Laparoscopic marsupialization of a giant nonparasitic splenic cyst

MAY 24, 2007

 

Mark Takata, MD
Fellow in Laparoscopic Surgery
Department of Surgery
University of California San Francisco
San Francisco, CA

Christine Rader, MD
Resident
Department of Surgery
University of Connecticut Health Center
Farmington, CT

Orlando Kirton, MD,
The Ludwig J. Pyrtek, MD, Chair in Surgery
Director of Surgery and Chief, Division of General Surgery
Hartford Hospital
Hartford, CT
Professor of Surgery
University of Connecticut School of Medicine
Farmington, CT

Laparoscopic marsupialization of a splenic cyst is a rewarding procedure, because it alleviates symptoms of pain, eliminates or minimizes many operative complications (such as bleeding or rupture), decreases morbidity, allows shorter hospital stays, and preserves splenic tissue. The authors provide a good review of the various classification systems used to categorize splenic cysts. Of these systems, I prefer Morgenstern’s classification. The authors also provide key technical details regarding laparoscopic marsupialization of a giant splenic cyst. Gradual aspiration of the cyst is important. I prefer to remove the free wall of the cyst with an ultrasonic dissector, as described by the authors.

Thomas Gadacz, MD
Series Guest Editor
Professor Emeritus
Department of Surgery
Medical College of Georgia
Augusta, GA

Splenic cysts are rare lesions that can be classified as primary (“true”) cysts or secondary (“false”) pseudocysts based on the presence or absence of an epithelial lining.1 The etiology of primary cysts can be parasitic or nonparasitic (congenital). Worldwide, Echinococcus infestation accounts for over 50% of all splenic cysts.2 In North America, secondary splenic cysts compose the majority of splenic cysts (75%) and are usually a late complication of previous abdominal trauma.3

Many treatment modalities have been described for nonparasitic splenic cysts to prevent or treat the rare but life-threatening complications of rupture, hemorrhage, and infection.4 Recently, minimally invasive procedures have been employed to preserve splenic parenchyma and decrease morbidity. We report a case of a giant nonparasitic splenic cyst that was managed successfully using laparoscopic marsupialization. We also discuss the etiology, classification, diagnosis, and management options for this uncommon disorder of the spleen.

Case report
A 27-year-old African American man came to our hospital because of mild abdominal discomfort and progressive abdominal fullness, which had started 3 weeks earlier. Approximately 3 years before his current presentation, he had experienced similar symptoms, and a large splenic cyst was identified and percutaneously drained. He had no other significant medical or surgical history and, despite being an avid soccer player, he reported no history of abdominal trauma. On physical examination, a large abdominal mass was easily palpable in the left upper quadrant, from which no tenderness was elicited.

An abdominal computed tomography (CT) scan confirmed a recurrent giant splenic cyst (Figure 1A). It was unilocular and measured 20 cm at its largest diameter. The remaining splenic parenchyma was displaced, forming the “beak sign.” The left kidney was shifted inferior and toward the midline (Figure 1B). Serologic testing for Echinococcus and Entamoeba histolytica were negative. Surgery was recommended because of the patient’s symptoms and the size and recurrent nature of the cyst. Two weeks before the operation, the patient received pneumococcal, Haemophilus influenzae, and meningococcal vaccines.

The patient was placed supine on the operating room table. After induction of general anesthesia, a roll was put under the left abdomen for anterior displacement of the spleen, and a Foley catheter was placed. Pneumoperitoneum was established after placing a 12-mm Hasson trocar in the supraumbilical position. A 30-degree, 10-mm laparoscope was inserted, and the abdomen was explored. A giant splenic cyst occupied the left upper quadrant and was moderately scarred to the anterior parietal peritoneum, presumably from the previous percutaneous drainage. A loop of small intestine was adhesed to the inferior border of the cyst, and the transverse colon was identified inferior to the mass.

A second trocar (10 mm) was placed in the left lower quadrant in the anterior axillary line, and a third trocar (5 mm) was placed 7 cm below the xiphoid process in the midline. The adhesions attaching the anterior portion of the cyst to the anterior parietal peritoneum were lysed using an ultrasonic dissector. The cyst was then decompressed by puncturing the anterior cyst wall with the dissector and removing the fluid in a controlled manner using a suction device. Over 3 L of dark brown fluid was drained from the cyst. Cytologic examination of the cyst fluid showed no malignant cells and no ova or parasites.

The cyst was widely unroofed by removing the anterior portion of the cyst wall with the ultrasonic dissector (Figure 2). Caution was taken to avoid the area of the cyst that was adherent to the loop of small intestine. The diameter of the cyst wall varied from a few millimeters to over 1 cm, and bleeding from the cyst wall was well controlled with the ultrasonic dissector. The excised cyst wall was then placed into a specimen bag and removed through the supraumbilical wound. The entire surgical procedure was completed in 1 hour and 10 minutes, and blood loss was minimal.

Final pathologic analysis of the cyst wall was consistent with a benign pseudocyst. The cyst wall did not have an epithelial lining and showed evidence of old hemorrhage (Figure 3). The cyst fluid specimen contained red blood cells, rare mesothelial elements, and cholesterol-like clefts consistent with hemorrhage or tissue infarction. The patient had an unremarkable postoperative course and was discharged home on postoperative day 2. He was back to his baseline activity level after 2 weeks. At 6-month follow-up, there were no signs of recurrence.

