The technique of laparoscopic retroperitoneal splenopexy for symptomatic wandering spleen in childhood

Wandering Spleen with Splenic Torsion: Unusual Cause of Acute Abdomen

INTRODUCTION

Wandering spleen is a rare condition characterised by laxity or lack of splenic ligaments as a result of acquired or congenital causes. There is a possibility of misdiagnosis due to its vague symptoms. In order to make a proper diagnosis, imaging techniques including abdominal ultrasonography and CT scanning are essential. Surgery is the main option of management. If the spleen is viable and there is no thrombosis in the splenic veins, splenopexy is the preferred surgical procedure. Alternatively, splenectomy plus prophylactic antibiotic and vaccination usage may be employed if spleen has infarction.

CASE PRESENTATION

A 12-year-old male child who had previously experienced constipation, mucoid diarrhoea, and abdominal distention arrived with crampy abdominal pain that had lasted for four days. The patient was tachycardic with abdominal tenderness. Whirlpool sign and lack of a spleen in its normal position were visualized on an abdominal ultrasound. The spleen was located intraoperatively in the lower abdomen, adhered to the ileum and appendix. It was 720° twisted and had necrotic areas. The patient underwent an appendectomy with splenectomy with a smooth post-operative course; combination meningococcal and pneumococcal vaccines were administered; and antibiotic prophylaxis was started for the patient.

CONCLUSION

High clinical suspicion and the use of imaging modalities like ultrasound and CT scan are extremely crucial to diagnose wandering spleen and perform splenic salvage surgery because its clinical diagnosis is challenging.

Patients with gastric volvulus recurrence have high incidence of wandering spleen requiring laparoscopic gastropexy and splenopexy

PURPOSE

Though gastric volvulus in neonates and infants resolves by conservative therapy and aging, some cases require surgical intervention. This study aimed to review the cases of gastric volvulus requiring surgical intervention and evaluate their characteristics.

METHODS

We retrospectively reviewed gastric volvulus cases requiring surgical intervention. Surgical indication was persistent acute gastric volvulus and repeated hospitalization for gastric volvulus. We evaluated the characteristics of those cases requiring surgical intervention and the surgical results of laparoscopic gastropexy.

RESULTS

The median age of patients included was 4 years (range: 1-6 years). All eight cases of gastric volvulus requiring sugery had congenital spleen diseases. Six of the eight cases suffered from a wandering spleen, while two cases presented with situs inversus with asplenia. Both splenopexy (preperitoneal distension balloon [PDB] or blunt separaion methods) and gastropexy were performed in cases with wandering spleen. No postoperative complications were reported in any of the eight cases, except the recurrence of gastric volvulus due to suture shedding in one case.

CONCLUSION

Laparoscopic gastropexy for gastric volvulus and splenopexy for cases concomitant with wandering spleen were found to be effective surgical approaches. Both PDB and blunt separation methods for making extraperitoneal pockets for the spleen were employed successfully.

Dwarfism associated with wandering splenomegaly

Dwarfism associated with splenomegaly during teenage years is known. The purpose of this report was to present the first case of dwarfism associated with wandering splenomegaly. A 14-year-old boy presented a wandering splenomegaly and torsion of the splenic pedicle associated with a retarded growth and sexual underdevelopment characterized by lack of sexual maturity and absence of secondary sexual physical appearance. The patient was submitted to detorsion of the spleen, and splenopexy. After the surgery, the patient grew up, and his sexual characteristics developed to normal. The size of the spleen reduced from the 22 × 16 × 13 cm to 14 × 12 × 10 cm after the surgical procedure. This is the first report of dwarfism associated with wandering splenomegaly, which was successfully treated without partial or total splenectomy. After releasing the venous blood flow, the spleen reduced its dimension and the patient grew up to the expected family size.

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.

Successful treatment of floating splenic volvulus: Two case reports and a literature review

BACKGROUND

The floating spleen refers to the spleen moving away from the normal anatomical position to other parts of the abdominal cavity.

