Robotically assisted laparoscopic management of pelvic splenosis

Robotically assisted laparoscopy is a superior technique for the management of abdominopelvic splenosis, which is an often unsuspected cause of pelvic pain. A 25-year-old female with a distant history of traumatic splenic rupture and splenectomy was diagnosed with splenosis at the time of laparoscopy for vague abdominopelvic pain. She was transferred to our service for evaluation and definitive surgical management. We report the use of robotically enhanced laparoscopy for the excision of the splenic tissue. Splenosis is a potential cause of pelvic pain in a patient with a history of splenic injury. Robotically assisted laparoscopy provides the manual dexterity and the enhanced field of view necessary for the meticulous nature of this surgery.     

Isolated Hepatic Splenosis: First Reported Case

Splenosis is the autotransplantation of splenic tissue, most commonly seen after traumatic splenic rupture and splenectomy. Post-traumatic splenosis is often considered a rare entity, but is probably underreported because of its asymptomatic nature. We describe the first reported case of splenosis presenting as a liver mass, indistinguishable from a liver tumor by standard preoperative evaluation. The pathophysiology, evaluation and management of splenosis is discussed as well as the decision to resect a benign appearing liver mass.     

A rare diagnosis for a pancreatic mass: splenosis

Splenosis, the autotransplantation of splenic tissue, has been designed to preserve organ functions after splenectomy. We present the first case of laparoscopic resection of a pancreatic splenosis, in a patient who had undergone a splenectomy 31 years before, complaining of abdominal pain and diarrhea. Abdominal computed tomography (CT) scan showed an enhancing hypervascular 3-cm solid mass in the body of the pancreas, mimicking a pancreatic cancer or a neuroendocrine tumor. A diagnostic laparoscopy was planned, and a 3-cm peripancreatic nodule with a long pedicle was visualized, with many nodules close to the tail of the pancreas and in the greater omentum. They were all resected, and the specimens obtained were immediately sent for frozen-section examination, which confirmed the diagnosis of heterotopic splenic tissue. Splenosis should be included in the differential diagnosis of the pancreatic masses in patients with previous splenic surgery. A hypervascular mass on CT scan should be regarded as an adenocarcinoma of the pancreas until proven otherwise. The possibility of a neuroendocrine tumor mandates an octreotide scan and gastrointestinal hormones dosage. In the unlikely event that all tests may produce equivocal results, a diagnostic laparoscopy is mandatory, in order to obtain an accurate histopathologic diagnosis.     

Case report: omental splenosis discovered during robotic prostatectomy

Splenosis describes ectopic splenic implants that usually occur after trauma and splenectomy. We present a case of omental splenosis discovered during robot-assisted prostatectomy.     

Unique case of intramural colonic splenosis

Splenosis is usually a sequel of splenic rupture from abdominal trauma but can be associated with elective splenectomy. Recurrence of the hematological disorder for which the patient underwent splenectomy may occur, and splenic nodules can be found anywhere in the thoracic or abdominal cavity, as well as subcutaneously. We are presenting intramural colonic splenosis, a large inoculum of the splenic tissue that has been found to have the capacity to maintain anemia and thrombocytopenia, in a child previously splenectomized because of a hematological problem.     

Splenosis. A cause of massive gastrointestinal hemorrhage

Splenosis is the autotransplantation of splenic tissue following surgery or trauma. While it has been reported to cause a number of complications, splenosis is most commonly an incidental finding at laparotomy or on imaging studies. In our study, a case of massive, acute gastrointestinal hemorrhage occurred secondary to splenosis involving the small bowel. While there are several reports of self-limited gastrointestinal hemorrhage secondary to splenosis involving the gastric fundus, we are aware of no reports of massive, acute intestinal bleeding caused by this condition. Splenosis should be considered in the differential diagnosis of gastrointestinal hemorrhage in patients who have experienced prior splenic trauma or splenectomy.     

Abdominal splenosis： CT and MRI features of 2 cases

Splenosis is ectopic autotransplantation of splenic tissue after splenic trauma or surgery. 1 The most frequent locations are the surface of visceral peritoneum and parietal peritoneum. Liver and retroperitoneum are rarely involved. 1,2 We present here 2 cases of splenosis involving the liver and retroperitoneum with clinical information, imaging findings, and literature review.     

Splenosis mimicking tumor recurrence in renal cell carcinoma: detection on selective spleen scintigraphy.

A 2-year-old boy had been operated on for a giant renal cell carcinoma including splenectomy because of disrupture of the splenic capsule. During a follow-up examination, 3 nodules were detected by ultrasound in the splenorenal area. This gave reason to suspect tumor recurrence. Considering the possibility of splenosis, a selective spleen scan using denatured red blood cells was performed as a final diagnostic step. This method confirmed the nodules as representing splenic tissue. Splenosis should be included in the differential diagnosis of solid masses in the postsplenectomy patient.     