Discussion
There are two standard classification systems for splenic cysts, which are based predominantly on the characteristics of the cyst lining. Fowler described primary and secondary splenic cysts in a comprehensive review, while Martin provided a simplified clinical classification (Table).1,5 In 2002, Morgenstern questioned the validity of the two standard classification systems and provided a third method for categorizing nonparasitic splenic cysts (Table).6 His classification system focused on specific features that define the cyst as congenital, neoplastic, traumatic, or degenerative, rather than the presence or absence of an epithelial lining. Morgenstern postulated that most nonparasitic splenic cysts are congenital in origin and the history of antecedent trauma usually is incidental.

Most patients with splenic cysts experience minor, nonspecific symptoms related to the mass effect of the cyst.7 The diagnosis is made by taking a thorough patient history, conducting a physical examination, and evaluating ultrasonography and CT scan findings. Rupture, hemorrhage, and infection, which may be life-threatening, have been reported.4 Splenic cysts may become very large and are considered giant when they grow larger than 15 cm.6

Few surgeons in North America ever encounter nonparasitic splenic cysts, and the overwhelming majority of such cysts are thought to form as a result of blunt abdominal trauma. Many management strategies have been described. The primary goal of treatment is to resolve symptoms and prevent complications. The secondary goal is to preserve splenic parenchyma.

Nonoperative measures, such as observation, have been recommended for asymptomatic cysts smaller than 5 cm.6 The natural history of these small cysts is largely unknown, but if the imaging characteristics reveal regularity of the cyst wall, absence of a solid component, and a typical round shape, there is no indication for cyst removal. Spontaneous resolution of traumatic pseudocysts can occur. Surgical treatment usually is recommended for symptomatic patients or for those with cysts larger than 5 cm.

Percutaneous aspiration of the cyst has been described as a definitive treatment, but this option often leads to recurrence.4,8,9 Chemical agents, such as alcohol or tetracycline, have been percutaneously injected into the cyst cavity after aspiration in an attempt to collapse the cyst wall, promote fibrosis, and prevent reaccumulation; however, a case by Moir and colleagues showed that despite repeated attempts in the same patient, fluid reaccumulated and the cyst recurred.4 Wu and Kortbeek reported on four patients who underwent percutaneous drainage.9 Of these patients, three had a cyst recurrence and one died after accidental puncture of the colon. Therefore, percutaneous aspiration with or without sclerosis should not be considered a definitive treatment and may complicate subsequent surgical management.

Total splenectomy used to be the treatment of choice for nonparasitic splenic cysts. In 1867, the French surgeon Jules Pean performed a total splenectomy for a splenic cyst that he initially attempted to excise.10 However, due to the increasing awareness of the immunologic function of the spleen, organ-preserving techniques were developed to avoid the rare but life-threatening risk of overwhelming postsplenectomy sepsis. These salvage procedures ranged from cyst excision with partial splenectomy to cyst marsupialization with partial cyst wall excision.11-16 Splenic cyst marsupialization is a simpler procedure with less risk of major blood loss; however, this technique leaves a portion of the cyst wall contiguous with the preserved splenic parenchyma and there is a theoretical risk of recurrence. Wu and Kortbeek performed fenestration procedures in two patients, and both patients experienced recurrences.9 In contrast, Touloukian and colleagues performed six partial decapsulations of splenic cysts over a 10-year period without any recurrences.16

With the advent of advanced laparoscopy, previously standard open operations for the treatment of nonparasitic splenic cysts have been undertaken using a minimally invasive approach. This has resulted in effective treatment with less morbidity and postoperative pain, shorter hospital stays, better cosmesis, and a faster return to normal activities.17

In 1985, Salky and associates reported the first laparoscopic treatment of a splenic cyst by creating a “cyst-peritoneal window.”18 The cyst was decompressed with an aspiration needle, and a 5-mm scissors instrument with cautery was used to make a 3-cm window in the cyst wall. Over the past 15 years, a variety of laparoscopic techniques have been successful and have resulted in minimal risk of recurrence; these include laparoscopic total splenectomy, laparoscopic partial splenectomy, and laparoscopic marsupialization.19-25 Despite such successes, it is important to note that laparoscopic splenectomy still incurs a risk of postsplenectomy sepsis and that laparoscopic partial splenectomy is a technically challenging operation with a longer operative time and the potential for greater blood loss.

Many reports of laparoscopic marsupialization of nonparasitic splenic cysts have been reported. The most common technique includes removing a large portion of the cyst wall without dividing splenic parenchyma. A variety of instruments can be used to unroof the cyst, such as scissors with electrocautery, staplers, and other bipolar devices. Our instrument of choice is the ultrasonic dissector. Omentum can be used to pack the cyst cavity. Unless the cyst is infected, a closed drain is unnecessary if the cyst is unroofed adequately.

Despite our patient having no history of splenic injury, the pathology suggests that the etiology of this secondary cyst was previous trauma. Laparoscopic cyst marsupialization proved to be a safe and effective treatment for our patient and provided the benefits of a minimally invasive approach; however, longer follow-up is needed to assess the long-term success of this procedure.

Conclusion
A wide range of treatment modalities have been described for symptomatic or very large nonparasitic cysts of the spleen. Laparoscopic marsupialization is a safe and effective management strategy that has the advantages of a minimally invasive approach, including minimal blood loss, reduced postoperative pain, shorter hospitalization, improved cosmesis, and quicker return to normal activities. It also eliminates the risk of overwhelming postsplenectomy sepsis.

References
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