Laparoscopic splenectomy for the treatment of wandering spleen

Wandering Spleen - A Possible Cause of Adrenal “Mass” - Case Report

Wandering spleen is a very rare clinical condition characterized by spleen absence in the normal anatomical location in the upper left quadrant of the abdomen and its presence at another location in the abdomen or pelvis. The ectopic spleen is extremely rare in children, where its increased mobility is the result of a congenital disturbance of the fixation for the anterior wall due to the absence or weakness of the supporting ligaments. Wandering spleen is usually asymptomatic, but its torsion is possible, as well as infarction or rupture which demand an urgent diagnosis and surgical treatment. The diagnosis of wandering spleen can easily be overlooked due to low incidence and insufficient clinical experience, which multiplies patient's risk from life-threatening conditions. We present a case of wandering spleen in an 11-year-old girl with acute abdominal pain, which after ultrasound examination raised suspicion on the right adrenal gland tumor. Additional diagnostics verified an ectopic spleen in the right adrenal box, after which the recommended preventive splenopexy was seriously considered. Due to the fixation of the vital spleen in the new position, but also the negative attitude of the parents towards the surgical intervention, clinical monitoring was selected, with exclusion of intense physical activity that carries the risk of traumatization of the spleen. As the girl has been in good health for over 3 years and without symptoms, we consider that the selection of conservative access although difficult, was correct. We hope that our experience in treating wandering spleen in girls will increase the number of valid facts about this rare condition.

Wandering spleen with chronic torsion in a patient with thalassaemia

Wandering spleen or splenoptosis is an uncommon entity and often an asymptomatic finding of acute abdomen in the emergency department. A high index of suspicion for splenic torsion is required, particularly in patients with known splenomegaly, as this condition could potentially lead to splenic infarction. Recognition of this condition can help avoid potential confusion with acute abdomen of other aetiologies. Herein, we present a unique case of wandering spleen with chronic torsion, which, to the best of our knowledge, has never been described in an elderly patient with haemoglobin H thalassaemia. We also review the literature for the aetiology and pathogenesis of wandering spleen, and discuss the relevant diagnostic modalities and treatment options.

Wandering spleen: a medical enigma, its natural history and rationalization

INTRODUCTION

Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted to hospital because of severe abdominal pain, vomiting or obstipation.

METHODS

This article aims to provide a historical overview of wandering spleen diagnostics and surgical treatment supplemented with an analyses of articles on wandering spleen included in the PubMed database.

RESULTS

One of the first clinical descriptions of a wandering spleen was written by Józef Dietl in 1854. The next years of vital importance are 1877 when A. Martin conducted the first splenectomy and in 1895 when Ludwik Rydygier carried out the first splenopexy to immobilize a wandering spleen. Since that time various techniques of splenectomy and splenopexy have been developed.

CONCLUSIONS

Introducing medical technologies was a watershed in the development and treatment of wandering spleen, which is confirmed by the PubMed database. Despite the increased number of publications medical literature shows that a wandering spleen still remains a misdiagnosed condition, especially among children.

Laparoscopic splenectomy of a wandering spleen with coincidental enormous splenomegaly

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.

Laparoscopic gastropexy for the treatment of gastric volvulus associated with wandering spleen

A 2.5-year-old boy was referred to the emergency room for a sudden onset of diffuse and increasing abdominal pain with lethargy, abdominal distension, and vomiting, all in the past 24 hours. A plain abdominal X-ray showed gastric distension. Two liters of gastric contents were evacuated by suction. The abdominal sonogram showed an unusual position of the spleen in the left-lower quadrant, with no splenic ischemia. The diagnosis of gastric volvulus associated with a wandering spleen was then evoked. Laparoscopic exploration revealed a nonischemic spleen, absence of normal supporting ligaments for the spleen, and gastric distension with flaccid gastric walls. The spleen was then easily moved in the left-under quadrant. A parietal peritoneal posterolateral incision was made, opposite the large gastric curve, up to the diaphragm (7 cm). This delimitated a sharp demarcation zone between the two edges of the incised peritoneum. The stomach was fixed to the peritoneal incision, covering and anchoring the spleen in a good position. Recovery was uneventful, and an abdominal sonogram performed 4 years after the surgery shows a viable spleen in its correct location. The rarity of gastric volvulus associated with a wandering spleen and its fast clinical improvement with medical treatment often delays the diagnosis and the surgical treatment. Laparoscopy in this case has a dual relevance: diagnosis and therapeutic management (splenectomy or gastropexy). Laparoscopic gastropexy for the treatment of gastric volvulus associated with a wandering spleen is an easy procedure and combines the advantages of all the surgical techniques previously described.

Esplenectomía laparoscópica por torsión de un bazo ectópico (wandering spleen)

Wandering spleen is an uncommon entity, characterized by the anomalous position of the spleen, caused by the absence or laxity of its suspensory ligaments. The most common symptoms are usually due to intermittent or complete torsion of the splenic pedicle with subsequent infarction. We report a case of torsion of a wandering spleen. Laparoscopic splenectomy was performed and recovery was uneventful. Although few cases of wandering spleen treated laparoscopically have been reported in the literature, laparoscopy has been demonstrated to be a safe technique for the treatment of this entity.