We described unusual presentation of PMF with spontaneous bleeding after laparoscopic adrenalectomy.
A 73 years old Caucasian man underwent laparoscopic right adrenalectomy for a rapidly increasing expansive mass (3.5 x 2.5 cm) of the right adrenal gland. It was an incidental finding on a computed tomography (CT) scan performed for dyspnoea. In the previous two years, the patient had a magnetic resonance (MR) and a positron emission tomography (PET) showing an increasing lesion with morphological features suggestive for adenoma, pheochromocytoma, tuberculosis (TB), and an enlarged spleen. Blood tests excluded secreting lesion or TB infection.
The list of comorbidities included hypertension on treatment with beta-blockers, benign prostatic hypertrophy treated with silodosin, chronic obstructive pulmonary disease (COPD) treated with steroids inhalers, hypothyroidism, previous appendectomy, unspecified previous surgery for head trauma.
An informed consent was obtained before surgery. According to standard procedure adopted in our Center for laparoscopic adrenalectomy, an open technique was used for laparoscopic access. Abdominal cavity exploration showed blood and clots on the surface of great omentum, in absence of any source of bleeding. After trocars placement, liver was retracted and posterior peritoneum was divided on the right side of the inferior vena cava to identify the adrenal gland (Fig. 1). After coagulation of adrenal vein, gland was dissected from its attachments and removed in a specimen retrieval bag. Haemostasis was accurately controlled, two drains were placed on the side of adrenal excision and on the perisplenic side, respectively, at the end of procedure.
After surgery, the patient was admitted on post-operative intensive care unit for parameters monitoring, due to COPD. The night of intervention the patient developed hypotension not responsive to fluids administration, tachycardia, anaemia not responsive to blood transfusions. Haematic fluid was present in drains bag. The patient underwent urgent explorative laparotomy, that highlighted massive haemoperitoneum, clots in the abdomen, on the splenic side, on Morrison's space, and at the confluence between right renal vein and inferior vena cava. No bleeding source was found. A lavage was performed with hot fluids and haemostatics were placed on the side of previous surgery. Two drains were placed under the liver and on the right adrenalectomy site.
First and second intervention were performed by the same surgeon (M.G.).
In the post-operative period, we observed a progressively increase of white blood cells count (WBC), until 53.000/mm3 with basophilia, monocytosis and thrombocytosis, in the absence of any foci of infection; haemoglobin (Hb) was normal and blood transfusion was unnecessary. Clotting screening was normal. Spontaneous bleeding on abdominal wall started after the second surgery and required arteriography and embolization.
Due to an increase of WBC in the absence of signs and symptoms of infection, the patient was referred to haematology.