Postoperative Hemodynamic Instability Following Adrenalectomy for Presumed Adrenocortical Carcinoma: Anesthetic Implications of a Rare Cavernous Hemangioma.

Adrenal cavernous hemangiomas are rare, often large, benign vascular lesions that can mimic adrenal malignancy on imaging. Their perioperative management poses significant anesthetic challenges, particularly regarding hemodynamic stability and intraoperative bleeding risk. We describe a 77-year-old with a 17 cm right retroperitoneal mass presumed to be adrenocortical carcinoma, presenting with vague abdominal discomfort. Cross-sectional imaging showed a large, heterogeneous, hypervascular mass displacing the right kidney, leading to surgical resection. Intraoperatively, the mass was highly vascular, requiring transfusion and vasopressor support. Postoperatively, the patient developed refractory hypotension, prompting an urgent but ultimately unnecessary re-exploration, which revealed no active bleeding. Final pathology confirmed a benign adrenal cavernous hemangioma with thrombosis and infarction. The patient recovered with supportive care and was discharged on hospital day seven. This case underscores the diagnostic challenges in distinguishing benign from malignant adrenal masses preoperatively and highlights the risk of hemodynamic instability following resection of large vascular tumors. It also illustrates the potential for avoidable reoperation in the absence of definitive evidence of hemorrhage. The case emphasizes the utility of perioperative point-of-care ultrasound (POCUS) for rapid assessment of volume status and cardiac function, which may aid in differentiating causes of postoperative hypotension and guide targeted management, potentially avoiding unnecessary re-exploration.