World Journal of Surgery

, Volume 32, Issue 1, pp 20–25

Laparoscopic Internal Marsupializaton for Large Nonparasitic Splenic Cysts: Effective Organ-Preserving Technique

Authors

  • Chinnusamy Palanivelu
    • Division of Surgical Gastroenterology, Department of SurgeryGEM Hospital
    • Division of Surgical Gastroenterology, Department of SurgeryGEM Hospital
  • Madhupalayam Velusamy Madankumar
    • Division of Surgical Gastroenterology, Department of SurgeryGEM Hospital
  • Suviraj James John
    • Division of Minimally Invasive Surgery, Department of SurgeryGEM Hospital
Article

DOI: 10.1007/s00268-007-9258-1

Cite this article as:
Palanivelu, C., Rangarajan, M., Madankumar, M.V. et al. World J Surg (2008) 32: 20. doi:10.1007/s00268-007-9258-1

Abstract

Background

Primary splenic cyst is a rare disease, and therefore there is no information regarding its optimal management. Most such cysts are classified as epithelial cysts. During the last few years, the laparoscopic approach has gained increasing acceptance in splenic surgery. We present our experience with the laparoscopic (organ-preserving) management of splenic cysts.

Methods

We managed 11 patients with large symptomatic nonparasitic splenic cysts from 1996 to 2006. All the patients had fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computed tomography. All patients were treated with either laparoscopic partial cystectomy or marsupialization.

Results

Seven patients had mesothelial cysts, two had epidermoid cysts, and two had pseudocysts. Nine patients did not have any problems or recurrence during an average follow-up of 29.5 months. Two patients had cyst recurrence after 14 months.

Conclusion

Laparoscopic organ-preserving surgery should be the goal of therapy in most cases. Total splenectomy is reserved for cases in which cyst excision cannot be done or most of the splenic tissue is replaced by the cyst. Plication of the cyst wall edges prevents the cyst walls from adhering and causing recurrence, as well as helping to control hemorrhage. Laparoscopic partial cystectomy/marsupialization is an acceptable procedure for the treatment of splenic cysts; and after short to mid-term follow-up, it seems that a reasonable rate of success is possible.

Splenic cysts are unusual in everyday surgical practice. The incidence of primary splenic cysts is 30% to 40%, and they are encountered more commonly in children and young adults [1]. Posttraumatic splenic cysts are also found. Most of the cysts are asymptomatic and are an incidental finding during abdominal ultrasonography (USG). The number of diagnosed splenic cysts seems to be rising because of the increased use of abdominal imaging techniques.

Primary splenic cysts are rare, and there is controversy regarding their optimal surgical management Laparotomy with splenectomy has been the technique of choice. During the last few years, the laparoscopic approach has gained increasing popularity in splenic surgery [2]. When minimally invasive surgery was introduced, laparoscopy was not considered a feasible method for the treatment of spleen diseases because of the risk of severe hemorrhage. However, because of the advances in surgical techniques and instrumentation, laparoscopic splenic surgery has rapidly developed into a standard procedure [3]. There is a trend towards more conservative surgery now with an aim to avoid postsplenectomy sequelae [4]. We present our experience with laparoscopic spleen-preserving management of a series of patients with large symptomatic nonparasitic splenic cysts.

Materials and methods

We managed 13 patients with large symptomatic splenic cysts in our institution between 1996 and 2006. Among them, two required splenectomy because the lesion was situated near the hilum and organ-preserving surgery was not possible; thus, they were excluded from the study. The other 11 patients (2 children, 9 adults) underwent organ-preserving laparoscopic procedures: 3 patients (initial experience) had near-total cystectomy; 5 patients had partial cystectomy (internal marsupialization); and 3 patients had marsupialization. Marsupialization was performed for the cysts that were difficult to approach.

The patients presented with the following findings: upper abdominal fullness (80%), dragging pain (16%), and a palpable mass in the left hypochondrium (21%) that moved with respiratory movements. Two patients had hiccoughs as well. None of the patients had a history of abdominal trauma.

Endoscopic examination of the upper gastrointestinal tract did not reveal any significant findings. All laboratory tests were normal, and serologic tests gave no evidence of parasitic infection with Echinococcus granulosus. The bleeding and clotting times were normal in all cases. A complete blood profile showed no signs of hypersplenism, and peripheral blood smears did not reveal any evidence of hematologic disorders.

