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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 289-291

Laparoscopic management of congenital splenic cyst with intracystic bleed


Departments of General Surgery and Surgical Gastroenterology, Apollo BGS Hospitals, Mysore, Karnataka, India

Date of Submission24-Jun-2020
Date of Acceptance28-Oct-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Nairuthya Shivathirthan
Department of Surgical Gastroenterology, Apollo BGS Hospitals, Kuvempunagar, Mysore - 570 023, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_53_20

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  Abstract 


Splenic cysts can be congenital, vascular, neoplastic, inflammatory, and posttraumatic contributing to 30%–40% of the total splenic lesions.Congenital splenic cysts are usually asymptomatic and are rarely seen in routine surgical practice. Due to lack of typical clinical presentation, they are discovered incidentally. Splenic congenital cysts constitute approximately 10% of total cysts. Primary (true) cysts make up approximately 20% of all types of cysts which occur in spleen. Epidermoid cysts are the rarest, which comprise only 10% of benign, nonparasitic cysts which occur in the spleen. Here, we present a case of 28-year-old female who presented to the hospital with vague upper abdominal pain and on clinical and radiological investigations was diagnosed as a case of congenital epidermoid cyst of the spleen with evidence of intracystic bleed which was managed laparoscopically.

Keywords: Congenital epidermoid cyst of the spleen, intracystic bleed, laparoscopy, marsupialization of cyst


How to cite this article:
Waseem SM, Nagaraja JB, Shivathirthan N. Laparoscopic management of congenital splenic cyst with intracystic bleed. Apollo Med 2020;17:289-91

How to cite this URL:
Waseem SM, Nagaraja JB, Shivathirthan N. Laparoscopic management of congenital splenic cyst with intracystic bleed. Apollo Med [serial online] 2020 [cited 2021 Jan 18];17:289-91. Available from: https://www.apollomedicine.org/text.asp?2020/17/4/289/303609




  Introduction Top


Splenic cysts are rare. They may be congenital, neoplastic, vascular, inflammatory, and posttraumatic in origin[1] and may contribute to 30%–40% of the total splenic lesions.[2] Splenic cysts are asymptomatic in around 30%–60% of patients.[3] Type I cysts are true (primary) cysts with a cellular lining of parasitic or nonparasitic origin. Type II cysts are false (secondary) cysts without a cellular lining and are most commonly found following blunt trauma to the spleen. Here, we present a case of 28-year-old female who presented to the hospital with vague abdominal pain and on clinical and radiological investigations turned out to be a congenital epidermoid cyst of the spleen. She underwent laparoscopic splenic cyst marsupialization with omentopexy.


  Case Report Top


History and examination

A 28-year-old woman presented with chief complaint of vague abdominal pain for 1 month, with no radiation of pain. There was no history of fever and trauma and there was no association with food intake. On physical examination, a firm, smooth, nontender mass was palpable in the left hypochondrium.

Computed tomography of the abdomen, after administering oral and intravenous contrast, showed a large hypodense nonenhancing lesion measuring 12.0 cm × 11.0 cm × 10.0 cm in the upper portion of the spleen with mass effect on stomach. No septations/calcifications were found in the lesion and a radiological diagnosis of a large nonenhancing splenic cyst was made.

Operative course

Relevant preoperative investigations were done. She was optimized for surgery. Under general anesthesia, patient in the right lateral 45° tilt, with standard three-port technique used, a large unilocular simple cyst of superior pole of the spleen around 12.0 cm × 10.0 cm with clots was found [Figure 1]. The presence of clots points to intracystic bleed is the cause of recent pain which was not picked up on contrast-enhanced computed tomography (CECT). Laparoscopic cyst marsupialization [Figure 2] with omentopexy [Figure 3] was performed. Postoperative ultrasound scan of the abdomen done did not reveal any perisplenic collection confirming the effectiveness of omentopexy.
Figure 1: Splenic cyst

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Figure 2: Marsupialization of the cyst

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Figure 3: Omentopexy

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Histopathology

The cyst was sent for histopathological examination, [Figure 4] and it showed cyst wall lined with columnar-to-cuboidal epithelium, stroma with fibrocollagenous tissue with hemorrhage areas of fibrosis, and hyalinization and a diagnosis of a splenic epidermoid cyst [Figure 5], [Figure 6] was made. The postoperative clinical course of the patient was satisfactory and uneventful.
Figure 4: Gross specimen of the splenic cyst