Decreased phagocytic capacity of autotransplanted splenic tissue

Background: Asplenic patients have an increased risk of infections. Operations such as autotransplantation have been proposed to restore functional splenic tissue after splenectomy, but the protective value of this tissue is unclear. Immune responses such as production of antibody remain impaired in humans and animals even when such tissue is present, and clearance of particles from the blood is reported to be less efficient than by normal spleen tissue. The present study investigated the phagocytic capacity of cells in the regenerated tissue in vitro, free of the confounding effects of hepatic clearance. Methods: Single cell suspensions were prepared from splenic tissue from rats 6 months after splenic autotransplantation or sham operation. Phagocytosis of killed, fluorescein‐labelled bacteria was measured by flow cytometry. Results: Autotransplanted tissue contained fewer phagocytic cells than normal tissue, and these cells phagocytosed less per cell. Phagocytosis by spleen cells was dependent on heat‐labile opsonic factors. Conclusions: Autotransplanted splenic tissue does not restore the phagocytic capacity lost following splenectomy.     

Splenosis mimicking local recurrence after radical nephrectomy: a report of two cases

Splenosis is autotransplantation of splenic tissue and usually follow traumatic or surgical rupture of the spleen. We report two cases of splenosis which presented as a local recurrence after radical nephrectomy for left renal cell carcinoma (RCC). The patients were a 65- and a 71-year-old male, who had been operated for RCC including splenectomy because of disrupture of the splenic capsule 8 and 9 years earlier respectively. In both cases, follow up computed tomographic scans showed small nodules under the left diaphragm. Although we initially suspected local recurrence, we considered the possibility of splenosis. Both patients underwent technetium-99m Sn colloid scans and were diagnosed with splenosis successfully. Therefore, we could avoid unnecessary surgical explorations.     

Spontaneous splenic vein aneurysm rupture in the puerperium

A case of intra- and retroperitoneal haemorrhage after a splenic vein aneurysm rupture is described. A 27-year-old woman complained of chest pain on her first postpartum day. Symptoms were initially suggestive of pulmonary embolism, but within 3 h she developed severe acute abdominal pain, abdominal distension and haemodynamic instability. Ultrasound demonstrated a non-echogenic mass in the abdomen suggestive of a fluid collection and a computed tomography scan confirmed the presence of a lesion at the pancreatic tail. Urgent laparotomy revealed splenic vein rupture near the pancreatic tail. Partial pancreatectomy and splenectomy were performed. The patient subsequently made an uneventful recovery. Histological examination revealed a splenic vein aneurysm and chronic inflammatory changes in the pancreatic tissue. Rupture of a splenic vein aneurysm is a rare event and the diagnosis may present difficulty because its presentation is similar to several other more common conditions. However, rupture of a splenic vein aneurysm should be suspected in any pregnant woman with unexplained abdominal pain or with clear signs of haemorrhage, as delay in diagnosis can have devastating consequences.     

Laparoscopic subtotal splenectomy

BACKGROUND: Since 1979, we have been studying subtotal splenectomy. This procedure was used in over 200 patients to treat splenic trauma, portal hypertension, myeloid metaplasia due to myelofibrosis, Gaucher disease, chronic lymphocytic leukemia, retarded growth, and sexual development associated with splenomegaly, and disorders of the pancreatic tail. On the basis of our clinic experience with laparoscopic splenectomy with and without splenic autotransplantation, open subtotal splenectomy, and after a training period with laparoscopic conservative splenic operations on animals, this communication presents laparoscopic subtotal splenectomy as a new treatment of severe pain due to ischemia of the spleen. PATIENTS AND METHODS: Two patients with severe splenic pain due to ischemia provoked by vascular obstruction of the spleen were successfully treated by laparoscopic subtotal splenectomy, with preservation of the upper splenic pole supplied only by the gastrosplenic vessels. RESULTS: This procedure was safely conducted with minor bleeding and no technical difficulties or complications. The postoperative follow-up of 5 and 21 months has been uneventful and the pain disappeared since the first postoperative day. CONCLUSIONS: It is feasible and safe to perform subtotal splenectomy by laparoscopy. This procedure seems to be a good treatment for pain due to splenic ischemia.     

Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.     

Splenosis presenting as a left renal mass indistinguishable from renal cell carcinoma

Splenosis following splenic trauma is a common but underdiagnosed entity before surgical exploration. In all previously reported cases the ectopic splenic tissue was distinctly separate from the kidney. To our knowledge we report the first known case in which the splenic tissue was located in direct apposition with the kidney. Using conventional imaging techniques, including renal ultrasonography, abdominal computerized tomography and selective renal arteriography, this ectopic splenic tissue appeared to be part of the left kidney and was indistinguishable from renal cell carcinoma. The pathophysiology, clinical presentation and diagnostic studies of splenosis are reviewed.     

Complicated omental splenosis

Splenosis results from autotransplantation of splenic tissue, usually after traumatic splenic rupture. The diagnosis is suggested by the history and the presence of multiple nodules on computed tomography. Selective splenic scintigraphy utilising heat denatured red blood cells confirm the diagnosis. Treatment is usually conservative with surgical excision reserved for complicated cases. We report a case of splenosis associated with phlegmon and infectious process, requiring surgical intervention.     

