Anesthetic challenges in perioperative hemodynamic management for combined radical nephrectomy and hepatic segmentectomy in an HBsAg-positive patient with renal cell carcinoma and segment 4B Metastasis

Background: Renal cell carcinoma (RCC) frequently metastasizes to the lungs, bones, and liver. In carefully selected patients, radical nephrectomy with metastasectomy offers potential curative benefit. Combined renal and hepatic resections, however, pose significant anesthetic and surgical challenges due to prolonged duration, major blood loss, and the requirement for advanced hemodynamic management. Case Presentation: We report the perioperative management of a 55-year-old male with left RCC, solitary segment 4B liver metastasis, and associated incisional hernia. He underwent radical nephrectomy, hepatic metastatectomy, and incisional hernia repair under general anesthesia with advanced hemodynamic monitoring. Invasive arterial pressure, central venous pressure, and stroke volume variation (SVV)-guided goal-directed fluid therapy (GDFT) were employed. Hemodynamic instability during surgery, particularly during hepatic resection and prolonged Pringle’s maneuver, was managed with vasopressor support, blood product transfusion, and individualized fluid therapy. This case underscores the critical role of multimodal monitoring and GDFT in guiding perioperative fluid and vasopressor therapy during combined renal and hepatic resections. The unique balance between renal perfusion post-nephrectomy and hepatic outflow during resection requires meticulous anesthetic planning. Conclusion: Combined nephrectomy and hepatic metastasectomy can be performed safely in selected patients with RCC. Perioperative optimization with advanced hemodynamic monitoring, GDFT, and tailored anesthetic strategies are vital for improving surgical outcomes.