The patient, a 58-year-old female, was admitted to the hospital due to the mass in the left adrenal gland for 1 week after the physical examination. A week ago, the abdominal CT examination showed that the left adrenal gland was occupied with a size of 2.0cm × 1.7 cm, with normal bowel movement and denied the history of hypertension, mouth numbness, periodic numbness, urination frequency, urgency, pain and discomfort. Since the onset of the patients, normal spirit, appetite, sleep and excretion, and no significant weight loss was observed. She had a history of lupus erythematosus for more than 10 years and took 5 mg/ day of oral prednisone, and denied familial-hereditary disease. Specialist examination showed that no tension in the abdominal muscles, no tenderness in the abdomen, no percussion pain in the bilateral kidney area, but tenderness in the bilateral ureteral region. And no uplift in the suprapubic bladder area and normal appearance of the external genitalia.
CT plain scan showed a 17.0 mm sized soft tissue shadow located in the left adrenal(Fig. 1A), while the mass enhanced in the arterial phase (Fig. 1B)and reduced in the venous phase(Fig. 1C). Laboratory data revealed that the 8 AM blood cortisol was slightly lower(6.66, 6.7–22.6), significantly decreased urinary cortisol(15.69, 58–403) and 4 PM corticotropin(1.30, 7.2–63.3) and normal level of 8 AM corticotropin(20.26,7.2–63.3)and 4 PM blood cortisol(1.66, < 10). Combined with the above results, neoplastic features and impaired adrenal function presented.
During the physical examination, the left adrenal mass has been discovered, then the patient went to the urology department of the local hospital for treatment, did not make further examination and consultation, and underwent the surgeon. After anesthesia, the right side-lying position took, laying routine disinfection towels. A 2 cm incision was made above the midaxillary iliac ridge and separated into the retroperitoneal cavity. Then performed puncture cannulas with a diameter of 5 mm and 10 mm under the anterior and posterior costal margin of the axilla, respectively and the laparoscope was placed after gasbag dilatation. The perirenal fascia is dissociated to the dome diaphragm along the dorsal side of the kidney and then separated from the upper pole to the ventral side of the kidney. The adrenal tissue was found at the upper pole of the kidney. On scrutiny, no obvious mass was observed among the abdominal cavity upper to the diaphragmatic apex, lower to the renal hilum anterior to the parietal peritoneum and posterior to the medial margin of the psoas major. The left adrenal gland and surrounding adipose tissue were completely removed and placed into a specimen bag.
Continue to separate from the dome diaphragm to the ventral side, and carefully investigate. One brown-yellow round mass was observed at the lateral edge of the splenic artery, and about 2.0cm × 1.7 cm. Using a blood vessel clamp at the base for hemostasis, then carefully separated and removed the mass completely from the original incision with an ultrasound knife. The excised tissue was put into a specimen bag, removed, and sent for pathological examination. After thorough hemostasis under laparoscopy, the wound surface was flushed, and no active bleeding was detected. Two drainage tubes were placed, the puncture cannula was pulled out, and the puncture incision was sutured in sequence. After the operation, the patient returned safely to the ward. Postoperatively, the patient is generally normal.
On day 10 after the operation, the fluid was about 100 ml per day, which was considered as lymphatic leakage. CT scan showed the left adrenal mass still existed(Fig. 2A) with a similar CT value with the spleen, and consistent with spleen after enhancement(Fig. 2B). Hence accessory spleen was considered. The patient was discharged with catheters on the same day.
On day 14 after the operation, approximately 500 ml of colorless fluid was expelled from one of the drainage tubes. Pancreatic leakage was considered and readmitted for treatment.
On day 15 after the operation, about 500 ml bright red blood drained out, and bleeding was considered. Acute arteriography revealed splenic artery hemorrhage, then underwent arterial embolization(Fig. 3).
On day 17 after the operation, the patient developed abdominal discomfort. The upper abdominal muscles were found to be slightly tense, tender, and without rebound pain. The local fluid was found on CT examination(Fig. 4), and an emergency laparotomy was performed. Hemoperitoneum around the retroperitoneal pancreas was observed,following cleared and double cannula and peritoneal drainage were placed.
After the operation, symptomatic treatment was given. The drainage tube was drained with colorless liquid of about 200 ml per day. The drainage fluid decreased and on day 40 after the secondary operation, no hydrops was found on CT examination. Pulled out the tubes and the patient was cured and discharged.
The patients were followed up for half a year without special discomfort. CT showed the formation of a pseudocyst of the pancreas (Fig. 5A) and ischemia of the upper pole of the left kidney (Fig. 5B).