Splenic pedicle control during laparoscopic de-capsulation of a giant splenic cyst

Splenic pedicle control during laparoscopic de-capsulation of a giant splenic cyst Splenic cysts are a rare entity in the Western population and are either true cysts (primary, 25%) or pseudocysts (secondary, 75%) complicating trauma, haemorrhage or infarction. Congenital or simple splenic cysts are the commonest primary cysts and surgery is recommended for cysts larger than 5 cm as these are prone to infection, bleeding or rupture and for symp- tomatic or complicated cysts. Splenic preservation techniques using the laparoscopic approach are the most prevalent. We present a case of a giant painful simple splenic cyst treated with laparoscopic de-capsulation with application of a new tech- nique for achieving vascular control, whereby control of the splenic pedicle was achieved using a Nylon tape. This approach was safe and well tolerated with a total splenic ischaemia time of 30 min and a successful result. The patient was dis- charged with no antecedent complications and no recurrence of the cyst at 6 months follow up ultrasound scan. INTRODUCTION structures [5]. The definitive diagnosis lies with histopathologic Splenic cysts are rare, particularly in the West [1], with around analysis of the resected cyst [5]. 1000 cases reported in the literature. Pathologically they are Management is mostly surgical and include aspiration, marsu- classified as true cysts (primary, 25%) that are lined by epithe- pialization, cystectomy, cyst de-roofing, cyst de-capsulation, par- lium or false cysts (secondary or pseudocysts, 75%) without tial splenectomy and splenectomy. Laparoscopic de-capsulation endothelial lining and are often secondary to trauma, haemor- involves a near total cystectomy with removal of the visible cyst rhage or infarction. True cysts can be further subdivided based wall and it’s contiguous splenic parenchyma, leaving the very on aetiology into parasitic, neoplastic or congenital [2, 3]. adherent part that cannot be denuded off the spleen [1, 4]. Congenital cysts are benign, sporadic, have a slight female pre- Current surgical trends are towards splenic preservation surgery ponderance and with an unclear pathogenesis [4]. Most of these to avoid post-splenectomy complications and laparoscopic tech- are asymptomatic and present at an early age as an incidental niques [6, 7]. Factors dictating the use of one procedure or another radiological finding in the upper pole of the spleen. Clinical pres- are the number of cysts as well as size and location in relation to entation is observed with cysts larger than 5 cm as these are prone the splenic hilum and the major splenic vessles [8]. Care should to infection, haemorrhage or rupture. Surgery is recommended for be taken when considering the differential diagnosis to rule out cysts larger than 5 cm, symptomatic or complicated cysts [2]. echinococcal cysts, using a combination of cross-sectional Computed tomography (CT) scan, ultrasound scan and mag- imaging and serological testing as these should be dealt with netic resonance imaging (MRI) are useful imaging modalities to carefully and preferably by open surgery to avoid spillage into the describe the cyst and its relation to the spleen and surrounding peritoneal cavity and dissemination. Received: October 3, 2017. Accepted: December 24, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 O. Elhardello and B.J. Ammori from vaccination as the patient was considerably troubled with CASE REPORT abdominal pain and we were confident that a total splenectomy A 19-year-old female presented with a 2-day history of severe could be avoided. left upper abdominal pain. There was no known history of Under general anaesthesia, the patient was placed in the abdominal trauma or travel outside the UK. She was systemic- right lateral position. Laparoscopic surgery proceeded with four ally well, had a soft abdomen with exquisite tenderness at the ports in the left upper abdomen (Fig. 3). Then under 15 mmHg left upper quadrant and loin regions. The provisional blood tests, capnoperitoneum, the spleen was retracted using a 5-mm dia- hydatid serology and chest and abdominal X-rays were unre- mondflex retractor (Lina Medical, Devon, UK). A large simple– markable. An ultrasound scan showed a large splenic cyst with appearing splenic cyst was demonstrated, arising from upper no increase in vascularity on Doppler assessment, while an pole of the spleen, with some inflammatory adhesions to the intravenous contrast-enhanced CT scan showed a 12.5 × 9.7 × under surface of the left lobe of liver and diaphragm. The 10.7 cm well-defined cystic mass arising from the upper pole of splenic hilum was exposed after dividing the gastrospelnic liga- the spleen (Fig. 1) with multiple fine echogenic shadows and ment and the hilar vessels were slung in a Nylon tape. The medial displacement of the stomach and the left kidney (Fig. 2). adhesions were divided using the Thunderbeat coagulation Findings were consistent with the diagnosis of a simple splenic device (Ethicon, Livingston, UK). The slung splenic hilum was cyst. The patient was scheduled for an urgent laparoscopic de- clamped