1Department of Anaesthesiology and 2Department of Urology, Rangueil Hospital, Toulouse University Hospitals, F-31403 Toulouse Cedex 4, France*Corresponding author
Accepted for publication January 4, 2001
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Abstract |
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Br J Anaesth 2001; 86: 7313
Keywords: phaeochromocytoma; cardiovascular system, responses; measurement techniques, retroperitoneoscopy
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Introduction |
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Retroperitoneal laparoscopy has some advantages compared with transperitoneal laparoscopy. It causes only a small increase in intra-abdominal pressure and fewer haemodynamic changes.3 It facilitates early clipping of the adrenal vein by direct retroperitoneal access to the vessels.
No previous study has reported the haemodynamic changes during retroperitoneal laparoscopy for phaeochromocytoma. We report them in seven such patients.
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Case reports |
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After induction, a central vein was cannulated. Patients were then placed in the lateral position. Retroperitoneal insufflation with carbon dioxide was maintained with a pressure between 1214 mm Hg. The duration of surgery varied between 100 and 255 min (mean 171 (SD 60) min) and that of anaesthesia varied between 195 and 360 min (269 (70) min). This difference is explained by the time needed to cannulate a central vein and the position changes of the patient. Patients received 2600 (450) ml of lactated Ringers solution and 710 (270) ml of hydroxyethyl starch solution (colloid); no blood transfusion was needed.
Transient hypertension (SBP >160 mm Hg) was observed in all patients during manipulation of the tumour, in two patients during pneumoretroperitoneal insufflation and in one patient during intubation. Small doses of nicardipine (bolus of 12 mg, followed by infusion of 26 mg h1) were sufficient to control these episodes of hypertension. Transient hypotension (SBP <100 mm Hg) was observed in two patients during exsufflation and in one patient during repositioning to the lateral position. No arrhythmia or tachycardia (>100 beats min1) was observed in any patient (Fig. 1A and B).
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Discussion |
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In this case-series, manipulation of the tumour was the only event consistently associated with hypertension (Fig. 1). In a report of eight patients undergoing laparoscopic transperitoneal adrenalectomy for phaeochromocytoma, Joris and colleagues observed two causes of significant hypertension: creation of the pneumoperitoneum and adrenal gland manipulation.2
Retroperitoneal laparoscopy produces only a small increase in intra-abdominal pressure; Chiu and colleagues3 reported an increase of 3 mm Hg. This difference may explain the relative haemodynamic stability we observed during insufflation. With retroperitoneoscopy, there is little stimulation of the peritoneum and, hence, less sympathetic response and less catecholamine release.
There is still some controversy concerning whether retroperitoneoscopy produces more4 5 or less6 7 carbon dioxide absorption than i.p. laparoscopy. Ng and colleagues recently demonstrated that the retroperitoneal approach produces the same or even less hypercapnia, provided that insufflation is limited to the retroperitoneal space.8 This can be explained by the larger absorptive area available in the peritoneal cavity and the greater absorptive capacity of the peritoneal membrane.9 Furthermore, operating on a retroperitoneal viscera by transperitoneal laparoscopy allows systemic carbon dioxide absorption from both the peritoneal cavity and the retroperitoneal areas.
Subcutaneous emphysema remains a common complication of retroperitoneal laparoscopy with a reported incidence of 45%.8 In our report, palpable surgical emphysema developed in patient 7 causing a refractory hypercapnia (PaCO2=6.06.4 kPa), despite doubling of the minute ventilation. This was not accompanied by any haemodynamic changes.
Operative time is decreasing with this teams experience. We recently reported a mean time of 135 min in 52 retroperitoneal laparoscopic adrenalectomies.10
Phaeochromocytoma is rare and although this report concerns a small number of patients, we reviewed the effect of the following possible predictive factors on haemodynamic instability: pre-operative degree and type of catecholamine excretion; size and side of the adrenal tumour; presence and severity of pre-operative symptoms; and choice of the halogenated anaesthetic. None of these factors seems to predict the incidence or the importance of the haemodynamic changes.
Our observations in seven patients suggest that retroperitoneal laparoscopy is a valuable technique for adrenalectomy, resulting in relatively good haemodynamic stability in patients with phaeochromocytoma.
A prospective, randomized comparative study between the two approaches, transperitoneal and retroperitoneal, is needed to confirm these findings. This may, however, be difficult because of the rarity of these cases and the satisfaction of our surgical and anaesthetic team with this new approach.
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References |
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2 Joris JL, Hamoir EE, Hartstein GM, et al. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Anesth Analg 1999; 88: 1621
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