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Figure 5: Computed tomography image depicting the splenic cyst

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Figure 6: Computed tomography scan view

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  Discussion Top


Splenic cystic lesions are rare, uncommon in routine surgical practice. Martin et al. classified splenic cysts as Type I primary (true) cysts with cellular linings of parasitic or nonparasitic origin.[4] Nonparasitic Type I splenic cysts are further divided into congenital and neoplastic cysts. Different types of congenital cysts are epidermoid, dermoid, and endodermoid cysts, whereas neoplastic cysts constitute hemangiomas and lymphangiomas. Of these, hemangiomas are the foremost common ones and dermoid cysts are the least type of common ones. Type II cysts without cellular linings are called false (secondary) cysts. Primary (true) cysts account to approximately 20% of all kinds of cysts which occur in the spleen. Epidermoid cysts are the rarest variety, which account only 10% of benign, nonparasitic cysts which occur within the spleen.[5]

The most common symptoms include left upper quadrant pain, vague sensation of fullness attributed to the distension of its capsule, and nausea and vomiting secondary to compression of the stomach. They will even be discovered following the complications such as rupture, intracapsular hemorrhage, or infection. Indications for operative intervention include cysts with a diameter >5 cm and people who are symptomatic. Cysts with a diameter >5 cm are more likely to rupture leading to life-threatening hemoperitoneum.[6]

Operative intervention aims to eradicate the cyst and prevent further recurrence. Operative methods include both open and laparoscopic techniques. In the past, splenectomy was thought to be the sole management. However, with recent advances, splenic preserving surgery has the advantage of avoiding the lifelong risk of the potentially fatal overwhelming postsplenectomy sepsis (OPSI). Postsplenectomy patients have a lifetime risk for developing OPSI is 5%, which carries a mortality of 38%–69%.[7] Options for splenic preservation include partial splenectomy, cystectomy, cyst decapsulation, and marsupialization.

Other drainage techniques using radiological guidance, the incidence of recurrence has been reported to be as high as 100%; hence, surgery is accounted as the treatment of choice. Radiologically, distinguishing between true and false splenic cysts preoperatively is often difficult, and also, the diagnosis relies on histopathological examinations of the cyst.


  Conclusion Top


Of the splenic cysts that are diagnosed, majority are parasitic and only few of them are congenital cysts. Congenital cysts are usually asymptomatic and intracystic bleed is one of the causes for pain. CECT may not always pick up intracystic bleeding if they are insignificant or chronic. Splenic preservation should always be the goal when dealing with benign splenic diseases, and laparoscopic splenic preservation techniques such as cyst marsupialization are effective techniques for management. The addition of cavity obliteration technique such as omentopexy is a simple addition in addressing the issues of cyst recurrence and avoiding cavity-related complications. Laparoscopic splenic preservation procedures for benign splenic cysts, when feasible, is preferable than total splenectomy due to low rates of recurrence and less patient morbidity, and advantage of preservation of splenic function and addition of a cavity obliteration technique increase the effectiveness of the procedure without additional morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Urrutia M, Mergo PJ, Ros LH, Torres GM, Ros PR. Cystic masses of the spleen: Radiologic-pathologic correlation. Radiographics 1996;16:107-29.  Back to cited text no. 1
    
2.
Rana AP, Kaur M, Singh P, Malhotra S, Kuka AS. Splenic epidermoid cyst A rare entity. J Clin Diagn Res 2014;8:175-6.  Back to cited text no. 2
    
3.
Labruzzo C, Haritopoulos KN, El Tayar AR, Hakim NS. Posttraumatic cyst of the spleen: A case report and review of the literature. Int Surg 2002;87:152-6.  Back to cited text no. 3
    
4.
Cianci P, Tartaglia N, Altamura A, Fersini A, Vovola F, Sanguedolce F, et al. A recurrent epidermoid cyst of the spleen: Report of a case and literature review. World J Surg Oncol 2016;14:98.  Back to cited text no. 4
    
5.
Marjanović ZO, Djordjević IM. Epidermoid splenic cysts in children and adolescents. Acta Chir Iugosl 2008;55:63-7.  Back to cited text no. 5
    
6.
Geraghty M, Khan IZ, Conlon KC. Large primary splenic cyst: A laparoscopic technique. J Minim Access Surg 2009;5:14-6.  Back to cited text no. 6
    
7.
Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:657-60.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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