CASE SUMMARY

In this report, we describe two cases of torsion of floating spleen, which were successfully treated by laparoscopic partial splenectomy and retroperitoneal fixation of the residual spleen. The clinical characteristics of previously reported cases are also discussed.

CONCLUSION

In conclusion, laparoscopic partial resection of splenic volvulus infarction and extraperitoneal fixation of residual spleen are safe and reliable.

Wandering splenomegaly reduction after splenopexy

INTRODUCTION AND IMPORTANCE

A wandering spleen is characterized by excessive splenic mobility due to the laxity of its ligaments, which leads to spleen migration and its long mobile vascular pedicle is liable to torsion. The purpose of this paper was to present a wandering splenomegaly reduction after splenic detorsion and splenopexy.

CASE PRESENTATION

A 14-year-old boy presented a symptomatic visible pelvic wandering splenomegaly with torsion of the splenic pedicle. He was submitted to laparotomy, detorsion of the spleen, and splenopexy to the left diaphragm and surrounded peritoneum. The patient had an uneventful follow-up and was discharged from the hospital on the second postoperative day. All laboratory exams went to normal. The size of the spleen reduced from the 22 × 16 × 13 cm before the treatment to 14 × 12 × 10 cm after the surgical procedure.

CLINICAL DISCUSSION

The most relevant aspect of this communication is the reduction of the huge splenomegaly to a normal size spleen after detorsion of the splenic vessels and splenopexy to the left diaphragm. Reduction of the splenic size is well-known after distal splenorenal shunt, but this is the first publication of a spontaneous splenic size reduction after treating a congestive wandering splenomegaly by detorsion of the spleen pedicle.

CONCLUSION

Ectopic congestive splenomegaly due to the splenic pedicle rotation is adequately treated by splenic detorsion and splenopexy in its proper subdiaphragmatic site, which reduces the splenic size to normal.

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.

Torsion of wandering spleen involving the pancreatic tail

Background

Wandering spleen (WS) is a rare clinical entity resulting from the absence or maldevelopment of the ligaments normally involved in the attachment of the spleen in its normal position. WS can be a cause of acute abdomen leading to different complications ranging from torsion of the vascular pedicle to spleen infarction. Often, in absence of symptoms, it is an occasional finding during radiological exams and surgery represents the gold standard in the management of this unusual condition.

Case presentation

We present a case of wandering spleen in a young nulliparous female with an history of recurrent abdominal pain. A preoperative CT-scan of the abdomen showed the presence of a multi-infarcted spleen twisted several times around its vascular pedicle, involving the tail of pancreas. The patient was electively treated with laparoscopic splenectomy.

Conclusions

A laparoscopic approach is feasible in the treatment of this pathology. A correct and timely diagnosis of this condition is crucial to allow an organ preserving surgery. There are only few reported cases in literature describing an involvement of the tail of the pancreas in the torsion of the vascular pedicle. Complete excision of the ectasic veins tributaries of the splenic vein avoids the risk of postoperative vein thrombosis and bleeding.

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.

Single-incision laparoscopic splenectomy and splenic autotransplantation for an enlarged wandering spleen with torsion

A wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant, but instead is found in the lower abdomen or in the pelvic region because of the laxity of the peritoneal attachments. The unusually long pedicle is susceptible to twisting, which can lead to ischemia, and eventually to necrosis. We herein report a case of an enlarged wandering spleen with torsion, successfully treated by single-incision laparoscopic splenectomy and autotransplantation. The transplanted splenic tissues could be identified on a spleen scintigram obtained 3 months after the surgery. Howell-Jolly bodies were not observed in blood specimens. This procedure is able to prevent an overwhelming postsplenectomy infection, and leads to satisfactory cosmetic results.

Wandering spleen in children: a report of 3 cases and a brief literature review underlining the importance of diagnostic imaging

BACKGROUND

Wandering spleen is a rare condition in children that is often caused by loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication.

