iprs000014 10.3205/iprs000014 urn:nbn:de:0183-iprs0000147 Case Report Laparoskopische Splenektomie einer Wandermilz bei ausgeprägter Splenomegalie Lemke Lemke Johannes J

Clinic of General and Visceral Surgery, University Hospital Ulm, Germany

johanneslemke@gmx.de author Scheele Scheele Jan J

Clinic of General and Visceral Surgery, University Hospital Ulm, Germany

jan.scheele@uniklinik-ulm.de author Juchems Juchems Markus M

Clinic of Diagnostic and Interventional Radiology, University Hospital Ulm, Germany

markus.juchems@uni-ulm.de author Henne-Bruns Henne-Bruns Doris D

Clinic of General and Visceral Surgery, University Hospital Ulm, Germany

doris.henne-bruns@uniklinik-ulm.de author Brockschmidt Brockschmidt Claas C

Clinic of General and Visceral Surgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89071 Ulm, Germany, Phone: +49-(0)-731-500-53500, Fax: +49-(0)731-500-53503Clinic of General and Visceral Surgery, University Hospital Ulm, Germany

claas.brockschmidt@uniklinik-ulm.de author German Medical Science GMS Publishing House

Düsseldorf

610 wandering spleen splenomegaly laparoscopic splenectomy Wandermilz Splenomegalie laparoskopische Splenektomie 20121203 engl 2193-8091 1 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 14 Ektopie der Milz, auch Wandermilz genannt, ist ein seltenes Krankheitsbild. Die Therapie der Wahl ist in der Regel die laparoskopische Splenopexie. Dennoch kann in komplizierten Fällen mit Torsion und konsekutiver Infarzierung der Milz eine Splenektomie indiziert sein. Die laparoskopische Splenektomie der Wandermilz wurde bereits als sichere Therapie beschrieben. Bei ausgeprägter Splenomegalie ist jedoch in aller Regel sowohl für die regulär lokalisierte Milz als auch für die Wandermilz die konventionelle Splenektomie die Therapie der Wahl. Dieser Fallbericht beschreibt eine laparoskopische Technik als Alternative zur konventionellen Splenektomie bei einer Patientin mit Wandermilz und gleichzeitig bestehender ausgeprägter Splenomegalie. Ectopy of the spleen also referred to as wandering spleen is a rare condition and preferentially treated by laparoscopic splenopexy. However, in complicated cases with torsion and consecutive infarction of the spleen splenectomy is required. Performing the splenectomy of a wandering spleen laparoscopically has already been reported as a save therapeutic option. However, open splenectomy is usually preferred in case of massive splenomegaly for both, wandering and regular localized spleen. In this case report we describe a laparoscopic technique as alternative for conventional splenectomy in the case of a huge wandering spleen. IntroductionWandering spleen is a rare condition predominantly found in young women. The aetiology remains unclear , . Clinically, patients may be asymptomatic or symptomatic, whereupon symptomatic patients often suffer from abdominal disorders of chronic or acute character , . A notable complication of the wandering spleen is torsion of the elongated spleen vessels with consecutive infarction of the spleen. This event may lead to an acute abdomen . Today standard therapeutic strategy is the laparoscopic splenopexy to avoid splenectomy and consecutive postsplenectomy complications like overwhelming postsplenectomy sepsis , . Anyway, torsion of wandering spleen with subsequent infarction usually requires splenectomy, which can be performed open or laparoscopically, whereas the open-surgery approach is preferred in case of pronounced splenomegaly. In this case report we present a 35-year-old woman that was diagnosed with a huge wandering spleen including torsion of the elongated splenic vein. Despite the splenomegaly and the ectopy of the spleen, she underwent laparoscopic splenectomy without any complications. This interesting case report presents the opportunity for laparoscopic splenectomy also in case of splenomegaly and coincidental ectopy of the spleen as a save alternative therapeutic option to the conventional open-surgery approach. Case reportA 35-year-old woman (Jehova’s witness) presented in November 2010 in our surgical clinic with pain of the lower abdomen. Anamnestically a wandering spleen was known for years with intermittent abdominal disorders. To this point the patient has always refused a surgical treatment. Except for