Laparoscopic splenectomy for epithelial cyst of the spleen

Splenic cysts of all types are a relatively rare entity. The origin of epithelial cysts of the spleen is controversial, most probably congenital in origin. Generally, epithelial cysts of the spleen are asymptomatic and discovered incidentally. We present the case of a 40-year-old woman with a 3.5 cm splenic cyst diagnosed four years before. The cyst raised progressively in dimension, the actual size being of 6.5 cm. Computed tomography scan and magnetic resonance showed a central splenic cyst in close relations with main splenic vessels. An initial indication of partial splenectomy was established, eventually a total splenectomy being performed by laparoscopy due to close relations of the cyst with the main hilar splenic vessels. The hemostasis was assured with the aid of Ligasure Atlas 10 mm instrument. The pathology examination revealed a multilocular splenic cyst with a cuboidal epithelial lining. Central localization of splenic cysts represents an indication for total splenectomy. Laparoscopy provides a minimal access method of obtaining pathological confirmation of diagnosis, reduction of cyst complications, and a short hospital stay. This article discusses different aspects of epithelial cysts related to pathology, diagnostic and indications for operative treatment, a review of the literature being also presented.     

Exposure of splenic hilum increases safety of laparoscopic splenectomy

Laparoscopic splenectomy is becoming the gold standard technique for the treatment of hematological disorders of the spleen. Hemostasis is a fundamental step during laparoscopic splenectomy leading some authors to develop several techniques to control splenic vessels such as hand assistance, preoperative splenic artery embolization, and the use of vascular linear staplers. However, intraoperative bleeding is usually due to inadequate exposure of the hilar splenic vessels itself. The authors describe a standardized technique for the exposure of splenic pedicle using an endoscopic triangular retractor. We have been used this technique in 16 consecutive laparoscopic splenectomies with minimal blood loss. The present technique may increase the safety of laparoscopic splenectomy with adequate exposure of the splenic hilum reducing the conversion rate and intraoperative blood loss.     

Partial Splenectomy in the Management of Nonparasitic Splenic Cysts

Background  Recognition of the importance of the spleen in immunological function and the potential threat of severe postsplenectomy complications have led to the development of parenchyma-preserving surgical procedures. The aim of the present study was to assess the impact of open splenic partial resection on the management of splenic cysts. Patients and methods  From April 2003 to June 2007, 11 patients with splenic cysts were evaluated. All patients fulfilled the criteria for surgical resection. Ten of the patients (6 women and 4 men) 15–42 years of age (mean: 26.4 years) were subjected to open partial splenectomy. In one patient, a centrally located splenic cyst was considered unsuitable for partial splenectomy, and the patient therefore underwent total spleen excision. Patients with splenic cysts constituted 3.8% of all 290 patients subjected to splenectomy during the study period. Spleen parenchyma was cut with the aid of a LigaSure instrument. Bleeding from the transected splenic parenchyma was secured with argon plasma coagulation and absorbable tape sutures or oxidized cellulose. Results  Nine of the ten patients underwent successful partial splenectomy. In one patient, insufficient arterial supply to the preserved splenic remnant after excision of the upper cyst-containing splenic pole led to total splenectomy. The mean operative time was 98 min (range: 85–160 min), and mean blood loss was 106 ml (55–200 ml). The mean cyst diameter was 9.1 cm (range: 7–17 cm) and weight was 738 g (range: 230–2,420 g). The postoperative course was uneventful in all cases. Pathological examination showed an epithelial cyst in 8 patients and a pseudocyst in 2. After a mean follow-up of 26.4 months, the size of the splenic remnant constituted, on average, 71% of preoperative spleen size. Moreover, normal splenic vein flow was observed. Platelet counts remained within the normal range, and no cyst recurrence was observed. There were no infections documented during the follow-up period. Conclusions  Open partial splenectomy is a safe and effective method in the management of nonparasitic splenic cysts. It ensures complete cyst removal, lack of cyst recurrence, and preservation of the spleen functions.     