by advancing a plastic tube (a mid-section of a naso- capsulation, and received triple vaccination (meningococcal, gastric tube) over the Nylon sling and fixing it in position with pneumococcal and Haemophilus influenzae type B). Although 2 a haemostat applied outside the abdomen (Fig. 4). The cyst was weeks are recommended between vaccination and splenectomy then decompressed by aspirating its clear straw-coloured fluid should this be needed, we proceeded to surgery after 10 days content which enhanced exposure and access. De-capsulation of the cyst was performed using the Thunderbeat coagulation device to include the thinned part of the spleen over the cyst, with removal of ~90% of the cyst wall. The remainder of the intra-splenic portion of the cyst wall was sprayed with dia- thermy to destroy its lining epithelium. The splenic edge was treated with Floseal Haemostatic Matrix (Baxter Helathcare S.A, Zurich, Switzerland) and a sheet of Surgicel (Gelita Medical, Eberbach, Germany) was applied to an oozy part and was over- sewn over the spleen edge with Vicryl 4/0 in a continuous man- ner. The hilum was unclamped after a total ischaemia time of 30 min and no bleeding was encountered despite reducing the intraperitoneal pressure to 7 mmHg for 3 min. The spleen appeared well perfused (Fig. 5). The patient made an uneventful recovery and was discharged on the third post-operative day. The histopathology confirmed a Figure 1: Computed tomography showing a giant splenic cyst. Figure 3: A schematic illustration of the ports positions. The working ports are Figure 2: Computed tomography showing medial displacement of the stomach numbered 1 and 3, port 2 is for the laparoscope, while port 4 is for a 5-mm dia- and the left kidney by the cyst. mondflex retractor. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Splenic pedicle control during laparoscopic de-capsulation of a giant splenic cyst 3 described recently such as partial splenectomy, cyst marsupiali- zation, cyst de-roofing and cyst de-capsulation [8]. Laparoscopic de-capsulation which was done here is simpler and quicker to perform with less blood loss than partial splenectomy, there is a small possibility of recurrence as a portion of the cyst lining is left in situ. The recurrence rate as reported in small series was lower than aspiration and marsupialization and is dependent on the amount of cyst lining left behind [3]. In this report, we describe for the first time a new approach that involved slinging and clamping the splenic hilum on a vascular tape, which enabled a bloodless approach to a radical de-capsulation without the need to tackle smaller arterial branches, avoided tedious bleeding that could have obscured the surgical field, and avoided taking down small arterial branches with the potential of segmental infarction of the spleen. This manoeuvre resembles in principle the Pringle manoeuvre [9] commonly used in liver resection. This approach can be added to the armamentarium of the lap- aroscopic surgeon to simplifyamoreradical resectionof Figure 4: An operative image showing the splenic hilum slung with the vascular simple splenic cysts. tape and clamped with a segment of a nasogastric tube. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Pastore V, Bartoli F. A report of a giant epidermoid splenic cyst. Afr J Paediatr Surg 2014;11:67–70. 2. Pitiakoudis M, Zezos P, Oikonomou A, Laftsidis P, Kouklakis G, Simopoulos C. Total splecnectomy due to an unexpected ‘Complication’ after successful expanded laparoscopic par- tial decapsulation of a giant epidermoid splenic cyst: a case report. Case Rep. Med. 2011;318208:1–7. 3. Chin EH, Shapiro R, Hazzan D, Katz LB, Salky B. A ten-year experience with laparoscopic treatment of splenic cysts. JSLS 2007;11:20–3. 4. Hiatt JR, Phillips EH, Morgenstem L. Surgical Diseases of the Spleen. Springer, 2012;278. 5. Fisher JC, Gurung B, Cowles RA. Recurrence after laparo- scopic excision of nonparasitic splenic cysts. J Pediatr Surg Figure 5: An operative image showing the splenic cyst after de-capsulation with a bloodless bed and minimal bleeding from edges of the cyst. 2008;43:1644–8. 6. Mertens J, Penninckx F, DeWever I, Topal B. Long-term out- come after surgical treatment of nonparasitic splenic cysts. primary cyst with no evidence of malignancy. She remains Surg Endosc 2007;21:206–8. asymptomatic 6 months after surgery when an ultrasound scan 7. Schier F, Waag KL, Ure B. Laparoscopic unroofing of splenic showed a normal spleen with no evidence of recurrence. cysts results in a high rate of recurrences. J Pediatr Surg 2007; 42:1860–3. DISCUSSION 8. Velanovich V, Weaver M. Partial splenectomy using a The conventional treatment of simple splenic cysts has been coupled saline-radiofrequency hemostatic device. Am Surg splenectomy, either open or laparoscopic. This would achieve a 2003;185:66–8. complete extirpation of the cyst with avoidance of recurrence. 9. Pringle JH. V. Notes on the arrest of hepatic hemorrhage due Different laparoscopic spleen preserving procedures were to trauma. Ann Surg 1908;48:541–9. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Splenic pedicle control during laparoscopic de-capsulation of a giant splenic cyst

