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Feleke AA, Zemariam MA, Belay SA, Worku AT, Yigezaw GS, Addis NA, Yitina EF. Ectopic splenic torsion-a challenging diagnosis in a resource-limited setting mimicking a gynecologic emergency: a case report. J Surg Case Rep 2025; 2025:rjaf182. [PMID: 40191661 PMCID: PMC11969148 DOI: 10.1093/jscr/rjaf182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Accepted: 03/11/2025] [Indexed: 04/09/2025] Open
Abstract
A 35-year-old woman presented with severe lower abdominal pain, a history of intermittent abdominal discomfort, increased abdominal girth, and weight loss over the past year. Physical examination revealed a tender abdomen with guarding and a palpable lower abdominal mass. Initial ultrasound suggested a torsed adnexal mass, prompting emergency laparotomy, which revealed a torsed, infarcted wandering spleen. Splenectomy was performed, and the patient recovered well with appropriate post-splenectomy care. Wandering spleen is a rare condition characterized by hypermobility and ectopic positioning of the spleen, often asymptomatic but potentially presenting emergently with torsion and infarction. Diagnosis is challenging, particularly in resource-limited settings, but imaging such as ultrasound or computed tomography (CT) scans can aid in identification. Surgical intervention, including splenopexy or splenectomy, is essential in acute cases.
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Affiliation(s)
- Ashenafi A Feleke
- Department of Surgery, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Muluken A Zemariam
- Department of Surgery, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Suleiman A Belay
- School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Ayalkebet T Worku
- Department of Surgery, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Getachew S Yigezaw
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Nigat A Addis
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
| | - Eyasu F Yitina
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Maraki Street, Gondar City, Central Gondar Zone, PO Box 196, Gondar, Ethiopia
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Splenic Torsion in Heterotaxy Syndrome with Left Isomerism: A Case Report and Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12122920. [PMID: 36552927 PMCID: PMC9776906 DOI: 10.3390/diagnostics12122920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Splenic torsion is an unusual condition that results in congenital abnormality, especially in the visceral abnormal arrangement. We report the case of an 8.5-year-old boy with features in the right upper quadrant. Radiological investigations revealed heterotaxy syndrome with polysplenia and a hypodense tumor in the right upper quadrant adjacent to several spleens. We initially treated it as an intra-abdominal tumor. Laparoscopy was performed to check the tumor condition and revealed a congestive tumor located in the abdomen of the right upper quadrant below the central liver, which was suspected to be a torsion spleen without attaching ligaments. Laparoscopic splenectomy was successfully carried out without complications. The pathological report shows splenic tissue with hemorrhagic infarction. Physicians should be vigilant of the differential diagnosis of the acute abdomen in adolescents.
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Ikeda T, Hosokawa T, Goto S, Hashimoto M, Nagasaki E, Masuko T. Successful laparoscopic-assisted partial splenectomy and splenopexy with umbilical approach to wandering spleen with an enlarged cyst in a pediatric patient. J Surg Case Rep 2022; 2022:rjac483. [PMID: 36285167 PMCID: PMC9584345 DOI: 10.1093/jscr/rjac483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/27/2022] [Indexed: 11/12/2022] Open
Abstract
A 10-year-old girl with a wandering spleen with an enlarged cyst was successfully treated by laparoscopic-assisted partial splenectomy and splenopexy. The patient visited our hospital with a complaint of a lower abdominal mass. Abdominal computed tomography showed malposition of the spleen and the presence of a 10 cm diameter splenic cyst (SC) in the lower pole. In surgery, the navel was opened with an inverted Y-shaped incision. The SC was punctured and aspirated the contents of the cyst, the migrating spleen was pulled out of navel and the partial splenectomy was done. The residual spleen was laparoscopically fixed by creating an extraperitoneal pocket. Pathologically, the cyst was covered with a vitrified fibrotic capsule and was diagnosed as a pseudocyst. We considered it a traumatic cyst. The postoperative course was uneventful. This minimally invasive laparoscopic procedure was feasible and effective for treating wandering spleen with a large SC in a pediatric patient.
