Laparoscopic Partial Splenectomy for Giant Hemangioma Misdiagnosed as Splenic Cyst:a Case Report

Jin Wang,Jian-chun Yu*,Wei-ming Kang,and Zhi-qiang Ma

Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences &Peking Union Medical College,Beijing 100730,China

ALTHOUGH unusual,hemangioma is the most common type of primary splenic neoplasm.1Usually,splenic hemangioma appears as solid mass,but sometimes it presents cystic component as well,which is difficult to discriminate from some other lesions,such as abscess,simple cyst,parasitic cyst,and lymphangioma.2Preoperative diagnosis of splenic hemangioma mainly depends on imaging study (e.g.ultrasonography,CT,MRI).As the laparoscopic technique develops,laparoscopic splenectomy is becoming the standard treatment for benign tumor of the spleen.Compared with that procedure,laparoscopic partial splenectomy (LPS) has some unique advantages except for higher requirements for surgical skills.We described in this report a successful LPS in a patient who was misdiagnosed as splenic cyst initially.

CASE DESCRIPTION

A 45-year-old woman had a mild left lower back pain for 18 years.A cystic mass in her left upper quadrant was detected by ultrasonography during health examination in 2008.Upon admission,the patient appeared well nourished,and results of physical examination and laboratory tests were unremarkable.Plain CT scan revealed a mass about 7 cm×6 cm×6 cm in size with homogeneous low density,surrounded by the tail of the pancreas,the lower pole of the spleen and the upper pole of the kidney.Contrast-enhanced CT scan showed that part of the cystic wall was enhanced during the arterial phase and portal venous phase,but the content inside remained at homogeneous low density all along (Fig.1).Preoperative evaluation led to the possible diagnosis of splenic cyst.

The surgical procedure was performed with an anterior approach.The first 12-mm port was inserted from the umbilicus.Two other 12-mm ports were inserted below the xiphoid process and the crossing point of left mid-clavicular line and horizontal line through umbilicus.The 5-mm port was inserted below the right costal margin on the midclavicular line.

The operation was begun with a thorough search of the abdominal cavity.Dissection began by opening the gastrocolic ligament to access the lesser sac.After opening the gastrosplenic ligament,the cystic mass was exposed(Fig.2).However,the cystic wall appeared extraordinarily thicker than common cyst.Additionally,it was close to the tail of the pancreas.Then we aspirated some clear yellow fluid from the cyst for biochemical analysis.Pancreatic amylase (58 U/L) and lipase (485 U/L) were both within normal limits,which excluded the possibility of pancreatic pseudocyst.The concentrations of alanine aminotransferase (4 U/L),total bilirubin (33.0 μmol/L),and direct bilirubin (5.1 μmol/L) demonstrated that there were blood components in sac fluid.We surmised that this lesion might be hemangioma,splenic hematoma,splenic cyst accompanied by bleeding,or caused by mistakenly puncturing into the vessel.Thus it was rather dangerous to perform fenestration and drainage for the cyst blindly without pathological support.At last,we performed partial splenectomy to excise the lesion completely.

First,short gastric vessels were separated with ultrasonic dissector,and then lower pole of the spleen was totally free,with vessels supporting it exposed clearly as well.The vessels were ligated by hunmlock (Fig.3A).No more than three minutes,a clear line of ischemic demarcation formed,and the cystic lesion and the lower pole of the spleen were lifted (Fig.3B).Along the ischemic line,spleen was transected by Endo GIA vascular linear cutting stapler (Ethicon,USA),which provides excellent haemostatic control (Fig.4).The excised spleen was removed out through the left inferior incision.The operation took 180 minutes.A latex tube was plac-ed in the left subphrenic space and subsequently removed on the 3rd postoperative day.Histological examination of the resected lesion revealed a racemose hemangioma accompanied by cyst formation (Fig.5).The patient was discharged on the 7th postoperative day without any complications,and her platelet count remained within normal limits.

Figure 1.Contrast-enhanced CT scan reveals a mass (arrows) with homogeneous low density which is 7 cm×6 cm×6 cm in size,and part of the cystic wall is enhanced during the arterial phase and portal venous phase,but the content inside remains at homogeneous low density all along.