Splenic epidermoid cyst: laparoscopic partial decapsulation

The splenic cysts are rare among all age groups and there are a few reports in the world literature. The splenic epidermoid cyst is a true congenital one, that can cause signs and symptoms, or suffer complications. For these reasons, some form of treatment is recommended. The management of splenic cysts continues to evolve. The standard treatment was splenectomy, but the knowledge about the immunologic function of the spleen and the existence of postesplenectomy mortal sepsis, have conduced most of pediatric surgeons to adopt techniques that preserves splenic tissue. The treatment by percutaneous drainage with injection of a sclerosing agent has complications and a significant recurrence rate. During the last two decades, preservation procedures such as partial splenectomy or partial cyst excision and omental packing have gained the preference of most pediatric surgeons. The second technique has advantages over the partial splenectomy. The possibility to perform the procedure by a laparoscopic approach add the advantages of this last technique. We present two patients with splenic epidermoid cyst treated by laparoscopic partial cyst decapsulation and review the literature.     

Total splenectomy for a recurrent giant splenic cyst

Primary splenic cysts are a rare finding. Some are large and require surgical removal. The Authors report a case of a recurrent huge splenic cyst in a 41-year-old female patient. A marsupialization was performed at another hospital 6 years before. Ultrasonography and computed tomography imaging revealed a cystic lesion in the spleen measuring approximately 20 cm in diameter. A total open splenectomy was performed. Postoperative course was uneventful. The histologic diagnosis was an epithelial cyst of the spleen with no atypical cells in the cyst wall, as previously found at the first operation. The epidermoid cysts have an epidermal lining, and prevention of recurrence is dependent on complete resection of the cyst wall preserving, whenever possible, the splenic tissue. Recurrence can be avoided with partial splenectomy in polar localization of the cyst, or complete removal of the cyst by "peeling" it off the splenic parenchyma. Marsupialization of the cyst, either via a laparoscopic or an open approach, is often ineffective.     

内结扎法腹腔镜儿童脾切除术的临床体会

目的:探讨內结扎法腹腔镜儿童脾切除术的可行性及临床效果.方法:回顾分析为7例患儿行内结扎法腹腔镜脾切除术的临床资料.镜下先游离显露脾动脉,分别用丝线结扎、切断,再逐一游离显露脾静脉,用丝线结扎、切断.丝线结扎代替Endo-GIA或Hem-o-lok等器械结扎脾门血管.并与同期施行的5例內镜切割闭合钉结扎脾门血管法进行对...     

Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications

BACKGROUND: This study was designed to test a hypothesis that intrahepatic hydatid cyst location can effect the incidence of cystobiliary communications and the cavity-related complications. METHODS: A total of 121 cysts treated by conservative surgical methods in 113 patients were evaluated prospectively. Cysts were grouped as near to the liver hilum (segment I, III, IVb, V, and VI) and far from the hilum (segment II, IVa, VII, and VIII). RESULTS: There were 58 (48%) hilar and 63 (52%) peripheral cysts. We found more cystobiliary communications (48% versus 27%, P = 0.015), more biliary leakage (36% versus 10%, P <0.001), and more biliary fistula (12% versus 3%, P = 0.080) in the cysts near to the hilum than far from the hilum. Postoperative hospital stay was longer in the cysts near to the hilum (12.3 +/- 3.1 days) than the cysts far from the hilum (7.7 +/- 2.7 days, P = 0.022). CONCLUSIONS: The location of the hydatid cyst near to the liver hilum is a risk factor for the cystobiliary communications and the cavity related complications.     

Laparoscopic partial splenectomy for congenital splenic cyst in a pediatric patient: Case report and review of literature

Non-parasitic splenic cysts (NPSC) are a rare condition that makes difficult to know their true incidence and represent 10% of all benign splenic cysts, they can be either congenital with the presence of epithelial lining that originate from invagination of the capsular mesothelial lining or post-traumatic with absence of epithelial lining. We present our management of a splenic congenital cyst in a pediatric patient. A 10-year-old female patient presented to the clinic complaining with a 3-week abdominal pain at the left upper quadrant. An ultrasound showed an enlarged spleen with a thinned walled cystic image on the lower pole of 5 cm. An abdominal CT confirmed the presence of a splenic cyst at the lower pole of the spleen of 5 cm in diameter. Three-port laparoscopic partial splenectomy was done isolating and dividing the lower splenic artery and vein and the lower pole of the spleen with a vessel sealing device. Management of a non-parasitic splenic cyst is controversial: cystectomy, fenestration, percutaneous drainage and sclerotherapy have been previously described, most of them aiming to preserve spleen function and avoiding overwhelming post-splenectomy infection. Partial splenectomy seems the most effective one in terms of preserving spleen function and avoiding recurrence.     