Long-term results of splenectomy in children with closed injuries of the spleen

Under study were indices of the immune reactivity and infectious morbidity in 30 persons subjected to splenectomy in childhood for traumatic rupture of the spleen. They were shown to have lower resistance to infections. Children after splenectomy need a continuous dispensary observation. Prophylactic measures require further development. The most perspective method of preserving the functioning splenic tissue in the organism after trauma of the organ is thought to be autotransplantation of the splenic pulp.     

Progressive splenomegaly following splenic artery embolization

Nonoperative management of splenic injury is standard in hemodynamically stable patients. Splenic artery embolization is a useful adjunct to nonoperative management for patients with ongoing hemorrhage. However, the complications of embolization are not well defined. We report a case of progressive splenomegaly requiring delayed splenectomy after embolization. A 57-year-old hemodynamically stable, blunt trauma patient had a Grade III splenic injury with associated subcapsular hematoma. Nonoperative management was initiated, but his hemoglobin levels progressively declined prompting proximal splenic artery embolization. His hemoglobin levels remained stable postembolization and he was discharged on postinjury day 5. The patient was readmitted 10 days later with increasing abdominal pain and shortness of breath. Repeat CT revealed an enlarged subcapsular fluid collection, but his hemoglobin level remained stable and he was discharged 5 days later. He returned again 2 days later with similar complaints, and CT demonstrated that his subcapsular fluid collection was further enlarged. Repeat hemoglobin level was again stable. The patient requested operative intervention due to intractable pain, and splenectomy was performed without complications. Operative findings included a sterile, contained subcapsular hematoma. Splenic embolization has emerged as an adjunct to nonoperative management of splenic injury; however, the indications for splenic embolization are yet to be defined, and the spectrum and frequency of potential complications are poorly documented. This case report highlights a potentially serious complication that can occur after splenic embolization.     

Optimal site and amount of splenic tissue for autotransplantation.

Clinical and basic studies have documented a high susceptibility to pneumococcal infection in asplenic humans and animals. It has been suggested that autotransplantation of splenic tissue might be a method of providing host resistance when total splenectomy is necessary. However, the effect of splenic autograft has remained controversial. This study was performed to evaluate the most effective site and amount of splenic autograft using rats. Rats were divided into five groups for the purpose of determining the site of splenic autotransplantation: splenectomy, sham operation, implantation into the omental pouch, intraperitoneal implantation, and intramuscular implantation. For determining the amount for autotransplantation, the rats were divided into seven groups: splenectomy, sham operation, and implantations of 25, 50, 100, 200, or 300 mg of splenic tissue. All animals were challenged with Streptococcus pneumoniae type 6, 16 weeks after surgery. Howell-Jolly bodies appeared postsplenectomy, but disappeared in the implanted rats 16 weeks after the operation. Histologically, the implanted tissue was indistinguishable from that of a normal spleen. Pneumococcal clearance from the bloodstream and survival rate were significantly higher in rats implanted in the omental pouch as compared with splenectomized rats. Intraperitoneal and intramuscular implanted rats did not show a significant difference from the splenectomized rats. More than 50% of splenic tissue for autograft showed a significant increase in pneumococcal clearance and survival rate as compared with that of splenectomized rats. It was suggested that the most effective site of autotransplantation is the omental pouch and approximately 50% of the whole spleen would be necessary for prevention from sepsis.     

Laparoscopic removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy

The clinical success of therapeutic splenectomy for idiopathic thrombocytopenic purpura depends on the complete removal of all functional splenic tissue. Among reasons for poor response to splenectomy, failure to remove accessory spleens is mentioned. We present our experience with laparoscopic removal of accessory spleen from retroperitoneal space in a patient with relapse of ITP 30 years after classical splenectomy. A 45-year-old female patient underwent in 1972 classical splenectomy for ITP. Progressive decline in thrombocyte count was observed 7 years ago. Scintigraphy, CT, and ultrasound revealed residual splenic tissue. A laparoscopic approach was proposed. Four trocars placed along left costal margin were used. After dissection of all the adhesions behind the pancreatic tail deep in the retroperitoneal space a round structure 4 cm in diameter, macroscopically resembling splenic tissue, was found. The accessory spleen was removed intact. The patient recovered well; 2 months later steroids were discontinued while the thrombocyte level was 251 x 10(9)/L. Identification of accessory spleen seems to be major intraoperative problem. We believe that accessory spleen can be safely removed laparoscopically, avoiding a major open procedure, and a satisfactory postoperative result could be expected.     

Splenosis as a cause of testicular pain: laparoscopic management.

This is a case report of a 37-year-old man with severe testicular pain unresolved after conventional investigative and therapeutic methods. On the basis of his history of abdominal trauma followed by emergency splenectomy and evidence of functioning splenic tissue on a radionuclide scan, the diagnosis of splenosis was established. Laparoscopic exploration was done, and the initial diagnosis confirmed. Splenic tissue located at the right inguinal ring was removed. Testicular pain abated after the procedure.