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Affiliation(s)
- Taro Ikeda
- Correspondence address. Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan. Tel: +81-48-647-2111; Fax: +81-48-658-5800; E-mail:
| | - Takashi Hosokawa
- Department of Pediatric Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shunpei Goto
- Department of Pediatric Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Makoto Hashimoto
- Department of Pediatric Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Eri Nagasaki
- Department of Pediatric Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takayuki Masuko
- Department of Pediatric Surgery, Ibaraki Children’s Hospital, Ibaraki, Japan
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Pappas TN. The First 40 Years of Gastrojejunostomy: From Billroth to Murphy to Mayo. ANNALS OF SURGERY OPEN 2022; 3:e200. [PMID: 37601146 PMCID: PMC10431371 DOI: 10.1097/as9.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022] Open
Abstract
In the early era of therapeutic laparotomy, surgeons developed operations where the extirpation of pathology only required simple ligation of blood supply, detachment of diseased organs or drainage of infection. In 1881, when sutured anastomosis was in its infancy, a surgeon at Billroth's clinic in Vienna, Anton Wolfler, performed the first successful gastrojejunostomy to treat gastric outlet obstruction. The patient was a 38-year-old male who presented weak and emaciated with an obstructing stomach cancer. After Dr Wolfler's sutured gastrojejunostomy, the patient recovered without complication and was able to eat by mouth. Over the next 40 years, surgeons around the world explored variations in the technique of this operation until it was used in common practice for the management of gastric outlet obstruction. During that same era, gastrojejunostomy severed as a testing ground for sutured anastomosis, which became the accepted method of enteric anastomosis. This article will review the early history of gastrojejunostomy, its origination and the European and American innovators who created modifications of this life-saving operation. The importance that gastrojejunostomy had in the evolution of sutured enteric anastomosis will be highlighted.
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Affiliation(s)
- Theodore N. Pappas
- From the Department of Surgery, Duke University School of Medicine, Durham, NC
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Sun C, Li SL. Successful treatment of floating splenic volvulus: Two case reports and a literature review. World J Clin Cases 2021; 9:8812-8819. [PMID: 34734060 PMCID: PMC8546827 DOI: 10.12998/wjcc.v9.i29.8812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Chi Sun
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Suo-Lin Li
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
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Bough GM, Gargan KE, Cleeve SJ, Farrell S. Diagnosis, management and outcome of splenic torsion; a systematic review of published studies. Surgeon 2021; 20:e296-e305. [PMID: 34666939 DOI: 10.1016/j.surge.2021.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/17/2021] [Accepted: 08/22/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management. METHODS A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution. RESULTS 408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis. DISCUSSION Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.
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Affiliation(s)
- Georgina M Bough
- Department of Paediatric Surgery, The Royal London Hospital, London, UK; Department of Paediatric Surgery, Addenbrookes Hospital, Cambridge, UK.
| | | | - Stewart J Cleeve
- Department of Paediatric Surgery, The Royal London Hospital, London, UK
| | - Stephen Farrell
- Department of Paediatric Surgery, Addenbrookes Hospital, Cambridge, UK
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Torsion of the wandering spleen as an abdominal emergency: a case report. BMC Surg 2021; 21:289. [PMID: 34107944 PMCID: PMC8190838 DOI: 10.1186/s12893-021-01289-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/06/2021] [Indexed: 01/19/2023] Open
Abstract
Background Wandering spleen is a rare clinical entity with a less than 0.2% reporting incidence rate. In this case, the spleen is present abnormally in the abdominal or pelvic cavity instead of its normal anatomical location. The aetiology is either congenital or acquired. The condition is caused by the absence or maldevelopment of the spleen's suspensory ligaments, which holds the spleen static in the left hypochondrium. Case presentation A 27-year-old female patient presented to the emergency department with complaints of abdominal pain, fever, nausea, vomiting, and constipation for three days. A palpable movable mass was found during the physical examination, and torsion of the wandering spleen’s pedicle was confirmed by CT scan. Open splenectomy was performed, and the patient was recovered uneventfully. Conclusion Even though ectopic spleen is a rare disease, clinicians should be aware of its incidence. Early diagnosis in the case of an acute abdomen is vital for the preservation of the spleen. Patients presented with acute abdomen and absence of splenic shadow under left hemidiaphragm should be suspected, and further radiological investigation will confirm the diagnosis. Surgery is the gold standard for wandering spleen with either splenopexy or splenectomy, depending on the spleen's condition during surgery.