an uncomplicated sectio no concomitant diseases or previous surgeries were known. Furthermore, the patient was not under long-term medication. Routine laboratory values were normal except for elevated C-reactive protein (CRP) and lowered potassium. After admission to our hospital we performed a sonography followed by a computed tomography of the abdomen which revealed a pronounced splenomegaly with ectopy cranial of the urinary bladder and torsion of the splenic vein (Figure 1 ). Because of recurring, progressive abdominal pain and radiological splenomegaly with torsion of the splenic vessels we decided on a splenectomy. In absence of any contraindications the procedure was planned laparoscopically and started with a mini-laparotomy left subcostal to insert the camera trocar and subsequently inserting two further trocars. Intraabdominally the huge spleen was found in the lesser pelvis (Figure 2 ) with torsion of the splenic vessels (Figure 3A ). Detorsion of the spleen following stapled transection of splenic vessels was performed (Figure 3B ). Subsequently the spleen was placed in an inserted large extraction bag (Figure 4A ). Inside the extraction bag the spleen was fragmented into small pieces and the extraction bag was recovered using a small cut of the sectio cicatrice (Figure 4B ). Histopathological analyses of the resected spleen revealed no pathological findings. After recovering from surgery the patient received all recommended vaccinations and was discharged 6 days after surgery without any complications. Discussion and conclusionSplenectomy can be performed open or laparoscopic, whereas laparoscopic splenectomy of the regular localized spleen is preferred because of minimal invasiveness, shorter operation and hospitalization time , . For ectopic spleen therapeutically splenopexy is preferred to avoid the risk of postsplenectomy sepsis. The laparoscopic splenopexy can be considered as a save surgical procedure . In contrast splenectomy is necessary if an infarcted spleen due to vessel torsion is diagnosed. There are only a few authors reporting a laparoscopic splenectomy of a wandering spleen , , , , , . The laparoscopic approach allows to confirm the diagnosis and provides the possibility to decide about splenopexy or splenectomy depending on viability of the spleen following detorsion . In the above described case we were confronted with both, a splenomegaly and ectopy of the spleen. Having no contraindications for a minimal-invasive approach, we performed a laparoscopic splenectomy of the wandering spleen, in which intrabdominal fragmentation of the spleen was necessary because of massive splenomegaly. The surgery and the postoperative recovery were uneventful. In this case the laparoscopic approach was preferred because an open splenectomy would have required a long incision due to the elongated vessels. With this report and our described technique we want to suggest that laparoscopic splenectomy is a save therapeutic option to treat a wandering spleen with all advantage of minimal-invasive surgery, also in case of pronounced splenomegaly. NotesCompeting interestsThe authors declare that they have no competing interests. Buehner M Baker MS The wandering spleen 1992 Surg Gynecol Obstet 373-87 Buehner M, Baker MS. The wandering spleen. Surg Gynecol Obstet. 1992 Oct;175(4):373-87. Qazi SA Mirza SM Muhammad AM Al Arrawi MH Al-Suhaibani YA Wandering spleen 2004 Saudi J Gastroenterol 1-7 Qazi SA, Mirza SM, Muhammad AM, Al Arrawi MH, Al-Suhaibani YA. Wandering spleen. Saudi J Gastroenterol. 2004 Jan;10(1):1-7. Lewis GA Byrne MP Wandering spleen 1981 Am Surg 275-7 Lewis GA, Byrne MP. Wandering spleen. Am Surg. 1981 Jun;47(6):275-7. Kapan M Gümüş M Onder A Gümüş H Aldemir M A wandering spleen presenting as an acute abdomen: case report 2012 J Emerg Med e303-5 Kapan M, Gümüş M, Onder A, Gümüş H, Aldemir M. A wandering spleen presenting as an acute abdomen: case report. J Emerg Med. 2012 Nov;43(5):e303-5. DOI: 10.1016/j.jemermed.2010.06.029 http://dx.doi.org/10.1016/j.jemermed.2010.06.029 Soleimani M Mehrabi A Kashfi A Fonouni H Büchler MW Kraus TW Surgical treatment of patients with wandering spleen: report of six cases with a review of the literature 2007 Surg Today 261-9 Soleimani M, Mehrabi A, Kashfi A, Fonouni H, Büchler MW, Kraus TW. Surgical treatment of patients with wandering spleen: report of six cases with a review of the literature. Surg Today. 