Figure 2.The cystic mass exposed is about 6 cm in diameter,located at the inferior pole of the spleen,and connected with the tail of the pancreas as well.

Figure 3.Excision line after cutting off the blood supply.

Figure 4.Along the ischemic line,the spleen is transected by Endo GIA vascular linear cutting stapler.

Figure 5.Histological examination shows the anastomosing vascular channels of the hemangioma inserting into the splenic parenchyma with irregular lumina.HE staining ×10

DISCUSSION

Diagnosis of splenic hemangioma

The splenic tumors are divided into three categories according to their biological behaviors:splenic benign tumor,splenic primary malignant tumor,and splenic metastases.3Hemangiomas are the most common benign tumors of the spleen.Clinically,they are often asymptomatic and incidentally detected by ultrasonography or CT.Occasionally,they may be accompanied by splenomegaly,abdominal pain,dyspnoea,diarrhea,or constipation.1

Splenic hemangiomas appear on CT scans as single or multiple lesions that are usually homogeneous,hypodense,or multicystic.Most of the hemangiomas are enhanced peripherally after intravenous contrast injection.However,splenic hemangioma can occur as cystic mass which is hard to discriminate from other diseases such as abscess,simple cyst,parasitic cyst,and lymphangioma.There are studies about the efficacy and safety of fine-needle biopsy from the spleen,but possible bleeding and tumor dissemination make the biopsy problematic.4Li et al5reported one case which was diagnosed as splenic lymphangioma by CT scan,and suspected it as a tuberculous abscess during the surgery.Finally,the histological examination and bacterial culture confirmed it as a paratyphoid abscess of the spleen.According to CT scan,another patient with recurrent fever was diagnosed as malignant lymphoma,and the pathology demonstrated it was splenic tuberculosis.6Therefore,the diagnosis of splenic mass may pose a preoperative challenge.

In our case,we presumed it was a simple cyst before the surgery.At the beginning of surgery,we considered it might be pancreatic pseudocyst given its appearance,so we aspirated some sac fluid for biochemical analysis,but the values of pancreatic amylase and lipase excluded the possibility of pancreatic origin.After exposing the inferior pole of the spleen completely,we confirmed it was originated from the spleen,but the values of alanine aminotransferase,total bilirubin,and direct bilirubin implied it might be a hemangioma or some other lesions with blood content instead of a simple cyst.LPS was performed at last.

Advantages of LPS for benign splenic tumor

Nowadays,laparoscopic splenectomy has become the standard treatment for splenic disorders.7Usually,hemangiomas are not treated unless they are symptomatic or very large with increased risk of hemorrhage or rupture,or accompanied by diarrhea,constipation,infarction,anemia,coagulopathy,thrombocytopenia,and malignant transformation.2,8As known to all,total splenectomy could increase the probabilities of postoperative infection,secondary atherosclerosis events,pulmonary hypertension,and thrombotic events.9Therefore,the surgeon should attempt to preserve as much of the spleen parenchyma as possible.

Previously,LPS was technically difficult.However,developments in surgical skill and anatomic knowledge of the splenic vascularization have rendered partial splenectomy possible.10Although taking longer time,LPS offers more rapid postoperative recovery and shorter duration of hospital stay.The incidence of conversion to open splenectomy is 0%-20%.1Danielson et al11reported that LPS in children could be performed safely with a lower conversion rate (2.9%).However,LPS remained a requiring surgical option because of perioperative bleeding.In our case,bleeding risk was limited by initial control of the pedicle,the use of ultrasonic scalpel and Endo GIA.These guarantee clean and non-hemorrhagic transection of the spleen.

Although the indications for LPS are the same as for open surgery,some cases still require extra caution.Absolute contraindications to the laparoscopic approach include severe cardiopulmonary disease and liver cirrhosis.12Short gastric vessels present unacceptable risk of operative hemorrhage in patients with portal hypertension.

In conclusion,splenic hemangiomas are rare and asymptomatic.Misdiagnosis may lead to inappropriate surgery.Careful exploration and sac fluid analysis may help intraoperative diagnosis.Compared with splenectomy,LPS achieves not only complete excision of splenic lesion,but also less invasion,preserving the functions of the spleen,shortening hospital stay and time for full recovery.

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