Pediatric wandering spleen--the case for splenopexy: review of 35 reported cases in the literature

[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.

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.

Surgical Management of a Volvulus of a Wandering Spleen Associated with a Volvulus of the Small Intestine

Introduction

A wandering spleen is a rare anatomical condition characterized by a free-floating splenic tissue that is not located in its normal position in the left upper quadrant. This condition is usually asymptomatic but can also manifest itself with volvulus of the spleen and consequent infarction and necrosis of the parenchyma, requiring an urgent surgical management. Additionally, a wandering spleen can be associated with other contemporaneous anatomical anomalies. Case Presentation. We report a case of a 21-year-old woman, admitted to our hospital for intense abdominal pain and vomiting. A CT scan revealed a wandering spleen in the mesogastric area with the spleen torted on its axis, associated with a volvulus of the small intestine. Abdominal exploration revealed a macroscopically normal free-floating spleen attached to an abnormally long vascular pedicle. The management of the wandering spleen was conservative, and a splenopexy was performed.

Conclusions

The torsion of the wandering spleen constitutes an infrequent but life-threatening abdominal emergency. The diagnosis of the wandering spleen is frequently challenging since clinical findings are usually not specific. Imaging such as computed tomography scan plays an important role in the differential diagnosis pathway. Treatment should be planned according to the splenic parenchyma conditions. Splenectomy is indicated when massive infarction and thrombosis of splenic vessels have occurred. When splenic parenchyma is not compromised, it is preferred to perform a conservative surgical technique, such as splenopexy, in order to avoid postsplenectomy complications.

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.

Infarcted wandering spleen: A case report from Saudi Arabia

Spleen is normally positioned in the left upper quadrant. Abnormal location where it is not found in its normal anatomical position is called wandering spleen (WS). Wandering spleen is a rare medical condition that occurs due to developmental abnormality or acquired laxity of the ligaments that hold the spleen in its normal anatomical position. It affects children and young adults, especially childbearing age women. Patients affected with this condition may present with nonspecific symptoms requiring a high index of suspicion. Here, we are presenting a 20-year-old female known to have WS ended up with infarcted WS requiring emergency splenectomy.

Challenge of diagnosing splenic torsion in a paediatric patient with gastroschisis

Gastroschisis is an uncommon congenital defect of the abdominal wall resulting in intestinal prolapse, most commonly associated with short gut syndrome or bowel obstruction. Wandering spleen, movement of the spleen due to the underdevelopment of splenic ligaments, has a prevalence of 0.25% and is asymptomatic in 15% of paediatric cases. An 11-year-old patient, admitted with a history of gastroschisis repaired at birth, presents with 18 months of intermittent, worsening abdominal pain. Imaging demonstrated splenomegaly and tortuosity of the splenic vein with abnormal positioning of the superior mesenteric artery and vein. The patient was found to have a wandering spleen with subacute splenic infarct secondary to splenic torsion, necessitating emergent surgical intervention. This patient experienced an extremely rare complication of gastroschisis that has not previously been reported. This complication is caused by a lack of appropriate abdominal fixation points for the spleen.

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.

Case Report: Conservative Non-operative Management of a Neonate With Torted Wandering Spleen

BACKGROUND

The management of wandering spleen (WS) with torsion, a rare pathological condition, is currently unclear. Most patients with this disorder are treated with surgical interventions, such as splenectomy or splenopexy.

CASE PRESENTATION

A newborn female presented with low hemoglobin (10.8 mg/L) and high total serum bilirubin (193 μmol/L) at 3 h of life. A palpable mass was observed during her physical examination, and a magnetic resonance imaging scan of the abdomen confirmed the presence of an infarcted WS with torsion. Upon conservative management with oral antibiotic prophylaxis, careful observation, and repeated follow-ups, the infant remained clinically stable. At 2 years of age, she had normal complete blood count, and a repeat technetium study revealed two splenunculi/splenules in the splenic bed.

CONCLUSION

Most patients with WS are treated surgically with splenectomy or splenopexy. Non-operative management may be a feasible treatment option in select cases with infarcted WS and may allow the natural process of autosplenectomy to occur.

Unusual association of Axenfeld-Rieger syndrome and wandering spleen: A case report

BACKGROUND

Axenfeld-Rieger syndrome (ARS) is an autosomal dominant genetic disease characterized by ocular developmental disorders and its association with torsion of wandering spleen (WS) has not been reported to date to the best of our knowledge. This study aimed to describe a rare case of ARS observed at our emergency department.