OBJECTIVE

To provide up-to-date information on the diagnosis, clinical management and diagnostic imaging approaches for wandering spleen in infants and children and to underline the importance of color Doppler US and CT in providing important information for patient management.

MATERIALS AND METHODS

We report a series of three children with wandering spleen treated at our children's hospital over the last 6 years. All three underwent clinical evaluation, color Doppler US and CT and were surgically treated. We also reviewed 40 articles that included 55 patients younger than 18 years reported in the Medline database from 2002 to 2012.

RESULTS

We correlated pathological data with imaging findings. Color Doppler US, the first imaging modality in investigating abdominal symptoms in children with suspected wandering spleen, yielded a diagnostic sensitivity of 54.9%, whereas CT achieved about 71.7%.

CONCLUSION

Radiologic evaluation has a major role in confirming the diagnosis of a suspected wandering spleen and avoiding potentially life-threatening complications requiring immediate surgery.

An unusual case of acute pancreatitis and gastric outlet obstruction associated with wandering spleen treated by laparoscopic splenopexy

Wandering spleen (WS) is an uncommon condition, usually asymptomatic, often recognized as an incidental finding. When symptoms occur, they can vary, although acute abdominal pain is the most common presentation in the pediatric population. In some cases, WS can become a dangerous condition because of the risk of splenic ischemia from persistent pedicle torsion. We describe a case of WS in a 3-year-old boy presenting with vomiting, abdominal swelling, and acute pancreatitis; the diagnosis was obtained by ultrasound and computed tomography. Laparoscopic splenopexy was successfully performed through an extraperitoneal pocket and a Vicryl mesh. To the best of our knowledge, the combination of gastric outlet obstruction and acute pancreatitis has never been reported as presenting symptoms of WS.

Laparoscopic splenopexy and gastropexy for wandering spleen associated with gastric volvulus

Wandering spleen is not a common condition in childhood and has been described only rarely in association with gastric volvulus. The authors report the successful management of wandering spleen associated with gastric volvulus using laparoscopic splenopexy and gastropexy in a 4-year-old girl.

Torsion of a wandering spleen

Wandering spleen is a rare condition defined as a mobile spleen only attached with its pedicle. It can be complicated by a volvulus, which is a surgical abdominal emergency. Preventing infarction is the aim of a prompt surgery that can preserve the spleen and then proceed to splenopexy. We report a rare case of torsion of a wandering spleen associated with a dolichosigmoοd.

Splenic cyst in a wandering spleen: laparoscopic treatment with preservation of splenic function

BACKGROUND

Wandering spleen and splenic cyst are rare benign congenital conditions that can both cause severe complications related to torsion or trauma.

CASE REPORT

A 14-year-old girl presented a mobile 10-cm-long abdominal mass in the left lower quadrant associated with mild abdominal pain. The diagnosis of an 8-cm-long nonparasitic cyst in a wandering spleen was confirmed by computerized tomography and negative serum indirect hemagglutination titer for hydatid disease. Laparoscopic unroofing of the cyst and splenopexy in a vycril mesh was performed.

RESULTS

No problems were encountered during laparoscopic surgery. Postoperative course was uneventful, and at a 1-year follow-up, the spleen is viable and maintains a normal position in the phrenorenal angle.

CONCLUSIONS

In the child, treatment of wandering spleen associated with a cyst should aim at the prevention of vascular accidents and at conservation of the spleen. We achieved these goals with unroofing and splenopexy through laparoscopic surgery.

Laparoscopic splenopexy for a wandering spleen in a child

We present a case of acute volvulus of a wandering spleen in a 5-year-old girl that was diagnosed preoperatively by computed tomography scan and which we treated with a laparoscopic splenopexy on an emergent basis.

