Adrenalectomy

Anesthesia Implications

Position: Supine, Lateral
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)

Type of Anesthesia – General with an endotracheal tube (ETT). 

Reduce Stimulation –  Consider an LTA kit to reduce stimulation during laryngoscopy.  Consider adjuncts during intubation to avoid sympathetic stimulation (eg. Esmolol or Remifentanil). A video laryngoscope may be recommended to make a smoother intubation.

Drug Preparation – Pre-drawn syringes with Phentolamine, NTG, and Nipride for BP control. Neosynephrine drip should be primed and ready for use post-tumor removal to manage hypotension.  Use of Neosynephrine or Norepinephrine (Levophed) drips may also be necessary for BP support.

IV Access – Two large-bore IVs are recommended for fluid management. Patients are often vascularly dry and require aggressive hydration before tumor resection.

A-line – Absolutely essential for continuous BP monitoring.  Typically these are inserted under heavy sedation.

Tumor Manipulation – Handling the tumor can trigger sudden spikes in BP. Alpha-blockers should be administered first, followed by beta-blockers if needed.

Tumor Removal – The surgeon will notify when resection begins, requiring preparedness for rapid BP fluctuations.  

Post-Tumor Resection – Hypotension is common after tumor removal due to the sudden absence of catecholamines. This is the time to have the Neosynephrine drip ready/closed.

Hypertensive Crisis – should be managed with Phentolamine or Nitroglycerine.

Cardiogenic Shock – Avoid beta-blockers before alpha-blockade to prevent unopposed alpha stimulation and worsening hypertension.

Pneumothorax Risk – watch for the signs: unstable hemodynamics, increases PIP, decreased SpO2.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

High blood loss RISK (general considerations): Though most of these cases don’t result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Adrenal glands are located atop each kidney and consist of two parts, the Cortex – Produces corticosteroids (cortisol, aldosterone) and androgens, and the Medulla – Secretes catecholamines (epinephrine, norepinephrine).

Common Disorders Requiring Adrenalectomy:

Adrenocortical Tumors – Can cause overproduction of cortisol (Cushing syndrome) or aldosterone (Conn’s syndrome).

Pheochromocytoma – A catecholamine-secreting tumor that leads to episodic hypertension.

Adrenocortical Carcinoma (ACC) – Malignant tumor affecting hormone balance and may invade nearby structures.

Adrenal Incidentaloma – Non-functioning tumors detected incidentally on imaging.

Adrenalectomy involves the surgical removal of one or both adrenal glands.

Approaches:

Open Adrenalectomy – Transabdominal or retroperitoneal approach for large or malignant tumors. Allows better control of vascular structures and surrounding tissues.

Minimally Invasive Surgery (MIS) – Laparoscopic Transabdominal, Preferred for benign tumors and small malignancies.

Posterior Retroperitoneoscopic Adrenalectomy (RPA) – Direct access to adrenal glands, ideal for bilateral adrenalectomy.

Robotic-Assisted Surgery –  Provides enhanced precision and visualization.

Medications to Avoid – Histamine Releasers – Atracurium, Morphine, etc. Succinylcholine is a drug that can be used during an adrenalectomy, but it may theoretically cause tumor catecholamine release.  Atropine, Droperidol, Reglan, Ephedrine, and Glucagon are also recommended. Avoid beta-blockers before alpha-blockers.