Chest radiography showed a mild elevation of the left hemidiaphragm in five patients. USG of the upper abdomen showed a cystic lesion (size varying in each patient) with irregular echoic patterns. Computed tomography (CT) confirmed the exact position of the cyst and demonstrated displacement and volume of the remaining splenic parenchyma. Two patients had calcifications in the cyst wall.

Laparoscopy was planned for all the patients after confirming the diagnosis of splenic cyst. All the adult patients received Pneumovac 23 (0.5 ml vaccine) (Aventis) 3 weeks before surgery; and the pediatric patients were administered Hibrex 0.5 ml (Glaxo SmithKline) and meningococcal vaccine 0.5 ml intramuscularly.

The patients were adequately prepared and posted for diagnostic laparoscopy. Pneumoperitoneum was established by Veress needle, and pressure was maintained at 13 mmHg. The patient was positioned supine, in a 45° right lateral tilt with the left hand supported. Surgeon, camera surgeon, and an assistant surgeon stood to the right of the patient and the scrub nurse on the left side. The monitor was placed on the left of the patient, directly opposite the operating surgeon. Four ports were used:
  • - 10-mm port 2 cm above the umbilicus for the laparoscope

  • - 5-mm port in the left lumbar area, along the mid-clavicular line for right-hand working

  • - 5-mm port in the left hypochondrium, along the left mid-clavicular line for left-hand working

  • - 5-mm port in the midline, 3 cm below the umbilicus, for stomach/colon retraction

At laparoscopy, the huge splenic cysts were revealed, the location being different in each case. First, the cyst was decompressed with intraoperative drainage of the fluid by introducing a suction nozzle directly into the cyst after puncturing it (Fig. 1). Most of the cysts contained hemorrhagic fluid (Fig. 2), and about 600 to 1000 ml was drained, resulting in partial collapse of the cyst. The cyst wall was then excised with harmonic shears, taking care to remove as much wall as possible (Fig. 3). The intrasplenic portion of the cyst was also excised in three patients, during the beginning of our experience (Fig. 4). In the two patients with intrasplenic cysts, a thin rim of splenic tissue surrounding the cyst was resected to expose the cyst, thereby facilitating cystectomy. The edges of the cut end of the cyst wall in these cases were plicated (oversewn) all around by placing continuous “locking” sutures using 2–0 Vicryl (Fig. 5). An argon plasma coagulator (APC) device was used to control small bleeding points from the splenic surface (Fig. 6). Drainage tubes were kept in place for all patients. The specimen was extracted through an enlarged 10-mm port and sent for histologic examination.
https://static-content.springer.com/image/art%3A10.1007%2Fs00268-007-9258-1/MediaObjects/268_2007_9258_Fig1_HTML.jpg
Fig. 1

Collapse of a superficial splenic cyst after suctioning the fluid

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Fig. 2

Hemorrhagic fluid in the cyst

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Fig. 3

Cystectomy in progress using ultrasonic shears

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Fig. 4

Appearance of the spleen after total cystectomy

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Fig. 5

Plicating the cut edges of the cyst

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Fig. 6

APC being used for hemostasis of surface hemorrhage

Results

There were a total of 11 patients (7 males, 4 females) with an age range of 8 to 67 years. Operating time was in the range of 62 to 85 minutes; and there were no conversions, morbidity, or mortality. Blood loss was not significant. Hospital stay was in the range of 3 to 6 days (mean 4.5 days). The two patients who were discharged on postoperative day (POD) 6 had had fluid collecting in the drainage tube for 4 PODs. Eight patients (72%) had hemorrhagic fluid in the cysts. The histologic type, the size, and the location of the cysts are summarized in Table 1.
Table 1

Results

Patient no.