CASE SUMMARY

A 25-year-old female presented with a constant lower abdominal pain of increasing severity. Diagnostic computed tomography with intravenous contrast material showed a non-homogenously enhanced splenic parenchyma with a twisted vascular pedicle. Further, an emergent laparoscopic exploration was performed, and an ischemic spleen without its normal ligamentous attachments was noted. Notably, the spleen did not regain its normal vascularity after detorsion; thus, we performed the laparoscopic total splenectomy. The postoperative course was uneventful, and the patient was discharged on the 5^th postoperative day. This case demonstrates a rare association of WS and ARS.

CONCLUSION

Early diagnosis of WS in the emergency department is important to prevent pedicle torsion or splenic necrosis and to avoid splenectomy.

Torsion of Wandering Spleen: Importance of Splenic Density and Liver-to- Spleen Attenuation Ratio on CT

BACKGROUND

Wandering spleen (WS) is a rare clinical condition which may cause fatal complication like torsion with subsequent infarction. Determination of splenic parenchyma viability is very important in deciding whether splenopexy rather than splenectomy is an option. Contrast- enhanced computed tomography (CECT) is important for the diagnosis of WS and assessment of the viability of spleen.

DISCUSSION

We reviewed the CT studies of four cases with WS. We measured the mean splenic and liver density and calculated liver-to-spleen attenuation ratio (LSAR). We also assessed the CT findings for each patient. Mean splenic density was measured as 40.77 Hounsfield Unit (HU) in cases with infarction, 127.1 HU in case without infarction. LSAR was calculated as 2.55 in cases with infarction, 0.99 in case without infarction. We detected whirlpool sign, intraperitoneal free fluid, splenic arterial enhancement in all patient, parenchymal and splenic vein enhancement in one patient without infarction, fat rim sign in three patients with infarction, capsular rim sign in one patient with infarction.

CONCLUSION

CECT should be obtained for the diagnosis of WS and assessment of the viability of spleen. CECT could suggest the diagnosis of infarction of the spleen with following findings; absence of parenchymal enhancement, very low density of spleen (<45 HU), and LSAR which is greater than 2.

"Wandering spleen" as a rare cause of recurrent abdominal pain: a systematic review

INTRODUCTION

Wandering spleen (WS) is a rare and generally acquired condition, resulting from abnormal ligamentous laxity failing to fixate the spleen in its normal location in the left upper quadrant, thus leading to its migration to the pelvis due to gravity. Such migration leads to an elongated vascular pedicle, which is prone to torsion causing splenic infarction; thus, a prompt surgical intervention is recommended. Since this adverse event affects childbearing women or children, it is crucial to choose the most appropriate surgical strategy, such as splenectomy or splenopexy, both effective and widely diffused options. The aim of this paper is to perform a literature review on WS reports treated by surgery. We also present a case of symptomatic WS migrated in pelvis in a young female treated by splenectomy.

EVIDENCE ACQUISITION

All relevant articles from 1895 up to December 2017 were identified by literature searches in PubMed, Scopus and Google Scholar.

EVIDENCE SYNTHESIS

A total of 376 patients treated with surgical approach for WS were identified. The most common presentations were abdominal pain and abdominal mass, and approximately half of the patients had an acute clinical onset. Radiology is essential for the diagnosis. Surgical strategy changed over the time; splenectomy is the most reported treatment although in the last years there is an increasing trend towards a more conservative strategy, preferring splenopexy or a laparoscopic approach.

CONCLUSIONS

Surgery is the gold standard strategy, and laparoscopic approach is recommended, for the treatment of wandering spleen. Both splenopexy or splenectomy are effective and safe surgical options.

Torsion of wandering spleen treated by laparoscopic splenopexy: A case report

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Wandering spleen.

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Laparoscopic splenopexy.

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Torsion of splenic pedicle.

Introduction

A wandering spleen is a mobile spleen as a result of deficient splenic peritoneal ligaments and elongation of its vascular pedicle. It is a rare entity affecting mainly young adults commonly females and children, presenting as an asymptomatic abdominal mass or abdominal discomfort due to torsion and de-torsion of the pedicle.

Presentation of case

We report a 35-year-old female presented with intermittent colicky abdominal pain that worsened in severity over three weeks. Diagnostic laparoscopy showed torsion of spleen without infarction. Detorsion and Splenopexy in an extra-peritoneal pouch was performed. Post operatively, the patient recovered well and was healthy at two months follow up.