Laparoscopic splenopexy and cystectomy for an enlarged wandering spleen and splenic cyst

Wandering spleen is an uncommon condition, which can present emergently in children. Similarly, nonparasitic splenic cysts are also rarely encountered. In this report, we describe a massive wandering spleen (22 cm in longitudinal dimension) with a pseudocyst (4.6 x 2 cm) in the inferior pole in an asymptomatic 16-year-old adolescent. Only 4 similar cases have been reported in the literature; 2 of them have been in the pediatric age group. These 2 conditions were diagnosed while she was being evaluated for dysmenorrhea, and she was referred for surgical consultation. The cyst was excised laparoscopically, and the spleen was placed into an extraperitoneal pouch. To date, there are no other reports describing laparoscopic cystectomy and splenopexy in a teenager.

Splenic autotransplantation for a congested and enlarged wandering spleen with torsion: report of a case

In children with diseases of the spleen, every effort should be made to preserve the organ, to prevent severe infections postsplenectomy. We report the case of a 7-year-old girl with torsion of a wandering spleen who we treated by autotransplantation of splenic tissues following splenectomy, when fixation of the enlarged spleen seemed impossible. Spleen scintigraphy showed uptake in the regenerating splenic tissues 9 months after surgery, and evidence of an increase in the size of the tissues 23 months after surgery. Howell-Jolly bodies had disappeared by 16 months after surgery. These findings suggested that the transplanted splenic tissues were resuming splenic functions. Based on our experience with this case, we conclude that autotransplantation after splenectomy is a treatment option for wandering spleen with torsion when fixation seems difficult because of splenic congestion and enlargement.

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.

Pediatric wandering spleen successfully treated by laparoscopic splenopexy

Wandering spleen is a rare clinical condition associated with a high incidence of splenic torsion and infarction. The preferred treatment is splenopexy to reposition the spleen in the left upper quadrant of the abdomen. We report the case of a 12-year-old girl who presented with intermittent abdominal pain. An abdominal sonography was diagnostic of wandering spleen. The patient was successfully treated by laparoscopic splenopexy. The spleen was repositioned in the left upper quadrant and fixed to the posterior abdominal wall by a mesh patch attached by staples. To reinforce the splenopexy we created an additional support by plicating the phrenocolic ligament and suturing it to the lateral abdominal wall, making a pouch for the inferior pole of the spleen. The postoperative course was rapid and uneventful. A normal spleen position was verified by radionuclide scans at 3 days and 6 months postoperatively. Laparoscopic splenopexy is an excellent option for organ-preserving treatment in wandering spleen.

Laparoscopic splenopexy for wandering spleen: extraperitoneal pocket splenopexy

Wandering spleen is a very rare disease. It is a very dangerous condition due to the risk of splenic ischemia from persistent pedicle torsion. Here, we describe a case of wandering spleen diagnosed by ultrasound and computed tomography scans in an 11-year-old boy who suffered from frequent urination and enuresis. A laparoscopic splenopexy was successfully performed with fixation of the spleen in an extraperitoneal pocket. Since the operation, the organ has remained in place with good perfusion. The details of the procedure are described.

Extrapleural, submuscular bars placed by bilateral thoracoscopy--a new improvement in modified Nuss funnel chest repair

BACKGROUND

Thoracoscopic Nuss funnel chest repair still has a significant complication rate. Bar dislocation, pneumothorax, pleural effusions, and pericarditis seem to be caused mechanical irritation by the bar. We intended to reduce these problems by further technical modification of the Nuss technique.

METHODS

Of 157 prospectively followed modified Nuss repairs, the last 57 patients had the bars placed in an extrapleural position and fixed by 10 to 14 pericostal sutures under bilateral thoracoscopy.

RESULTS

Entirely, extrapleural bar position was feasible in 53 of 57 patients. Four patients had minor holes over one of the bars, predominantly on the left side of the thorax. Pleural effusions, pneumothorax, and pain were greatly reduced, so that we discontinued the so far routine use of bilateral pleural drainages.

CONCLUSIONS

Extrapleural bar position is feasible in more than 90% of modified Nuss repairs. It reduces pleural secretion and pain, and seems to reduce pneumothorax, pulmonary bar adhesions, and pericardial effusions. The technique is easy and safe, and reduced the incidence of most complications in this early experience of 57 adolescent patients, although no sportive restrictions were imposed at all.