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Abstract

Splenic cysts are a rare entity in the Western population and are either true cysts (primary, 25%) or pseudocysts (secondary, 75%) complicating trauma, haemorrhage or infarction. Congenital or simple splenic cysts are the commonest primary cysts and surgery is recommended for cysts larger than 5 cm as these are prone to infection, bleeding or rupture and for symp- tomatic or complicated cysts. Splenic preservation techniques using the laparoscopic approach are the most prevalent. We present a case of a giant painful simple splenic cyst treated with laparoscopic de-capsulation with application of a new tech- nique for achieving vascular control, whereby control of the splenic pedicle was achieved using a Nylon tape. This approach was safe and well tolerated with a total splenic ischaemia time of 30 min and a successful result. The patient was dis- charged with no antecedent complications and no recurrence of the cyst at 6 months follow up ultrasound scan. INTRODUCTION structures [5]. The definitive diagnosis lies with histopathologic Splenic cysts are rare, particularly in the West [1], with around analysis of the resected cyst [5]. 1000 cases reported in the literature. Pathologically they are Management is mostly surgical and include aspiration, marsu- classified as true cysts (primary, 25%) that are lined by epithe- pialization, cystectomy, cyst de-roofing, cyst de-capsulation, par- lium or false cysts (secondary or pseudocysts, 75%) without tial splenectomy and splenectomy. Laparoscopic de-capsulation endothelial lining and are often secondary to trauma, haemor- involves a near total cystectomy with removal of the visible cyst rhage or infarction. True cysts can be further subdivided based wall and it’s contiguous splenic parenchyma, leaving the very on aetiology into parasitic, neoplastic or congenital [2, 3]. adherent part that cannot be denuded off the spleen [1, 4]. Congenital cysts are benign, sporadic, have a slight female pre- Current surgical trends are towards splenic preservation surgery ponderance and with an unclear pathogenesis [4]. Most of these to avoid post-splenectomy complications and laparoscopic tech- are asymptomatic and present at an early age as an incidental niques [6, 7]. Factors dictating the use of one procedure or another radiological finding in the upper pole of the spleen. Clinical pres- are the number of cysts as well as size and location in relation to entation is observed with cysts larger than 5 cm as these are prone the splenic hilum and the major splenic vessles [8]. Care should to infection, haemorrhage or rupture. Surgery is recommended for be taken when considering the differential diagnosis to rule out cysts larger than 5 cm, symptomatic or complicated cysts [2]. echinococcal cysts, using a combination of cross-sectional Computed tomography (CT) scan, ultrasound scan and mag- imaging and serological testing as these should be dealt with netic resonance imaging (MRI) are useful imaging modalities to carefully and preferably by open surgery to avoid spillage into the describe the cyst and its relation to the spleen and surrounding peritoneal cavity and dissemination. Received: October 3, 2017. Accepted: December 24, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 O. Elhardello and B.J. Ammori from vaccination as the patient was considerably troubled with CASE REPORT abdominal pain and we were confident that a total splenectomy A 19-year-old female presented with a 2-day history of severe could be avoided. left upper abdominal pain. There was no known history of Under general anaesthesia, the patient was placed in the abdominal trauma or travel outside the UK. She was systemic- right lateral position. Laparoscopic surgery proceeded with four ally well, had a soft abdomen with exquisite tenderness at the ports in the left upper abdomen (Fig. 3). Then under 15 mmHg left upper quadrant and loin regions. The provisional blood tests, capnoperitoneum, the spleen was retracted using a 5-mm dia- hydatid serology and chest and abdominal X-rays were unre- mondflex retractor (Lina Medical, Devon, UK). A large simple– markable. An ultrasound scan showed a large splenic cyst with appearing splenic cyst was demonstrated, arising from upper no increase in vascularity on Doppler assessment, while an pole of the spleen, with some inflammatory adhesions to the intravenous contrast-enhanced CT scan showed a 12.5 × 9.7 × under surface of the left lobe of liver and diaphragm. The 10.7 cm well-defined cystic mass arising from the upper pole of splenic hilum was exposed after dividing the gastrospelnic liga- the spleen (Fig. 1) with multiple fine echogenic shadows and ment and the hilar vessels were slung in a Nylon tape. The medial displacement of the stomach and the left kidney (Fig. 2). adhesions were divided using the Thunderbeat coagulation Findings were consistent with the diagnosis of a simple splenic device (Ethicon, Livingston, UK). The slung splenic hilum was cyst. The patient was scheduled for an urgent laparoscopic de- clamped by advancing a plastic tube (a mid-section of a naso- capsulation, and received