Age (years)

Sex

Location

Size (cm)

Procedure

Histology

1

43

M

Intrasplenic

7.4 × 6.0

Partial cystectomy

Mesothelial

2

65

M

Subcapsular

8.0 × 6.3

Near-total cystectomy

Epidermoid

3

9

F

Intrasplenic

7.0 × 6.2

Partial cystectomy

Mesothelial

4

23

F

Upper pole, posterior

10.4 × 6.8

Marsupialization

Pseudocyst

5

26

M

Upper pole, anterior

9.0 × 8.3

Partial cystectomy

Mesothelial

6

8

M

Lower pole, anterior

8.4 × 7.0

Marsupialization

Epidermoid

7

54

F

Subcapsular

8.6 × 8.4

Near-total cystectomy

Mesothelial

8

67

M

Lower pole, anterior

9.2 × 5.0

Near-total cystectomy

Pseudocyst

9

49

M

Subcapsular

10.0 × 8.2

Partial cystectomy

Mesothelial

10

38

F

Upper pole, posterior

10.8 × 6.8

Marsupialization

Mesothelial

11

28

M

Subcapsular

7.4 × 7.0

Partial cystectomy

Epidermoid

The patients were followed up for 12 to 47 months (average 29.5 months). USG was done for all cases during each follow-up. Ten patients did not have any problems or recurrence during follow-up. Two patients (with mesothelial cysts) had cyst recurrence after 14 months. Because the cyst size was 4 to 6 cm and patients were asymptomatic, no active intervention is planned and they are being closely followed.

Mesothelial cysts were the most common type (54.5%) type found, epidermoid cysts were present in 27.3% patients, and 18.2% had pseudocysts. Microscopically, the mesothelial cysts showed a fibrocollagenous cyst wall lined by cuboidal to low columnar nonciliated mesothelial-like epithelium. Epidermoid cysts had features of dense fibrous tissue covered by stratified squamous or cuboid epithelium. The pseudocysts were characterized by the presence of densely cytopenic connective tissue with no epithelial lining. There was no evidence of malignancy in any case.

Discussion

Splenic cysts do not produce any specific symptoms until they reach a significant size. Occasionally, splenic cysts present with complications, such as infection, rupture, or hemorrhage. Malignant degeneration of primary splenic cysts is generally not thought to occur, but it has been described and in such cases a partial splenectomy is ideal [5]. In our series, nine patients had complicated cysts (infection in one, hemorrhage in eight). Also, two patients had pseudocysts with no prior history of trauma. The reason for hemorrhage in these cysts is not known, as trauma is the most common cause, although it could not be clinically elicited.

The entity splenic pseudocyst is somewhat confusing. Morgenstern believed that it does not exist, as the epithelial lining can be identified, provided the entire cyst wall is sectioned and examined [1]. Our pathologist had analyzed 10 blocks/section in each specimen and failed to identify an epithelial lining in two cases. In all our patients, the cysts were of significant size and had produced clinical manifestations. USG and CT imaging gave us most of the necessary information, such as the morphology of the cyst, composition of the cystic fluid, location in the spleen, position of the cyst, and its relation with the surrounding tissues. We are of the opinion that because of the increased risk of complications associated with splenic cysts >5 cm surgery is the treatment of choice. Conservative options such as percutaneous aspiration or sclerosis do not result in long-term control [6]. Various surgical procedures have been described based on the patient’s age and the size, location, and nature of the cyst. Earlier, the classic approach to splenic cysts was laparotomy and complete splenectomy. Today, the optimal treatment options are partial splenectomy (preserving >25%), total cystectomy, marsupialization or cyst unroofing, and use of a TA stapler with access by open laparotomy or laparoscopy. There are several studies to support each technique [79].

Splenectomy is indicated for very large cysts, those located in the splenic hilum, or those covered completely by splenic parenchyma (intrasplenic cyst), or if there are multiple cysts (polycystic), using the open or laparoscopic approach [10] Based on anatomic and technical findings, many authors, especially in the pediatric literature, have reported excellent results with partial splenectomy of splenic nonparasitic cysts [11, 12]. A more conservative option could be simple partial cystectomy (unroofing) of the cyst. Laparoscopic unroofing of a splenic cyst was introduced by Salky et al in 1985 [13]. However, it has yet to be determined how much of the cyst wall should be resected and whether unroofing should be partial or radical. Nevertheless, simple unroofing of the cyst wall offers a valid alternative to partial spleen resection or splenectomy, the only problem being cyst recurrence. The exact incidence following laparoscopic unroofing of the cyst wall is not known, although 22% was cited in a large study [14].