Discussion

A wandering spleen is either congenital or acquired. The condition results in a long vascular pedicle, which predispose to the torsion resulting in a partial or complete infarct of the spleen. Laparoscopic approach is the preferred technique and de-torsion of the splenic pedicle and splenopexy is a reasonable surgical option, when there is no evidence of infarction of the spleen.

Conclusion

The diagnosis of wandering spleen is very rare and extremely difficult to establish and is clinically nonspecific. An early diagnosis and surgical care are required for preserving the spleen. Additional imaging examinations can help establish a diagnosis.

Laparoscopic splenectomy for a simultaneous wandering spleen along with an ectopic accessory spleen. Case report and review of the literature

BACKGROUND

Wandering spleen and accessory spleen are uncommon entity occurring during embryonic development. Wandering spleen results in an excessive mobility and migration of the spleen from its normal position in the left hypochondrium while accessory spleen is characterized by ectopic splenic masses or tissue disjointed from the main body of spleen. Due to the nonspecific and multiple symptoms the clinical diagnosis of both conditions is uncertain even with imaging techniques, such as CT and MRI. The coexistence of both diseases (wandering spleen ad accessory spleen) is uncommon.

CASE REPORT

A 17-year old European female with a history of minor beta thalassemia and recurrent attacks of abdominal pain. Pre- operative management consisted of routine laboratory tests, ultrasound, CT scan. An ectopic spleen along with an accessory spleen were diagnosed. After a multidisciplinary board a laparoscopic splenectomy was performed. Post-operative recovery was uneventful, and the patient was discharged on the 6th post-operative day with the indication to continue the therapy with low molecular weight heparin (LMWH) for 30 days CONCLUSIONS: This case represents a simultaneous condition of wandering splenomegaly along with an ectopic wandering spleen. The coexistence of these two rare conditions is peculiar such as the age of the patient, as literature reports such diseases to affect children or more commonly people in the range of 20-40 years of age. Laparoscopic treatment for this particular condition is also unusual.

Acute Torsion of a Wandering Spleen Causing Acute Abdomen

Wandering spleen is a rare clinical entity characterised by splenic hypermobility resulting from laxity or maldevelopment of the suspensary gastrosplenic, splenorenal, and phrenicocolic ligaments. Diagnosis is quite difficult because of the lack of symptoms and signs until splenic torsion have occured. In this article, we present and discuss a 23-year-old caucasian woman presenting with acute abdomen, diagnosed as splenic torsion by ultrasound and magnetic resonance imaging and managed surgically.

The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature

Wandering spleen is a rare condition, typically not only due to embryological defects of the splenic ligaments, but also secondary to trauma and splenomegaly. The most common presentation is acute abdomen with a mobile abdominal mass or recurrent abdominal pain. However, the spleen may be temporary in its normal position, and patients could be asymptomatic. A familiarity, if present, strengthens the diagnostic suspect.Abdominal ultrasonography and computed tomography are the examination of choice, and the management is surgical.

Dynamic MRI in the diagnosis and post surgical evaluation of wandering spleen

Wandering spleen is a rare but potentially clinically significant entity, and may be a cause for a patient presenting with acute abdomen. Because wandering spleen may present with non-specific symptoms and presentation, it can be a difficult diagnosis to make clinically. This paper describes a case report of the use of dynamic Magnetic Resonance Imaging (MRI) in a young woman to confirm the diagnosis of wandering spleen pre-operatively. The patient underwent a splenopexy and a post-operative MRI confirmed the successful surgical fixation of the patient's spleen.

Accessory wandering spleen: Report of a case of laparoscopic approach in an asymptomatic patient

INTRODUCTION

Accessory wandering spleen is a rare but dangerous condition. Abnormalities of the ligamentous apparatus of an accessory spleen may evolve into torsion of its vascular axis, which can lead to a splenic infarct making surgery necessary. Patients are often asymptomatic and the diagnosis can be accidental. An early diagnosis and a correct treatment are fundamental.

PRESENTATION OF CASE

In this case report a young woman underwent laparoscopic surgery after an incidental finding at a Pelvic Ultrasound of an accessory wandering spleen.

DISCUSSION

In literature are reported cases of asymptomatic patients with an accessory wandering spleen treated with a conservative approach. However, a torsion or infarct of the accessory wandering spleen leads to emergency surgery. The presence of an independent vascular axis of the accessory spleen reduces the risk of postoperative complications (e.g. thrombocytosis) and the administration of low molecular weight heparin should prevent the risk of portal thrombosis.

