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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 78-80

Incidental finding of multiple splenosis in patient who had ventral hernia repair


Department of General Surgery, Moolchand Medicity Hospital, New Delhi, India

Date of Web Publication30-May-2019

Correspondence Address:
Dr. Mohit Bhatia
1, Bank Colony, Opposite Old Sessions Courts, Ambala City - 134003, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_32_18

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  Abstract 


Splenosis in itself is a rare condition and its presence in a patient with ventral hernia can pose an unusual challenge. Ventral incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various mesh repairs and laparoscopic repair. Splenosis is a benign condition caused by an ectopic autotransplantation of splenic tissues after splenic trauma or surgery. It is usually diagnosed accidentally and usually occurs within the abdominal and pelvic cavity. We report a female patient who had undergone splenectomy for abdominal trauma at the age of 12 years and was diagnosed as a case of abdominal splenosis at the age of 47 years on laparoscopy done for paraumbilical incisional hernia. This case report intends to share some important aspects of ventral hernia and splenosis and the approach followed in the repair of ventral hernia in our case.

Keywords: Laparoscopy, mesh repair, splenectomy, splenosis, ventral hernia


How to cite this article:
Goel P, Bhatia M, Ambekar S. Incidental finding of multiple splenosis in patient who had ventral hernia repair. Arch Int Surg 2018;8:78-80

How to cite this URL:
Goel P, Bhatia M, Ambekar S. Incidental finding of multiple splenosis in patient who had ventral hernia repair. Arch Int Surg [serial online] 2018 [cited 2019 Oct 18];8:78-80. Available from: http://www.archintsurg.org/text.asp?2018/8/2/78/259458




  Introduction Top


The presence of splenosis in varied clinical scenario can pose an unusual challenge to the operating surgeon. The true incidence of this rare condition is unknown, because splenosis is usually an incidental finding at imaging or surgery,[1] and in the literature, we could not find any data throwing light on the repair of ventral hernia in the presence of splenosis. We report a rare case of the therapeutic approach followed in the repair of paraumbilical hernia in a 47-year-old female patient incidentally diagnosed as a case of abdominal splenosis on laparoscopy done for hernia.


  Case History Top


A 47-year-old female patient presented to us with a moderately sized (6 × 6 cm defect), symptomatic paraumbilical hernia. The patient had undergone exploratory laparotomy at the age of 12 years for abdominal trauma after a road traffic accident leading to splenectomy as a life-saving procedure, following which she had recovered well. Presently, the patient was planned for a laparoscopic repair of paraumbilical hernia. Preoperative biochemical investigations (complete blood count, liver function test, kidney function test, and blood sugar) were within normal limits. Considering the scar of the previous laparotomy, an open technique through the right hypochondrium was used for creating pneumoperitoneum. On entering the abdomen, laparoscopy revealed paraumbilical hernial defect with omentum as its content and small to moderate sized multiple reddish blue masses all over the anterior abdominal wall and in the omental fat [Figure 1] and [Figure 2]. Histological examination of these masses had confirmed splenosis postoperatively.
Figure 1: Incidental finding of mass (splenosis) along with hernia content

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Figure 2: Hernia content adjacent to the splenosis

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Intraoperatively, the paraumbilical defect was subjected to further adhesiolysis, and all the hernial contents were reduced; however, the dilemma occurred about doing an intraperitoneal onlay mesh (IPOM) repair since the area surrounding the hernial defect was studded with multiple reddish blue masses as mentioned above. To avoid disintegration of these masses and consequent bleeding, we planned to abandon further laparoscopic intervention and performed an open hernia mesh repair. Instead of the parietex composite mesh that was supposed to be used for IPOM repair, we used a polypropylene mesh for open hernia repair. We did not do any therapeutic procedure for splenosis. The patient recovered well after surgery.


  Discussion Top


The repair of ventral hernia in the presence of splenosis can pose an unusual challenge to the operating surgeon depending on whether splenosis is an incidental diagnosis at laparoscopy or a definitive diagnosis preoperatively. This discussion will focus on some important aspects of ventral hernia and splenosis, the definitive preoperative versus incidental diagnosis of the latter, and the surgical approach followed in repair of ventral hernia in our case.

