Laparoscopic management of a 23-cm hemorrhagic adrenal pseudocyst presenting with acute inflammatory symptoms: a case report

Abstract

Introduction and importance: Adrenal pseudocysts are rare cystic adrenal lesions that may present incidentally or with symptoms related to hemorrhage or mass effect. Giant hemorrhagic adrenal pseudocysts are uncommon and can mimic malignant intra-abdominal cystic masses. Presentation of case: A 48-year-old woman presented with severe abdominal pain, fever, abdominal distention, and dyspnea. Laboratory studies showed leukocytosis and elevated C-reactive protein. Contrast-enhanced CT demonstrated a 23 × 20 × 18 cm well-demarcated, thin-walled cystic mass in the right hemiabdomen and retroperitoneum, containing homogeneous low-attenuation fluid (9 Hounsfield units) without solid components or abnormal enhancement. Marked mass effect with leftward displacement of abdominal structures was observed. Plasma-free metanephrines were normal, tumor markers were within normal limits, and hydatid serology was negative. Due to persistent symptoms, laparoscopic exploration was performed. Controlled decompression yielded 4000 mL of hemorrhagic fluid without gross spillage, followed by complete laparoscopic excision. Operative time was 90 minutes with minimal blood loss. The patient was discharged on postoperative day 3. Histopathology confirmed a hemorrhagic adrenal pseudocyst. Clinical discussion: Giant adrenal pseudocysts may present with acute inflammatory features and significant mass effect, closely simulating malignant disease. Careful radiologic assessment and appropriate preoperative biochemical evaluation are essential before intervention. In selected patients with benign imaging features, laparoscopic resection with controlled decompression may be feasible even for lesions exceeding 20 cm. Conclusion: Laparoscopic resection with controlled decompression may be feasible for carefully selected giant adrenal pseudocysts when imaging and biochemical evaluation do not suggest malignant or functional disease, while maintaining oncologic caution.