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Barabino M, Luigiano C, Pellicano R, Giovenzana M, Santambrogio R, Pisani A, Ierardi AM, Palamara MA, Consolo P, Giacobbe G, Fagoonee S, Eusebi LH, Opocher E. "Wandering spleen" as a rare cause of recurrent abdominal pain: a systematic review. MINERVA CHIR 2019; 74:359-363. [PMID: 30019879 DOI: 10.23736/s0026-4733.18.07841-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Matteo Barabino
- Unit of Hepatobiliary, Pancreatic, and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | | | | | - Marco Giovenzana
- Unit of Hepatobiliary, Pancreatic, and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | - Roberto Santambrogio
- Unit of Hepatobiliary, Pancreatic, and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | - Andrea Pisani
- Unit of Hepatobiliary, Pancreatic, and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | | | | | - Pierluigi Consolo
- Unit of Digestive Endoscopy, G. Martino Hospital, University of Messina, Messina, Italy
| | - Giuseppa Giacobbe
- Unit of Digestive Endoscopy, G. Martino Hospital, University of Messina, Messina, Italy
| | - Sharmila Fagoonee
- Institute for Biostructures and Bioimages, Center for Molecular Biotechnology, National Research Council, University of Turin, Turin, Italy
| | - Leonardo H Eusebi
- Department of Medical and Surgical Sciences, S. Orsola University Hospital, Bologna, Italy
| | - Enrico Opocher
- Unit of Hepatobiliary, Pancreatic, and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Milan, Italy
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Memari M, Nikzad M, Nikzad H, Taherian A. Wandering spleen in an adult man associated with the horseshoe kidney. ARCHIVES OF TRAUMA RESEARCH 2013; 2:129-32. [PMID: 24693523 PMCID: PMC3950916 DOI: 10.5812/atr.9332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 05/20/2013] [Accepted: 05/29/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A wandering spleen occurs when there is a laxity of the ligaments that fix the spleen in its normal anatomical position. CASE PRESENTATION This is a case report of a wandering spleen with horseshoe kidney in a 29-year-old male admitted with acute lower abdominal pain and vomiting to emergency department of Shariati hospital in Isfahan province. Sonographic examination showed a homogeneous 21 × 15 × 8 cm mass in the lower part of the abdomen and pelvis associated with a horseshoe kidney. Laparotomy confirmed the clinical and ultrasound findings. CONCLUSIONS The association of horseshoe kidney with a wandering spleen in this case may be due to an embryological anomaly.
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Affiliation(s)
| | - Mohsen Nikzad
- Faculty of Medicine, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Hossein Nikzad
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
- Corresponding author: Hossein Nikzad, Anatomical Sciences Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel: +98-3615550480, Fax: +98-3615550480., E-mail:
| | - Aliakbar Taherian
- Anatomical Sciences Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
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Abstract
INTRODUCTION Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted to hospital because of severe abdominal pain, vomiting or obstipation. METHODS This article aims to provide a historical overview of wandering spleen diagnostics and surgical treatment supplemented with an analyses of articles on wandering spleen included in the PubMed database. RESULTS One of the first clinical descriptions of a wandering spleen was written by Józef Dietl in 1854. The next years of vital importance are 1877 when A. Martin conducted the first splenectomy and in 1895 when Ludwik Rydygier carried out the first splenopexy to immobilize a wandering spleen. Since that time various techniques of splenectomy and splenopexy have been developed. CONCLUSIONS Introducing medical technologies was a watershed in the development and treatment of wandering spleen, which is confirmed by the PubMed database. Despite the increased number of publications medical literature shows that a wandering spleen still remains a misdiagnosed condition, especially among children.
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Affiliation(s)
- Anita Magowska
- History of Medical Sciences, Poznan University of Medical Sciences, ul. Przybyszewskiego 37A, 61-111, Poznan, Poland.
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Anyfantakis D, Kastanakis M, Katsougris N, Papadomichelakis A, Petrakis G, Bobolakis E. Acute torsion of a wandering spleen in a post-partum female: A case report. Int J Surg Case Rep 2013; 4:675-7. [PMID: 23792478 DOI: 10.1016/j.ijscr.2013.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/06/2013] [Accepted: 05/10/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Wandering spleen is a rare condition characterized by ectopic position of the spleen due to the absence or laxity of peritoneal ligaments that hold the organ within the left upper quadrant. Lower abdomen and pelvis are the most common locations of the wandering spleen. The disorder usually remains asymptomatic. PRESENTATION OF CASE We present a case of acute abdomen due to torsion of a wandering spleen in a primiparus, healthy female shortly after delivery. Diagnosis was based on ultrasonography and computed tomography and was confirmed later on surgery. Total splenectomy was performed successfully. DISCUSSION The rarity of the condition and the nonspecific clinical symptoms and signs make prompt diagnosis challenging. CONCLUSION Prompt recognition and intervention are necessary in order to minimize the risk of complications. For this reason physicians have to include the condition in the differential diagnosis of acute abdominal pain especially when they encounter females in a pregnancy or post-natal period.
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Soleimani M, Mehrabi A, Kashfi A, Fonouni H, Büchler MW, Kraus TW. Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature. Surg Today 2007; 37:261-9. [PMID: 17342372 DOI: 10.1007/s00595-006-3389-0] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 07/25/2006] [Indexed: 12/19/2022]
Abstract
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.
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Dawson JH, Roberts NG. Management of the wandering spleen. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1994; 64:441-4. [PMID: 8010910 DOI: 10.1111/j.1445-2197.1994.tb02249.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A case of torsion of a wandering spleen in an 8 year old girl is reported. The authors discuss the aetiology and management of this rare condition and review the literature. Wandering spleen is relatively more common in children than in adults. Under the age of 10 the sex distribution is even; over 10, females outnumber males by seven to one. In 66 children under 10 years, 50% of wandering spleens were lost through acute ischaemia. The authors recommend that early splenopexy replace conservative management.
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Affiliation(s)
- J H Dawson
- Department of General Surgery, Box Hill Hospital, Victoria, Australia
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