腹腔镜部分脾切除治疗脾囊肿2例报告并文献复习

脾囊肿相对比较少见,较大囊肿或有压迫症状需外科治疗。传统治疗手段包括脾囊肿开窗引流术和全脾切除术,脾囊肿开窗引流术相对比较简单易行,但术后易出现囊肿复发、积液感染及出血等风险,全脾切除术无复发风险,但破坏患者免疫功能,术后可能出现爆发感染以及静脉血栓;目前认为最理想的治疗方法是行脾部分切除术,既切除病变的脾组织同时也保留了部分健康脾组织,从而保存了脾脏正常的免疫功能。开腹部分脾切除术临床报道较多,但腹腔镜脾部分切除术少见报道。在这里,我们报道两例腹腔镜脾部分切除治疗脾巨大囊肿,术中通过解剖脾门血管,选择性结扎脾上、中极动静脉,在脾缺血带内侧1 cm用超声刀和Hem-o-lok离断脾实质,术后随访无复发。我们认为腹腔镜脾部分切除治疗脾囊肿是安全可行的,具有创伤小、恢复快等优点,值得临床推广应用。     

Partial splenic decapsulation: a simplified operation for splenic pseudocyst

Splenic pseudocysts have traditionally required splenectomy because of the risks imposed by partial splenectomy or excision of the cyst lining. During the past 2 years, a 6-year-old boy and a 9-year-old girl presenting with vague upper abdominal discomfort, palpable splenomegaly, and a large unilocular sonolucent cyst within the spleen, were treated by partial splenic decapsulation with preservation of the hilar blood supply. This procedure involves mobilizing the spleen by dividing the renal, colic, and diaphragmatic attachments; decompressing the liquefied cyst contents through a thoracostomy trochar; excising the outer splenic capsule and gaining hemostasis of the splenic wall with a running interlocked silk suture; and providing external tube drainage of the left upper quadrant. During the follow-up period of 26 and 12 months, splenic size has returned to normal. Serial nuclear scan and ultrasound show a small residual crescent-shaped deformity of the functioning splenic remnant. We conclude that partial splenic decapsulation for splenic pseudocyst is simpler and safer than other preservation procedures attempted, and carries no increased risk of recurrence from leaving a portion of the pseudocyst wall.     

Posterolateral approach

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports. Received: 24 January 1997/Accepted: 28 October 1997     

Partial splenectomy for benign cystic lesions of the spleen

Cystic lesions of the spleen are uncommon, about 600 cases being reported in the world literature. This report concerns three pediatric patients treated by partial splenectomy for benign cyst. In the world literature most of the cystic lesions of the spleen are treated by splenectomy and more recently by partial splenectomy. The infected lesions are treated by splenectomy or by incision and drainage only. Partial splenectomy has evident advantage over splenectomy. Although in the world literature we have not found a single case of infected splenic benign cyst treated by partial splenectomy, we believe that this procedure also has an advantage over drainage as the infected and necrotic part of the cyst is removed, thereby reducing morbidity and further possible complications.     

Cystic masses of the spleen

Cystic masses of the spleen are unusual, and identification of their origin is critical to proper management. Presenting symptoms frequently are due to compressive effects of the mass or are due to infection. These cystic splenic masses are most commonly secondary cysts that lack a true epithelial lining and are usually related to prior splenic injury. Primary splenic cysts are rare and have an epidermal lining. Computed abdominal tomography outlines the anatomy and character of cystic masses of the spleen. Cystic splenic masses that are large, inflammatory in origin, involve the splenic hilum, or are infected, should be excised by splenectomy. Cysts localized to a single pole can be treated by partial splenectomy. An experience with three illustrative cases is presented.     

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy

Background and Objectives:

Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.

Methods:

The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients'' postoperative courses are described.

Results:

The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.

Conclusions:

The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.     

Giant congenital infected splenic cyst: An interesting case report and review of the literature

Splenic cysts are rare lesions. The congenital non-parasitic cysts of the spleen are rarely met in the clinical practice. Primary cysts have a cellular lining that can be caused by congenital events or parasitic infection (Echinococcus). Secondary cysts have no cellular lining and may be of hemorrhagic, serous, inflammatory, or degenerative origin. We report a rare case of congenital cyst of spleen in a child aged 10 years treated successfully by splenectomy because of total involvement of the splenic parenchyma along with involvement of hilum by the cyst, and we review the literature.     

