Adrenal gunshot wound: Laparoscopic approach. Report of a case
29-years-old man comes to the emergency room, in good general clinical condition (heart rate 78/min; blood pressure 120/65 mmHg), with a penetrating wound in left lumbar region without signs of peritonitis (). We perform routine blood tests (Hb 14.8 g/dl, WBC 11,000), chest X-ray and abdominal CT. The chest X-ray shows, in left subfrenic space, the presence of foreign metallic body (diameter 9 mm). The abdominal CT was performed with triphasic technique for the study of the urinary tract. The metallic bullet (diameter 1 cm) was found in retroperitoneum associated with cortical lesion of the upper pole of left kidney with perirenal subcapsular hematoma (transverse diameter 5.2 cm, sagittal 6.5 cm, coronal 11 cm). The excretory phase of both kidneys is regular and there are not lesions of the other abdominal organs (). Given the hemodynamic stability and the absence of hemoperitoneum we decide to take a NOM. Control blood test is repeated after 3 and 6 h with evidence of significant decline in hemoglobin (Hb 10.8 g/dl vs 14.8 g/dl); heart rate and blood pressure are normal. The rapid anemia and the CT report (renal cortical lesion with retroperitoneal hematoma) encourage us to carry out an exploratory diagnostic laparoscopy. The patient is placed in right lateral recumbency with an inclination of 50–60° relative to the operating table which is broken to extend the space between the last rib and the iliac crest. We used Veress needle to induce pneumoperitoneum and three trocars in the left subcostal region. In contrast to retroperitoneal approach, we chose a transperitoneal laparoscopic procedure because allows for a larger working space, adequate maneuverability and the presence of familiar anatomic landmarks. Careful exploration of the peritoneal cavity did not show lesions of the peritoneal organs. Considering CT results, the spleno-pancreatic block is medially mobilized to access the retroperitoneum and reach the adrenal and renal space. We opened Gerota on the upper pole of the kidney with identification of peri-renal hematoma, without any signs of active bleeding. We decide to carry out intraoperative radiological control using an image intensifier. Only a careful and accurate comparison of these X-ray images and laparoscopic vision allows us to identify and extract the bullet out of the adrenal parenchyma (a and b). Accurate hemostasis is made through a bipolar forceps and further application of fibrin glue in the renal and adrenal loggia for the purpose of a correct repositioning of the spleno-pancreatic block. We settle a tubular drainage in renal region. In postoperative period hemoglobin values were stable and were not required transfusion. The abdominal drain is removed during the fourth postoperative day and the patient is discharged without complications.