triple vaccination (meningococcal, gastric tube) over the Nylon sling and fixing it in position with pneumococcal and Haemophilus influenzae type B). Although 2 a haemostat applied outside the abdomen (Fig. 4). The cyst was weeks are recommended between vaccination and splenectomy then decompressed by aspirating its clear straw-coloured fluid should this be needed, we proceeded to surgery after 10 days content which enhanced exposure and access. De-capsulation of the cyst was performed using the Thunderbeat coagulation device to include the thinned part of the spleen over the cyst, with removal of ~90% of the cyst wall. The remainder of the intra-splenic portion of the cyst wall was sprayed with dia- thermy to destroy its lining epithelium. The splenic edge was treated with Floseal Haemostatic Matrix (Baxter Helathcare S.A, Zurich, Switzerland) and a sheet of Surgicel (Gelita Medical, Eberbach, Germany) was applied to an oozy part and was over- sewn over the spleen edge with Vicryl 4/0 in a continuous man- ner. The hilum was unclamped after a total ischaemia time of 30 min and no bleeding was encountered despite reducing the intraperitoneal pressure to 7 mmHg for 3 min. The spleen appeared well perfused (Fig. 5). The patient made an uneventful recovery and was discharged on the third post-operative day. The histopathology confirmed a Figure 1: Computed tomography showing a giant splenic cyst. Figure 3: A schematic illustration of the ports positions. The working ports are Figure 2: Computed tomography showing medial displacement of the stomach numbered 1 and 3, port 2 is for the laparoscope, while port 4 is for a 5-mm dia- and the left kidney by the cyst. mondflex retractor. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Splenic pedicle control during laparoscopic de-capsulation of a giant splenic cyst 3 described recently such as partial splenectomy, cyst marsupiali- zation, cyst de-roofing and cyst de-capsulation [8]. Laparoscopic de-capsulation which was done here is simpler and quicker to perform with less blood loss than partial splenectomy, there is a small possibility of recurrence as a portion of the cyst lining is left in situ. The recurrence rate as reported in small series was lower than aspiration and marsupialization and is dependent on the amount of cyst lining left behind [3]. In this report, we describe for the first time a new approach that involved slinging and clamping the splenic hilum on a vascular tape, which enabled a bloodless approach to a radical de-capsulation without the need to tackle smaller arterial branches, avoided tedious bleeding that could have obscured the surgical field, and avoided taking down small arterial branches with the potential of segmental infarction of the spleen. This manoeuvre resembles in principle the Pringle manoeuvre [9] commonly used in liver resection. This approach can be added to the armamentarium of the lap- aroscopic surgeon to simplifyamoreradical resectionof Figure 4: An operative image showing the splenic hilum slung with the vascular simple splenic cysts. tape and clamped with a segment of a nasogastric tube. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Pastore V, Bartoli F. A report of a giant epidermoid splenic cyst. Afr J Paediatr Surg 2014;11:67–70. 2. Pitiakoudis M, Zezos P, Oikonomou A, Laftsidis P, Kouklakis G, Simopoulos C. Total splecnectomy due to an unexpected ‘Complication’ after successful expanded laparoscopic par- tial decapsulation of a giant epidermoid splenic cyst: a case report. Case Rep. Med. 2011;318208:1–7. 3. Chin EH, Shapiro R, Hazzan D, Katz LB, Salky B. A ten-year experience with laparoscopic treatment of splenic cysts. JSLS 2007;11:20–3. 4. Hiatt JR, Phillips EH, Morgenstem L. Surgical Diseases of the Spleen. Springer, 2012;278. 5. Fisher JC, Gurung B, Cowles RA. Recurrence after laparo- scopic excision of nonparasitic splenic cysts. J Pediatr Surg Figure 5: An operative image showing the splenic cyst after de-capsulation with a bloodless bed and minimal bleeding from edges of the cyst. 2008;43:1644–8. 6. Mertens J, Penninckx F, DeWever I, Topal B. Long-term out- come after surgical treatment of nonparasitic splenic cysts. primary cyst with no evidence of malignancy. She remains Surg Endosc 2007;21:206–8. asymptomatic 6 months after surgery when an ultrasound scan 7. Schier F, Waag KL, Ure B. Laparoscopic unroofing of splenic showed a normal spleen with no evidence of recurrence. cysts results in a high rate of recurrences. J Pediatr Surg 2007; 42:1860–3. DISCUSSION 8. Velanovich V, Weaver M. Partial splenectomy using a The conventional treatment of simple splenic cysts has been coupled saline-radiofrequency hemostatic device. Am Surg splenectomy, either open or laparoscopic. This would achieve a 2003;185:66–8. complete extirpation of the cyst with avoidance of recurrence. 9. Pringle JH. V. Notes on the arrest of hepatic hemorrhage due Different laparoscopic spleen preserving procedures were to trauma. Ann Surg 1908;48:541–9. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx255/4788811 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Published: Jan 1, 2018

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