Reticuloendothelial clearance and splenic mononuclear cell populations after resection and autotransplantation

Although the preservation of splenic tissue may prevent overwhelming infection after splenectomy, the degree of protection conferred by small remnants has not been optimal. We investigated whether either splenic reticuloendothelial clearance of a blood flow-dependent colloid or macrophage and T-cell populations might be altered by resection or autotransplantation of the spleen. Our results have shown that bloodstream reticuloendothelial clearance of technetium 99m sulfur colloid is not impaired by splenectomy, partial resection of the spleen, or splenic autotransplantation. Such clearance is dependent on spleen weight and is not related to differences in either macrophage or helper or suppressor T-cell populations. This suggests that autotransplantation of the spleen is inferior to preservation of even a small hilar remnant and implies that repair or partial resection of the spleen will provide greater protection than autotransplantation.     

Open and laparoscopic treatment of nonparasitic splenic cysts

BACKGROUND: Nonparasitic splenic cysts are rare. Therefore, there is no 'evidence-based' information regarding their optimal surgical management. In the last years the laparoscopic approach has gained increasing acceptance in splenic surgery. The aim of this study is to present our experience with the laparoscopic management of splenic cysts. METHODS:The medical records of 7 patients with splenic cysts were reviewed retrospectively. RESULTS: One patient had an open partial splenic resection. Five patients, 3 of them with a posttraumatic and 2 with an epidermoid splenic cyst, underwent laparoscopic unroofing of the cyst. In 4 of these cases the postoperative course was uneventful, whereas in 1 case the patient developed a cyst relapse soon postoperatively. Later on this patient successfully underwent an open partial splenic resection. The 7th patient had an explorative laparoscopy. The cyst was located intrasplenically, entirely covered with unaffected splenic parenchyma, and reached the splenic hilus. Therefore, a conversion to open partial splenectomy was performed. CONCLUSION: Open partial splenectomy and laparoscopic cyst wall unroofing are both effective tools in the management of splenic nonparasitic cysts. Surgeons must master both techniques as nowadays spleen-preserving techniques should be attempted in every case of splenic nonparasitic cyst.     

Nonparasitic splenic cysts: a case report and review

Cysts of the spleen are rare but usually benign. The authors describe the case of a young woman with a splenic cyst who underwent splenectomy. Ultrasonography and computed tomography have helped improve the preoperative diagnosis of nonparasitic splenic cysts, and as the use of ultrasonography increases, so will the finding of incidental splenic cysts. Whether all splenic cysts enlarge is unknown, and it is uncertain whether all small asymptomatic cysts need treatment. The cysts may enlarge, become infected or rupture. Total splenectomy has been the most common treatment in the past, but, because of the risk of postsplenectomy sepsis, partial splenectomy may be preferred when technically possible.     

Oversized pseudocysts of the spleen: Report of two cases: Optimal management of oversized pseudocysts of the spleen

INTRODUCTION

Pseudocysts of the spleen are usually asymptomatic and associated with a history of trauma, infection or infarction. In this report, we present two uncommon cases of solitary, oversized pseudocysts of the spleen.

PRESENTATION OF CASE

Two patients (cases A and B), with symptoms of abdominal pain, were investigated. The laboratory and ultrasound examination confirmed the diagnosis of a large, non-parasitic splenic cyst in both cases. Computed tomography described an oversized pseudocyst occupying almost the entire splenic parenchyma in both cases and in patient A, the cyst was located in the splenic hilum. The medical history revealed a previous abdominal injury only in case A. The two patients underwent an open total splenectomy. The pathology examination verified the diagnosis of a non-parasitic splenic pseudocyst.

DISCUSSION

Both patients presented with symptoms, in contrast to the majority of patients with splenic cysts. The medical history of patients with splenic pseudocysts does not always reveal the cause of the pseudocyst formation. Any type of spleen-sparing procedure is not easy to perform in cases of surgical and anatomical difficulty, because of recurrence and the risk of intractable bleeding from the spleen.

CONCLUSION

Partial splenectomy is the recommended method for parenchymal preservation, but total splenectomy is preferred when the splenic cyst is oversized or cannot be excised with safety.