Ventral incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various prosthetic mesh repairs and laparoscopic repair. Prosthetic material may be placed as an onlay patch to buttress a tissue repair, interposed between the fascial defect, sandwiched between tissue planes, or put in an intraperitoneal position.[2] Laparoscopic ventral hernia repair is being used with increasing frequency in everyday surgical practice.[3] But it goes without saying that this approach has to be modified in certain coexistent conditions; the one encountered in our case was splenosis.

Splenosis is an uncommon benign condition resulting from heterotopic autotransplantation of splenic tissues onto exposed vascularized intra- and extraperitoneal surfaces following splenic trauma and surgeries. Generally, the splenic implants are numerous and are located within the peritoneal cavity; however, extra-abdominal splenosis does occur. The implants are rarely clinically significant and are incidental findings at autopsy or at abdominal operation, although they can seldom present as a vague abdominal or testicular pain, intestinal obstruction from adhesions, gastrointestinal bleeding, and spontaneous rupture. When present as an incidental imaging mass, it has been reported on to mimic renal, adrenal, or abdominal tumors, accessory spleens, endometriosis, hemangiomas, metastasis, lymphoma, and ectopic testicles.

Any incidental finding of splenosis during an operation for another indication should be sent for histopathology examination.[4] The therapeutic approach followed in the management of various conditions in the presence of splenosis may alter depending on accurate preoperative versus incidental diagnosis of the latter. Therefore, a high index of suspicion should be maintained for the diagnosis of splenosis. Nuclear scintigraphy using Technetium-99m heat-damaged erythrocytes (red blood cell) or Indium-111-labeled platelets is more sensitive and specific for splenic uptake, making these tests the current diagnostic tools of choice.

Splenosis does not require any additional treatment if the patient does not present with symptoms. Minimally invasive surgery such as laparoscopy is the ideal treatment for patients with symptomatic splenosis.[5]

We could not find previous experience (published and unpublished) regarding how to proceed with multiple splenic implants present at the site of recommended mesh placement while performing a laparoscopic IPOM repair for a ventral hernia, that is, either to place the mesh over these implants or to first excise the splenic implants and then place the mesh over the hernial defect, or to abandon the laparoscopy and rather perform an open hernia mesh repair. Placing the mesh over these implants may not be feasible due to the size and location of the implants, and excision of these implants to facilitate mesh placement may lead to significant bleeding and disintegration of these implants leading to further seeding of the peritoneal cavity with splenic tissue. Also, as already mentioned, no treatment is indicated for asymptomatic splenosis. Due to these reasons, in our case we abandoned laparoscopy and performed an open hernia mesh repair. It is also obvious that the therapeutic approach as in our case may also alter with accurate preoperative diagnosis of splenosis and in symptomatic versus asymptomatic splenosis.

Anomalies like splenosis may present to us in varied clinical scenario in future and we need appropriate documentation of these cases and research work to deal with these kinds of cases in future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta K, Ahluwalia A, Jain T, Saggar K. Abdominal splenosis mimicking peritoneal deposits – A case report. Pan Afr Med J 2014;17:269.  Back to cited text no. 1
    
2.
Towsend C, Beauchamp R, Evers B, editors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 18th ed. Philadelphia, PA: Saunders Elsevier; 2008. p. 1173.  Back to cited text no. 2
    
3.
Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas A. Current trends in laparoscopic ventral hernia repair. JSLS 2015;19.doi: 10.4293/JSLS.2015.00048.  Back to cited text no. 3
    
4.
Smolar M, Lucan J, Dedinska I, Hosala M, Laca L. Splenosis as a rare cause of abdominal pain. Rozhl Chir 2016;95:168-71.  Back to cited text no. 4
    
5.
Park SY, Kim JY, Lee JH, Choi JS, Ko JH, Park SH. Laparoscopic management of pelvic splenosis. Obstet Gynecol Sci 2014;57:89-91.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
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Case History
Discussion
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