CONCLUSION

We suggest performing surgery with a laparoscopic approach in patients with accessory wandering spleen, though asymptomatic, because of the risk of serious complications in case of accessory spleen torsion.

Ectopic spleen: An easily identifiable but commonly undiagnosed entity until manifestation of complications

INTRODUCTION

Ectopic spleen is an uncommon clinical entity as splenectomy for treatment of ectopic spleens accounts for less than 0.25% of splenectomies. The most common age of presentation is childhood especially under 1 year of age followed by the third decade of life.

PRESENTATION OF CASE

The present report refers to a patient with torsion of a pelvic spleen treated with splenectomy. The patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days. On the first 65 days, vague pain was attributed to progressive torsion of the spleen which resulted in venous congestion. On the last 6 days, exacerbation of pain was attributed to irreducible torsion, infraction of the arterial supply, acute ischemia, strangulation and rupture of the gangrenous spleen. Diagnosis was made by CT which revealed absence of the spleen in its normal position, a homogeneous pelvic mass with no contrast enhancement, free blood in the peritoneal cavity, and confirmed by laparotomy.

DISCUSSION

Clinical manifestations of ectopic spleen vary from asymptomatic to abdominal emergency. Symptoms are most commonly attributed to complications related to torsion. Operative management, including splenopexy or splenectomy, is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic ectopic spleen is associated with a complication rate of 65%.

CONCLUSION

Although an ectopic spleen can be easily identified on clinical examination, it is commonly misdiagnosed until the manifestation of complications in adulthood.

Wandering spleen with gastric volvulus and intestinal non-rotation in an adult male patient

We report an extremely rare case of wandering spleen (WS) complicated with gastric volvulus and intestinal non-rotation in a male adult. A 22-year-old man who had been previously treated for Wilson disease was admitted with severe abdominal pain. Radiological findings showed WS in the midline of the pelvic area. The stomach was mesenteroaxially twisted and intestinal non-rotation was observed. Radiology results did not show any evidence of splenic or gastrointestinal (GI) infarction. Elective emergency laparoscopy confirmed WS and intestinal non-rotation; however, gastric volvulus was not observed. It was suspected that the stomach had untwisted when gastric and laparoscopic tubes were inserted. Surgery is strongly recommended for WS because of the high risk of serious complications; however, some asymptomatic adult patients are still treated conservatively, such as the patient in this study. The present case is reported with reference to the literature.

The cardiac malpositions

Dextrocardia was known in the 17th century and was 1 of the first congenital malformations of the heart to be recognized. Fifty years elapsed before Matthew Baillie published his account of complete transposition in a human of the thoracic and abdominal viscera to the opposite side from what is natural. In 1858, Thomas Peacock stated that "the heart may be congenitally misplaced in various ways, occupying either an unusual position within the thorax, or being situated external to that cavity." In 1915, Maude Abbott described ectopia cordis, and Richard Paltauf's remarkable illustrations distinguished the various types of dextrocardia. In 1928, the first useful classification of the cardiac malpositions was proposed, and in 1966, Elliott et al's radiologic classification set the stage for clinical recognition. The first section of this review deals with the 3 basic cardiac malpositions in the presence of bilateral asymmetry. The second section deals with cardiac malpositions in the presence of bilateral left-sidedness or right-sidedness. Previous publications on cardiac malpositions are replete with an arcane vocabulary that confounds rather than clarifies. Even if the terms themselves are understood, inherent complexity weighs against clarity. This review was designed as a guided tour of an unfamiliar subject.

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.

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.

Wandering spleen in children: multicenter retrospective study

Wandering spleen in children is a rare condition. The diagnosis is difficult, and any delay can cause splenic ischemia. An epidemiologic, semiological, and surgical diagnosis questionnaire on incidence of wandering spleen in children was sent to several French surgical teams. We report the results of this multicenter retrospective study. Fourteen cases (6 girls, 8 boys) were reported between 1984 and 2009; the age range varies between 1-day-old and 15 years; 86% were seen in the emergency department. Ninety-three percent had diffuse abdominal pain. For 57% of the cases, it was their first symptomatic episode of this type. No diagnosis was established based on the clinical results alone. All patients had presurgical imaging diagnosis. Open surgery was performed on 64% cases. Forty-three had splenectomy for splenic ischemia. Thirty-six percent had splenopexy, 14% had laparoscopic gastropexy, and 7% had spleen repositioning and regeneration. Complications were noted in 60% of the cases resulting in postsplenopexy splenic ischemia. Early diagnosis and surgery are the best guarantee for spleen preservation. Even if the choice of one technique, splenopexy or gastropexy, can be argued, gastropexy has the advantage of avoiding splenic manipulation and restoring proper physiologic anatomy. When there is no history of abdominal surgery, laparoscopy surgery seems the best procedure.

