F. Chen1, M. Adhami1, M. Tan1, S. Grodski1,2, J. W. Serpell1,2, A. Orr3, A. Stark3, J. C. Lee1,2 1The Alfred Hospital,Department Of General Surgery, Monash University Endocrine Surgery Unit,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia 3The Alfred Hospital,Department Of Anaesthesia And Perioperative Medicine,Melbourne, VIC, Australia
Introduction:
Hemodynamic instability is a major challenge during adrenalectomy. We hypothesized that the prone jack-knife position for posterior retroperitoneoscopic adrenalectomy (PRA) is associated with greater intraoperative hypotension than transperitoneal laparoscopic adrenalectomy (TPA). The aim of this study was to compare intraoperative hemodynamic parameters between PRA and TPA.
Methods:
A retrospective study of patients undergoing PRA and TPA without conversion or concomitant intra-abdominal pathology from 2008 to 2019. The primary outcome was intraoperative hypotension defined by mean arterial pressure (MAP) <60 mm Hg or a need for ≥2 intravenous vasopressors at least 30 minutes after anaesthetic induction.
Results:
Overall, 108 patients met the inclusion criteria; 33 (30.6%) had pheochromocytoma, 26 (24.1%) Conn's syndrome, 8 (7.4%) Cushing’s disease, and 41 (38.0%) non-functioning adrenal tumours. Of these, 68 (63.0%) underwent PRA and 40 (37.0%) TPA. Age, sex, body mass index, pre-induction blood pressure (BP), number of pre-operative anti-hypertensives, and histopathological diagnosis were similar in the 2 groups. Tumour size was greater in the TPA group. The lowest MAPs of PRA patients were lower than TPA patients (Figure 1, P=0.04). Multivariate analysis showed PRA was more likely to be associated with a lowest MAP of < 60 mmHg (OR 4.44, 95% CI 1.27-15.54, P=0.02), and a need for ≥2 intravenous vasopressors (OR 5.44, 95% CI 1.52-19.46, P=0.009) compared with TPA. When pheochromocytoma patients were excluded from analysis, PRA patients were more likely to require ≥ 1 intravenous vasopressors (OR 21, 95%CI 4.61-96.65, P=0.001); but the risk of the lowest MAP being < 60 mmHg was similar in both groups. PRA was associated with reduced operative time (P=0.01) and length of hospital stay (P=0.03) compared with TPA.
Conclusion:
While PRA offers several advantages over TPA, it carries a greater risk of intraoperative hypotension. Both surgeons and anaesthetists should be aware of this association to minimize periods of hypotension, in order to avoid adverse outcomes. A larger multi-centre prospective trial is required to validate these findings.
