KSA.

A 58 year old Saudi obese woman was seen in nephrology clinic at SFH, and diagnosed to have essential hypertension since 20 years, on treatment, NIDDM since fourteen years, nephrotic syndrome since 4 years, and cholelithiasis. Investigation was directed twards secondary causes of hypertension like renal artery stenosis and adrenal tumor including pheochromocytoma. Clinically she had general oedema, ascites, anaemia, hypoalbuminemia, hyponatremia, uremia, high serum creatinine and proteinurea. Catecholamine blood level; measured on two occasions (Reference labratory: JSPS London) noradrenaline 6.4 nmol/l (normal range 2-6 nmol/l) adrenaline 0.39 nmol/l ( normal range 0.1-5 nmol/l). urinary catecholamines /24h, Noreadrenaliene 212 umol /24h, Adrenaline 18 umol/24h, and Dopamine 1335 Umol/24h. Kidney biopsy demonstrated immune complex mediated glomerulopathy complicating diabetic nephropathy. The ultrasound scan of the kidneys, adrenals, Magnatic Resonance Imaging (MRI) and Metaiodobenzylguinidine (MIBG) nuclear scanning demonstrated a solid mass lesion in the right suprarenal area probably tumor within the right adrenal which measure 38 mm, otherwise the other organs of the abdomen looked normal [fig 1;a,b,c,&d]. EKG showed evidence of ST segment depression, with left ventricular hypertrophy. Echocardiogram was normal. Examining the back showed marked lordosis.

Preanesthetic preperation:

The preoperative preparation included Alpha-adrenergic blockers prazocin (15 mg), Beta-blockers atenolol 100mg, adalat 60 mg, Lasix 80 mg, clonidine 150 mg and predinsolone 30 mg daily. This regime has optimized the blood pressure which was at the morning of the operation 160/80 Torr. and no changes in these parameters in the 72 hours before the day of surgery. But hyponatremia was present.

Anesthetic management:

The anesthetic management included preoperative diazepam 10 mg orally 3 h before surgery, 5 mg iv midazolam in induction room. attaching the EKG leads, oximetry, insertion of radial artery catheter. Swan-Ganz catheter for CVP, PAP. and PAWP. Thoracic epidural catheter T9-T10. Other monitored parameters included FiO2, capnography, and body temprature. The induction was gradual and using fentanyl 100 ug, Thiopentone 210 mg, and intubation was facilitated by atracurium 40 mg. xylocaine 1% intravenously was given to suppress the laryngoscopy and intubation response. Also topical lignocaine 10% over the larynx, vocal cords and in the trachea. Maintanence of the anaesthesia was acheived by adding isoflurane to 50:50 oxygen nitrous oxide mixture, 200 ug of fentanyl intravenously during the lenght of the surgery, in intermittent doses. 100 ug of fentanyl epidurally. Muscle relaxation was maintained by infusion of atracurium 10 ug/kg/min. The course of the anaesthesia was uneventful. Fluctuation in blood pressure was minimal and adjusted by deepening of the anaesthesia, and guided by CVP, and PCWP reading, a pressure of 10-12 mmHg and 15-20 mmHg respectively was maintained. and infusion of plasma protein 5% 500 ml. Albumin 20% 100 ml and whole blood 300 ml.

The patient was placed in the right nephrectomy position with table bridge at the level of the left flank. Then hewas strapped to the table and put into 45° anti-Trendelenburg position. with 30° tilt to the left. Pneumoperitonium was obtained through a Veress needle introduced at the mid-clavicular line below the costal margin. Then through a 10 mm port at the mid line above the umbilicus at a 30° lens was introduced. All the subsequent 4 ports were introduced under direct vision. The liver and gall bladder were retracted cephalad while the other viscera retracted downward and medially exposing the retroperitoneal area at the superior port of the right kidney. The right adrenal gland was exposed through the perinephric fat after dissecting the retroperitoneal covering. Dissection of the adrenal gland started laterally and working through towardd the inferior vena cava in order to expose the central draining veins. Small vessels were controlled by diathermy while the medium size vessels were divided between metal clips. the whole gland was mobilized and dissected free and palced into an endo-bag. The gall bladder which contained several stones was also removed laparoscopically and placed in an endo-bag [fig. 2,3,&4]. Haemostasis was secured and the endo-bags were removed through one of the 10 mm ports opening and the the port openings were closed with skin clips.

