Urgent laparoscopic mesh splenopexy for torsion of wandering spleen and distal pancreas: A case report

[Torsion of the wandering spleen in childhood - report of 3 cases]

A vándorlép gyermekkorban ritkán előforduló fejlődési rendellenesség, melynek lényege, hogy a lépet a has bal felső kvadránsában rögzítő szalagok vagy lazák, vagy hiányoznak. Ez az anatómiai környezet kedvez a lépcsavarodásnak, mely a leggyakoribb szövődmény vándorlép esetén. Ammenyiben vándorlép igazolódik, műtétre van szükség. Két műtéti stratégia közül választhatunk: megtartjuk és fixáljuk, vagy egyértelmű infarktus esetén eltávolítjuk a lépet. A szerzők egy 16 éves periódust (2004–2020) tekintenek át, amelynek során két intézetben három gyermeket kezeltek lépcsavarodás miatt. A hasi panaszok kezdetétől 12–48 órán belül történt hasi ultrahangvizsgálat. A gyermeksebészeti vizsgálatok előtt a gyermekek székrekedés gyanúja miatt mindhárom esetben béltisztító kezelést kaptak, mivel az első észlelők a vándorlépet kitapintva skybalának tartották. A képalkotó vizsgálatok ectopiás helyen lévő lépet igazoltak, és felvetették a lépcsavarodás gyanúját. Nyitott műtét során mindhárom esetben lépmegtartó műtét történt. Posztoperatív szövődmény nem alakult ki. A megtartott lépek életképességét illetően nyomon követéses vizsgálatok történtek. Orv Hetil. 2024; 165(22): 866–871.

Torsion of a Wandering Spleen Involving the Pancreatic Tail and Splenic Flexure and Isolated Left-Sided Portal Hypertension due to Chronic Splenic Vein Thrombosis

Wandering spleen is a rare entity, wherein the spleen is attached only by an elongated vascular pedicle, predisposing it to complications like hilar torsion, infarction, rupture, etc. Pancreatic volvulus is another very rare anomaly, with isolated case reports described in association with wandering spleen. The presentation varies from asymptomatic lump (stimulating a mass) to acute abdomen (due to torsion). We present a case of 26-year-old female patient who complained of pain in abdomen, and was radiologically diagnosed and surgically confirmed to have a torsion of wandering spleen with involvement of pancreatic tail and splenic flexure. Few cases with associated finding of gastric volvulus and sigmoid volvulus have been described previously. Involvement of descending colon in a 9-year-old child has been reported. However, to the authors' knowledge, this is the first case report describing the combination of wandering spleen with splenic flexure and pancreatic tail involvement in an adult.

Diagnosis, management and outcome of splenic torsion; a systematic review of published studies

INTRODUCTION

Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management.

METHODS

A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution.

RESULTS

408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis.

DISCUSSION

Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

Laparoscopic retroperitoneal splenopexy for wandering spleen: A novel technique using a three-incision retroperitoneal pouch

INTRODUCTION

Wandering spleen is a rare condition for which splenopexy is indicated to prevent splenic torsion. We present a novel laparoscopic splenopexy technique for wandering spleen based on creation of a three-incision retroperitoneal pouch.

MATERIALS AND SURGICAL TECHNIQUE

A 12-year-old male patient with abdominal distention and vomiting was transferred to our institution. Contrast-enhanced CT revealed a swollen wandering spleen with associated gastric volvulus, and the patient underwent laparoscopic surgery. A 5-mm camera port was inserted through an umbilical incision with two additional ports, one in the right upper abdomen and one in the left flank. Normal saline was injected into the retroperitoneal space from the left flank with a 23-G needle to create a retroperitoneal pouch. Three ventrodorsal peritoneal incisions were created at the same site in the peritoneum. The swollen spleen was inserted into the retroperitoneal pouch from the central incision, and the upper and lower poles of the spleen were exposed to the abdominal cavity from the cranial and caudal incisions to prevent splenic torsion. Finally, anterior gastropexy was performed. The postoperative period was uneventful. The patient was discharged on postoperative day 11 without complaints. As of 10 months after surgery, the patient had no recurrences of splenic torsion or gastric volvulus.

DISCUSSION

In the present method, the retroperitoneal pouch was created without difficulty by injection of normal saline. Even in a patient with a swollen spleen, this novel method could prevent splenic torsion without using artificial materials or extensively dissecting the retroperitoneal space.

Surgical Approach of Wandering Spleen in Infants and Children: A Systematic Review

Introduction: Splenopexy has been proposed as the treatment of choice in case of wandering spleen (WS). We report our experience and review the current literature focusing on surgical management and outcomes of children affected by WS. Materials and Methods: Data regarding demographics, clinical manifestations, diagnosis, and treatment of children treated for WS at our Institution were analyzed. Systematic review was registered on Prospero (CRD42018089971). Scientific databases were searched using defined keywords. Articles were selected using predefined exclusion and inclusion criteria. Analysis was conducted adding our center's cases. Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished. Female/male ratio was 1.5:1 and median age at diagnosis was 8 years. Most frequent clinical manifestation was isolated abdominal pain (42.6%). Torsion of splenic pedicle was diagnosed in 56.3%. Among surgical procedures, 39% underwent splenopexy and 54.8% underwent splenectomy. In case of splenopexy, the most commonly used techniques were using of a mesh (45.5%) or creation of a retroperitoneal pouch (30.9%). In 48.2% of splenopexies, minimally invasive surgery (MIS) was used. Splenopexy was effective in 94.8% (88% considering only cases with a spleen torsion). Conclusion: WS is a rare condition potentially leading to torsion of the spleen. This entity has to be kept in mind as a differential diagnosis in case of abdominal pain. Splenopexy should be the treatment of choice; its success rate in terms of preserved spleens can be affected by the presence of a torted organ. Retroperitoneal pouch or mesh fixation are the most preferred techniques. Authors recommend MIS approach.

Is laparoscopic approach for wandering spleen in children an option?

Aim:

Wandering spleen present generally as an acute abdomen after twisting of the splenic vascular pedicle. This study aimed to review the literature with regard to the management and outcomes of the laparoscopy in children with wandering spleen.

Methods:

The literature was reviewed for articles on PubMed with regard to the following search terms ‘laparoscopy’, ‘wandering’, 'spleen’ and ‘children’. The inclusion criteria included article only in the paediatric age group of 0–16. Articles that did not meet the inclusion criteria were excluded from the study.

Results:

The PubMed search from 1998 to 2016 identified 15 articles. There were 20 children with an age range from 2 to 16 years who underwent the laparoscopic procedure for wandering spleen. The median age was 8 years. Associated conditions were present in 45% of patients: gastric volvulus (n = 3), torsion of the distal pancreas (n = 3), splenic cyst (n = 2), mental retardation and myotonic dystrophy (n = 1). In two cases, the spleen was twisted around the pedicle and was non-viable, and therefore, a splenectomy was performed. Other 18 cases were managed by splenopexy using a 3–5-port technique. An extraperitoneal pocket was created using a balloon device in five patients. Fixation of the spleen was performed using a mesh in 10 cases and omentum in three cases. In one case, additional support was created by plicating the phrenicocolic ligament. Simultaneous gastropexy was performed in four patients. There were no post-operative complications.

Conclusions:

Wandering spleen is a rare entity and in the paediatric age group 10% cannot be salvaged for which splenectomy is the only option. Of the 90% that can be pexied, the literature has favoured the application of meshes followed by the extraperitoneal pockets and omental pouch. Laparoscopic splenopexy is feasible, with no reported conversions or complications.