Wandering spleen: Report of two cases

Wandering spleen is a rare clinical condition which presents with a variety of symptoms with abdominal pain, abdominal mass, and acute abdomen. It may also remain silent until diagnosed by a routine imaging study. Treatment options may differ depending on the presenting clinical picture. Herein we present two cases of wandering spleen treated by splenectomy, with one of them admitted to our emergency clinic with torsion.

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.

Acute torsion of wandering spleen: report of one case

Wandering spleen is a rare condition that can lead to splenic infarction or rupture if torsion persists. Early diagnosis and intervention are necessary, and abdominal ultrasonography and abdominal computed tomography are well accepted as the diagnostic imaging modalities. In this study, we present a boy with nic infarction due to acute torsion of a wandering spleen, after initial failure to demonstrate an ectopic spleen. Instead, acute torsion of the wandering spleen with spontaneous partial detorsion was incidentally found by multi-detector row CT with angiography. The patient was managed by splenectomy instead of splenopexy, because poor reperfusion after Laparoscopic detorsion.

Marfanoid hypermobility syndrome and skeletal abnormalities in a rare case of torsion of wandering spleen

Wandering spleen is a rare clinical entity characterized by splenic hypermobility resulting from laxity or maldevelopment of supporting splenic ligaments. Its major complication is splenic torsion, which is a potentially fatal surgical emergency. We present a rare case of wandering spleen with torsion and splenic infarction in a patient with marfanoid hypermobility syndrome and vertebral abnormalities.

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.

Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature

Wandering spleen, which is defined as a spleen without peritoneal attachments, is a rare disease and a delay in the clinical and/or radiological diagnosis may lead to splenic torsion, infarction, and necrosis. Owing to the physiologic importance of the spleen, especially in children, and the risk of postsplenectomy sepsis, early diagnosis and splenopexy are recommended. In the present article, we describe the results of our management of this rare problem on six patients, and we review all available literature from 1895 to 2005. Briefly, our technique includes flap creation from parietal peritoneum and settlement of spleen in the fossa splenica. Free edges of this flap are stitched to the stomach and the left end of transverse colon and the beginning of the descending colon. The body of the stomach was stitched to the abdominal wall to prevent gastric volvulus, while the fundus region was fixed to the diaphragm to support the spleen. Finally, an omental patch was stitched to the intact abdominal wall above the flap. In conclusion, the procedure of splenopexy without using mesh is considered to be a safe and curative modality for wandering spleen without imposing any undue risk of infection or foreign material reaction.

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.

Splenoptosis complicated by a large splenic cyst: case report and discussion of combined management

Splenoptosis is a rare condition in children. Its association with a cyst is rare. A case of splenoptosis complicated by a large cyst is reported. The child presented with features of intermittent abdominal pain, constipation and clinical examination revealed a mass apparently rising out of the pelvis. Ultrasound confirmed the mass as spleen with a 15 cm cyst in the lower pole. At surgery the cyst was marsupialised and splenopexy undertaken placing the cyst in a retro-peritoneal pouch. This is only the second report of such a case in the English literature.

Laparoscopic splenopexy of a pediatric wandering spleen by creation of a retroperitoneal pocket

Wandering spleen is a rare condition in which the spleen is attached by a long, vascular pedicle and lacks its usual peritoneal attachments and supporting ligaments. This condition predisposes the spleen to torsion and infarction. We report the case of a 2-year-old boy with a history of intermittent abdominal pain and early satiety who presented with abdominal pain and severe gastric distention. A work-up including computed tomographic and ultrasonographic imaging suggested a wandering spleen. The diagnosis was confirmed during laparoscopy, and splenopexy was performed by anchoring the spleen in a retroperitoneal pocket in the left upper quadrant at the level of the tenth rib. To our knowledge, this is the first reported case of minimally invasive splenopexy for wandering spleen that involves the creation of a retroperitoneal pocket without the use of mesh. The authors believe that this is a safe and effective method that takes advantage of laparoscopy and avoids the risk of infection and complications associated with the use of synthetic material.