2007;37(3):261-9. DOI: 10.1007/s00595-006-3389-0 http://dx.doi.org/10.1007/s00595-006-3389-0 Delaitre B Pitre J Laparoscopic splenectomy versus open splenectomy: a comparative study 1997 Hepatogastroenterology 45-9 Delaitre B, Pitre J. Laparoscopic splenectomy versus open splenectomy: a comparative study. Hepatogastroenterology. 1997 Jan-Feb;44(13):45-9. Maurus CF Schäfer M Müller MK Clavien PA Weber M Laparoscopic versus open splenectomy for nontraumatic diseases 2008 World J Surg 2444-9 Maurus CF, Schäfer M, Müller MK, Clavien PA, Weber M. Laparoscopic versus open splenectomy for nontraumatic diseases. World J Surg. 2008 Nov;32(11):2444-9. DOI: 10.1007/s00268-008-9727-1 http://dx.doi.org/10.1007/s00268-008-9727-1 Carmona J Lugo Vicente H Laparoscopic splenectomy for infarcted splenoptosis in a child: a case report 2010 Bol Asoc Med P R 47-9 Carmona J, Lugo Vicente H. Laparoscopic splenectomy for infarcted splenoptosis in a child: a case report. Bol Asoc Med P R. 2010 Apr-Jun;102(2):47-9. Castellón-Pavón CJ Valderrábano-González S Anchústegui-Melgarejo P Alvarez-Alvarez J Morales-Artero S Pérez-Algar C Corrales-Castillo S García-Serrano FR Esplenectomía laparoscópica por torsión de un bazo ectópico (wandering spleen). 2006 Cir Esp 406-8 Castellón-Pavón CJ, Valderrábano-González S, Anchústegui-Melgarejo P, Alvarez-Alvarez J, Morales-Artero S, Pérez-Algar C, Corrales-Castillo S, García-Serrano FR. Esplenectomía laparoscópica por torsión de un bazo ectópico (wandering spleen) [Laparoscopic splenectomy due to torsion of a wandering spleen]. Cir Esp. 2006 Dec;80(6):406-8. DOI: 10.1016/S0009-739X(06)70996-4 http://dx.doi.org/10.1016/S0009-739X(06)70996-4 Rosin D Bank I Gayer G Rimon U Gur D Kuriansky Y Morag B Pras M Ayalon A Laparoscopic splenectomy for torsion of wandering spleen associated with celiac axis occlusion 2002 Surg Endosc 1110 Rosin D, Bank I, Gayer G, Rimon U, Gur D, Kuriansky Y, Morag B, Pras M, Ayalon A. Laparoscopic splenectomy for torsion of wandering spleen associated with celiac axis occlusion. Surg Endosc. 2002 Jul;16(7):1110. DOI: 10.1007/s00464-001-0078-3 http://dx.doi.org/10.1007/s00464-001-0078-3 Corcione F Caiazzo P Cuccurullo D Miranda L Settembre A Pirozzi F Bruzzese G Laparoscopic splenectomy for the treatment of wandering spleen 2004 Surg Endosc 554-6 Corcione F, Caiazzo P, Cuccurullo D, Miranda L, Settembre A, Pirozzi F, Bruzzese G. Laparoscopic splenectomy for the treatment of wandering spleen. Surg Endosc. 2004 Mar;18(3):554-6. DOI: 10.1007/s00464-003-4254-5 http://dx.doi.org/10.1007/s00464-003-4254-5 Benevento A Boni L Dionigi G Ferrari A Dionigi R Emergency laparoscopic splenectomy for "wandering" (pelvic) spleen: case report and review of the literature on laparoscopic approach to splenic diseases 2002 Surg Endosc 1364-5 Benevento A, Boni L, Dionigi G, Ferrari A, Dionigi R. Emergency laparoscopic splenectomy for "wandering" (pelvic) spleen: case report and review of the literature on laparoscopic approach to splenic diseases. Surg Endosc. 2002 Sep;16(9):1364-5. DOI: 10.1007/s00464-002-4213-6 http://dx.doi.org/10.1007/s00464-002-4213-6 Yücel E Kurt Y Ozdemir Y Gun I Yildiz M Laparoscopic splenectomy for the treatment of wandering spleen in a pregnant woman: a case report 2012 Surg Laparosc Endosc Percutan Tech e102-4 Yücel E, Kurt Y, Ozdemir Y, Gun I, Yildiz M. Laparoscopic splenectomy for the treatment of wandering spleen in a pregnant woman: a case report. Surg Laparosc Endosc Percutan Tech. 2012 Apr;22(2):e102-4. DOI: 10.1097/SLE.0b013e318246beb5 http://dx.doi.org/10.1097/SLE.0b013e318246beb5 0

1 1 Figure 1: Computed tomography of the abdomen revealed the huge wandering spleen (black arrows) cranial of the urinary bladder in the lesser pelvis.

2 2 Figure 2: Intraabdominally the huge spleen was found in the lesser pelvis.

3 3 Figure 3: The CT graphical assumed torsion of the splenic vessels could be confirmed (A) and the laparoscopic abscission of the vessels was performed (B).

4 4 Figure 4: A large extraction bag was inserted (A). Following fragmenting the spleen into small pieces, the extraction bag was recovered using a 3 cm long cut of the sectio cicatrice (B).

4 0 0