In most cases residual cysts are small and asymptomatic and need no further treatment. This compares favorably with our series, where the recurrence rate was 18%. The two patients who had recurrence after 14 months are being followed up as they are asymptomatic at present. Both these patients underwent marsupialization, further confirming the fact that this procedure is associated with higher recurrence. Our follow-up is only short-term, and long-term recurrence rate can only be determined at a later date. To minimize the risk of recurrence, the largest possible amount of the cyst wall was resected.

At the beginning of our laparoscopic experience, we performed total cystectomy in two cases, following which we were satisfied with partial cystectomy/marsupialization. In most cases, resection of the cyst wall was terminated when the unaffected splenic parenchyma was reached. Because of the softness of the spleen, this may result in cyst wall collapse and recurrence. The edges of the excised cyst were plicated to prevent collapse of the cyst wall. This type of marsupialization was called “internal marsupialization” by Morgenstern [1]. He also stated that the word “decapsulation” is a misnomer. Some authors also recommend suturing an omentum plug into the remaining cavity [15], as we did in our earlier cases. This technique, combined with APC application on the cut edges of the cyst provided excellent control of hemorrhage in all of our patients.

Advances in operative techniques such as splenorrhaphy with resorbable mesh; hemostasis with fibrin glue, oxidized cellulose, or APC; radiofrequency ablation; and stapler techniques have made spleen-preserving procedures safe and feasible [16, 17]. As far as our understanding of the published literature, no final judgment can be made as to the choice of an optimal surgical technique, and there are no randomized control trials comparing the various techniques in the literature.

According to a recent study on long-term outcome of splenic cysts, it was concluded that for patients with recurrent or suspected primary splenic cysts laparoscopic partial splenectomy is preferable [5]. Laparoscopic partial splenectomy as a treatment option has been well described in the literature and has the advantage of complete cyst removal with preservation of the spleen as well [1]. Table 2 shows the results of recent large studies published in the literature. Based on our experience, laparoscopic partial cystectomy seems to be effective in the management of nonparasitic splenic cysts if organ-preserving surgery is chosen. After a short- to mid-term follow-up, it seems that laparoscopic organ-preserving procedures have a reasonably high rate of success. Uranues et al. described laparoscopic partial splenectomy for 20 patients with cysts, among whom there were two conversions and two postoperative complications, and one patient required blood transfusions [18]. There were no conversions, postoperative complications, or blood transfusions in our series, showing that partial splenectomy is more technically demanding and probably associated with more morbidity, especially for the inexperienced surgeon. The only limitation of organ-preserving procedures is in the case of a rare malignant cyst, where it may be inadvisable to preserve the spleen. In a study of open and laparoscopic surgery for splenic cysts, Gianom et al. concluded that open partial splenectomy and laparoscopic cyst wall unroofing are both effective tools in the management of splenic nonparasitic cysts [19]. They went on to comment that surgeons must master both techniques as nowadays spleen-preserving techniques should be attempted in every case of a splenic nonparasitic cyst.
Table 2

Summary of published literature

Study

No. of patients

Cyst diameter (cm)

Laparoscopic procedures

Complication (no. of patients)

Recurrence (no. of patients)

Morgenstern [1]

23

1–25

Open partial splenectomy: 14 cases Total splenectomy: 4 cases (1 lap) Decapsulation: 3 cases (2 lap)

NA

2 (1 case recurrence after alcohol injection)

Uranues [18]

20

Partial splenectomy (2 conversions)

2

Mertens [5]

15

4.5–17.0

Spleen-preserving: 6 cases

3

Palanivelu

11

5.0–10.8

Partial splenectomy: 8 Marsupialization: 3

2

Gianom [19]

7

Partial splenectomy: 2 cases Cyst wall unroofing: 4 cases

1

Reck [20]

3

8–20

Partial splenectomy

1

Heintz [21]

2

7–10

Spleen-preserving: 2 cases

1

Feliciotti [22]

2

8–11

Spleen-preserving: 1 case

Unless specified, all procedures were laparoscopic

Conclusions

The laparoscopic management of splenic cysts offers the benefits of minimally invasive surgery: minimal postoperative pain, faster recovery, shorter hospital stay, and reduced morbidity and length of recovery. At present, splenectomy should be performed only for cysts with unsure etiology or as a salvage procedure and when spleen-preserving techniques are technically not feasible.

Copyright information

© Société Internationale de Chirurgie 2007