[Torsion of the spleen in children]

The wandering spleen is caused by congenital absence of fixating ligaments or abnormally long ligaments. It is an uncommon clinical entity, which rarely affects children. The clinical presentation of wandering spleen is variable, but the most dangerous complication is splenic torsion. A 7 year-old boy presented with abdominal pain and vomiting. The abdominal ultrasound scan discovered spleen ischemia. Volvulus of the spleen was evoked. Laparotomy was carried out and the patient underwent splenectomy. In this case the anatomical means of spleen fixity were absent. Because wandering spleen is uncommon in the paediatric population, a heightened awareness of the condition is required for accurate diagnosis and appropriate management. The treatment of choice is splenopexy, while if splenic necrosis is present, splenectomy is required.

Enlarged wandering spleen treated with hemisplenectomy and fixation of the residual spleen

A case of enlarged wandering spleen presenting as an abdominal mass in a 7-year-old girl is reported. The diagnosis was performed by ultrasonography and confirmed by aortography. Treatment consisted of an elective partial splenectomy and fixation of the residual spleen to the left hemidiaphragm. The patient's symptoms regressed, and now, after more than 2 years, she is doing well. Two years postoperatively scintigraphy demonstrated a good captation of radionuclide by a normal-sized spleen at the left hypochondrium. The results obtained with the procedure that was adopted for treating this case of wandering spleen allow the authors to state that hemispleen fixation is a valid option for treating symptomatic enlarged wandering spleen.

Laparoscopic pocket splenopexy for wandering spleen: a case report

Wandering spleen is a very uncommon condition. Because of the risk of pedicle torsion and splenic ischemia, severe consequences may occur if not diagnosed and treated in time. Unfortunately, splenectomy is sometimes necessary (ie, when splenic infarction occurs). Once the diagnosis of wandering spleen is made, splenopexy is the treatment of choice. There are numerous techniques designed for splenopexy, either by open surgery or by minimally invasive approaches. We describe here a laparoscopic procedure that allows an excellent fixation of the spleen using the patient's own tissues. After a 2-year follow-up, the organ remains in place with good perfusion.

[Floating spleen with chronic torsion of the pedicle causing splenomegaly and secondary hypersplenism]

If the spleen is not fixed within the left subphrenic space, it gradually passes into the lower abdomen, where is much more exposed to trauma. Torsion of the splenic pedicle can also occur, causing the infarct necessitating an immediate surgery. Venous stasis causes splenomegaly and sometimes secondary hypersplenism. The authors present 16.5-year old girl with torsion of the splenic pedicle of floating spleen for 720 degrees: in spite of that, the patient had neither splenic infarct nor splenic vein thrombosis, possibly due to thrombocytopenia, but she had splenomegaly and secondary hypersplenism with pancytopenia causing bleeding, sideropenic anemia and mild jaundice. After treatment with iron, the patient underwent splenectomy which resulted in almost immediate rise of the number of all blood cells, and even thrombocytosis. The authors suggest early surgical treatment of the floating spleen, preferably splenopexy, before development of severe complications when splenectomy had to be performed in the majority of patients. Accessory spleens, if present, should be saved.

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

BACKGROUND

Wandering spleen is an uncommon diagnosis, difficult to prove by standard investigations. The authors report a new method for laparoscopic splenopexy in children using a balloon-dilated retroperitoneal pouch.

METHODS

From 3 accesses, the spleen is mobilized and displaced into a retroperitoneal pouch dilated to the double splenic volume. The pouch is dilated by a self-made balloon via a further intercostal access and narrowed by sutures incorporating the cranial and caudal edge of the gastrosplenic ligament.

RESULTS

The peritoneal pouch contracts around the retroperitoneal spleen resulting in a firm fixation of the organ. This technique was successful in a 9-year-old girl with a 5-year history of severe recurrent abdominal pain.

CONCLUSIONS

Laparoscopic retroperitoneal pouch splenopexy is a safe and effective procedure for symptomatic wandering spleen precluding the use of foreign materials in this age group.

Autoinfarcted wandering spleen and fatal pneumococcal sepsis in an infant

A wandering or ectopic spleen, a rare congenital condition caused by improper fixation of the ligamentous attachments, was identified during a postmortem examination of a 10-month-old female who had died of Streptococcus pneumoniae sepsis. The wandering spleen was autoinfarcted and adherent to the left hepatic lobe, with resultant functional hyposplenism.