Spontaneous Hemo-Mediastinum Following Laparoscopic Appendectomy: A Case Report

Abstract

BACKGROUND Intra-thoracic bleeding in the form of hemo-mediastinum is a rare condition often resulting from trauma or malignancy, or can occur spontaneously. Spontaneous intra-thoracic bleeding, particularly following laparoscopic appendectomy, is extremely uncommon and not typically associated with such procedures. CASE REPORT A 65-year-old man with a history of interstitial lung disease due to mixed connective tissue disease, chronic cough, pleurodesis, and coronary artery disease developed massive mediastinal hematoma and hemodynamic instability following an uncomplicated laparoscopic appendectomy for gangrenous appendicitis. Symptoms included chest pain and hemoptysis with a hemoglobin drop from 16.2 g/dL preoperatively to 13.2 g/dL. Contrast-enhanced computed tomography (CT) of the chest identified a large right upper-mediastinal hematoma with active contrast extravasation. Interventional radiology (IR) embolized the bleeding vessel. Due to continuous hemoptysis and hemodynamic instability, the patient was taken back to IR for a right bronchial artery angiogram and bronchoscopy. The angiogram showed an irregular segment, likely the source of the hemoptysis; this was embolized with glue. Persistent respiratory compromise and concern for tamponade physiology prompted surgical intervention. A video-assisted thoracoscopic approach was converted to thoracotomy for complete evacuation of the hematoma and lysis of adhesions. The patient's condition stabilized postoperatively, and he was discharged home in good condition on hospital day 10. CONCLUSIONS This case highlights an unusual complication of spontaneous hemo-mediastinum after laparoscopic appendectomy, emphasizing the importance of early identification and timely intervention in managing this complication. To our knowledge, this is the first reported case of post-appendectomy hemo-mediastinum.

Figure 1

Chest X-ray showing widening of mediastinum (arrow).

Figure 2

CT chest axial view showing mediastinal hematoma (arrow).

Figure 3

CT chest coronal view showing mediastinal hematoma (arrow).

Figure 4

Angiogram showing bleeding from right second intercostal artery (left) and after embolization (right).

Figure 5

Right bronchial artery angiogram showing an irregular segment (arrow, left) and after embolization (right).