Dr Rafiq Simnani, MS and Dr Mubashir Shah, MS (senior residents) and Dr Omar J Shah (Professor) are from the Department of Surgical Gastroenterology, Sheri-Kashmir Institute of Medical Sciences Srinagar, Kashmir, India.
Address for Correspondence: Dr. Omar Javed Shah, Kral-Sangri, Brein, Nishat, Srinagar, Kashmir, India.
Tel.(Res): 0194-2463774 Tel.(O):0194-2401013-Ext-2189
Wandering spleen is a rare condition characterized by the absence of the normal ligamentous attachments of the spleen to the diaphragm, the retroperitoneum and the colon. Most reported cases present as an acute abdomen due to torsion of spleen with splenic infarction requiring splenectomy or are detected accidentally by various imaging techniques. We report a 2nd case of wandering spleen which presented as an abdominal lump.
A 9-year old girl presented with one month history of lump in the upper abdomen which was noticed by her, unaccompanied by any other significant complaint. Her general physical examination was unremarkable. On examination, her pulse was 80 beats/min and blood pressure was 110/70mmHg. The abdominal examination revealed a firm spleen - slightly tender on deep palpation – in right hypochondrium extending to the epigastric region. The mass was slightly mobile both transversely as well as vertically. Hemogram was normal for the age and no abnormal cells were seen on peripheral blood film. Ultrasound revealed the swelling as a homogenous mass about 6cm x 9cm in the right hypochondrium, separate from the liver with non-visualization of spleen. CT scan of the abdomen was performed which confirmed the USG findings of a homogenous mass with non visualization of spleen (Fig.A). A presumptive diagnosis of wandering spleen was made.
Hemogram was normal for the age and no abnormal cells were seen on peripheral blood film. Ultrasound revealed the swelling as a homogenous mass about 6cm x 9cm in the right hypochondrium, separate from the liver with non-visualization of spleen. CT scan of the abdomen was performed which confirmed the USG findings of a homogenous mass with non visualization of spleen (Fig.A). A presumptive diagnosis of wandering spleen was made.
Laparotomy was performed using an upper midline incision and the diagnosis was confirmed. The spleen was present in the right hypochondrium just below the porta hepatic crossing the midline between the liver and transverse colon with which it had many adhesions. The spleen was slightly distended, devoid of any peritoneal attachments and was viable without any signs of infarction. The spleen was mobilized from the right hypochondrium with its vascular pedicle and was fixed by multiple interrupted prolene sutures to the diaphragm and the anterior abdominal wall in the left hypochondrium. Postoperative period was uneventful and the patient was discharged on the 8th postoperative day.
Wandering spleen is a relatively rare condition; 57 children under the age of 10 years have been reported in English literature from 1960 to 199210. Wandering spleen has been reported as relatively uncommon in children but more common in women aged between 20 and 40 years3,4. Normally the lienorenal and gastrosplenic ligaments containing the splenic vessels and the tail of pancreas form the splenic pedicle. The spleen develops in the dorsal mesogastrium and with gut rotation it moves posterolaterally to the left. The dorsal mesogastrium fuses to the posterior abdominal wall and the left kidney, forming the lienorenal ligament containing the tail of pancreas and the splenic vessels. The failure of this fusion produces an abnormally long pedicle, which can predispose to both acute and chronic torsion. Torsion of a wandering spleen covers a clinical spectrum anywhere from asymptomatic to episodic mild abdominal pain to acute surgical abdomen. Torsion of the splenic pedicle can also lead to splenic vein thrombosis with subsequent gastric varices. Recurrent torsion causing arterial compromise can lead to infarction, fibrosis and eventually to functional asplenia accompanied by corresponding haematological changes.
The recommendations in the literature for the management of a wandering spleen are varied. There is a growing trend that early splenopexy should replace the conservative medical management10. Thus splenopexy is considered to be the optimal treatment for the non-infarcted uncomplicated spleen, where as splenectomy should be reserved for spleens, which remain infarcted even after detorsion. In our patient splenopexy was performed. Various techniques for splenopexy have been described:
In our case splenopexy was performed and spleen was secured in its normal position by suturing the spleen to the diaphragm and to the anterior abdominal wall. Although haemorrhage can occur following suturing of the spleen, but it seems that it is not a problem especially in children where the splenic capsule is thicker and more excusing. As in elective cases, splenopexy may still end in a splenectomy, so it is advisable to immunize the patient preoperatively against pneumococcus and H. influenzea at least two weeks before surgery so as to have good response to capsular antigens18. At present it is advisable to remove the non-viable spleen, while every effort should be made for splenic preservation, and there is no place for nonoperative management of wandering spleen.