Intensive care management:

At the end of the procedure, the patient was awake and extubated and transferred to the SICU for further management and monitoring. During the next five hours in the post operative period, the blood pressure tended to rise which neccessitate the infusion of Na nitroprusside 4 ug/Kg/min. CVP and PCWP readings were reflecting good filling and at no time hypotension occured. The urine output was showing diuresis at rate of 200 ml/h and that continue for 18 hours post operatively. Hyponatremia improved, urea, and creatinine decreased. Early mobilization, incentive spirometry and chest physiotherapy were repeated at 2 hourly interval. The patient needed minimal epidural narcotics consisted of 3 mg of morphine in 10 ml saline /12 h. On the morning of the second post operative day the patient was mobile, pain free, and starting soft diet.

A long standing hypertension, with finding of a suprarenal mass should alert the clinical staff to the possibility of pheochromocytoma. which constitute a serious risk for patient going for surgery (1)

The control of the blood pressure peri-operatively is a major concern to the managing team. Two approaches are described in literature, the use of alpha [2,3] and beta sympathetic blockade[4,5], or Magnesium sulfate infusion.[6] If blood pressure is fluctuating Na nitroprusside is used for hypertension, and norepinephrine infusion if hyotension occurred after removal of the tumor. In this case blood pressure intraoperatively was controlled simply by the balanced anaesthesia technique adjusting isoflurane inhaled concentration and using thoracic epidural for pain relief. The manupilation of the mass by the surgeon did not affect the blood pressure, after recovery from anaesthesia the blood pressure rised to 190/110 Torr in the post operative period, which indicated the use of Na nitroprusside. Pheochromocytoma, was a working diagnosis since all the clinical and scan informations made it a possibility, and the anaesthesiologist was preparing himself for this possibility. Nephrotic syndrome added new consideration in regard the fluid therapy and the amount of the fluid in the body (ascites and edema fluid), the use of direct cardiovascular pressure measurements helped in controlling the fluid balance.

laparascopy in this obese patient with ascites call for more attention guarding against the complications [7]. It is known that pneumoperitonium affects the lung function tests and cardiac functions adversely, so it affect the diaphragmatic functions. The resorption of carbon dioxide from the peritonium may demand greater rate of elimination, capnography alione does not reflect the extent of blood carbone dioxide level. Our technique involved close monitoring of the blood gases, saturation and capnography. The controlled ventilation was adjusted to prevent hypercarbia and acidosis, or hypoxemia.

The choice of anesthetic agent was in accordance with the drugs suitable for quick recovery from anaesthesia e.g. isoflurane, and non dependent on urinary excretion e.g. atracurium. does not interact with the drugs used to control the blood pressure which helped in cardiovascular stability.[8-13] . In renal compromised patient the reduction of preload, Alph adreergic blockade and adeqauate anlgesia would assure the haemodynamic stabilities[14].

Laproscopic adrenelectomy is well tolerated in this compromized patient, although many coexistant diseases complicated the picture, the precausion against the effects of pneumoperitoniumand careful monitoring of the cardiovascular and respiratory parameters, the use of post operative SICU admission help to shorten the patient post operative recovery and good outcome.

We would like to thank the medical photography department at the security force hospital in Riyadh for the prompt production ofthe medical photographs, and we mention in particular Mr Jhun Palma, and Arnie Sajor. Also we would like to thank Mrs. Mary Germaine C. Villavert operating room secretary for secreterial and typiing help she gave.

Fig 1 Relevant MRI pictures demonstrationg the right adrenal tumour; (1.A ) T1 W1 Scanogram reveal an isotense mass in the right adrenal gland in section No 6. (1.B) T1 W1 shows oval-shaped isotense mass in the right adrenal gland. (1.C) T1 W1 after iv DTPA (contrast) shows central enhancement. (1.D) T2 W1 shows hypertense mass in the adrenal gland.

Fig 2 The laparoscopic picture immediately after excision of the right adrenal tumour, showing the bed of the gland 9above) and the gland (below)

Fig 3. The gall bladder(above) and the adrenal gland (below) after excision

Fig 4. Gross section of the adrenal gland showing remarkebly a yellow colour

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