Laparoscopic Management of Splenic Cyst

May 3, 2023 By Dr. Ashish Prasad

Laparoscopic Management of Splenic Cyst

Fig 1: CECT abdomen showing large upper pole splenic cyst.

Nonparasitic splenic cysts (NPSC) are rare in children (< 1000 cases). They are mostly asymptomatic and diagnosed incidentally. The most common symptom is abdominal pain. Their management is controversial asno definite guidelines for management have been prescribed. The Aims of management include -:

  • Spleen preservation
  • No recurrence
  • Minimal morbidity

A 10-year-old female child presented with intermittent complaints of mild left upper abdomen pain. She was evaluated and was diagnosed with a splenic cyst in the upper pole of the spleen of approximately 4X3.5 cm. She was closely followed up for 2 years with serial ultrasounds which showed progressive increase in the size of the cyst. Contrast enhanced computed tomogram (CECT) abdomen was done which showed an upper pole splenic cyst of size approximately 6X6X5 cm(Fig1). The cyst was involving the upper one third of the spleen. Because the child was symptomatic, and the size was increasing the child was planned for laparoscopic excision of the cyst. In view of the young age and to avoid the future risk of post splenectomy sepsis, the preferred option was splenic preservation surgery. Although technically challenging, laparoscopic surgery was planned to offer better cosmesis (Fig 2 port placement) and faster recovery.

To plan for partial splenectomy and to avoid the risk of hemorrhage, it was important to understand the vascular anatomy of the spleen. CECT angiogram revealed a separate upper polar vessel branching from the hilum and supplying the cystic area.

On laparoscopy, the large cystic mass was identified in the upper pole of the spleen(Fig3). A careful dissection of the hilum was done, and the upper polar branch splenic artery was identified and secured. This created a well-defined avascular plane which further facilitated the resection of the cyst with minimal blood loss.

Postoperatively, the child was stable and was discharged on second postoperative day. Histopathology was suggestive of epidermoid cyst of the spleen. After 2 years of follow up the child is asymptomatic and there is no recurrence of the cyst.

Congenital epidermoid cysts are rare and comprises 2.5% of all splenic cysts in childhood. Traditionally total splenectomy has been advocated for large cysts, but it has high incidence of post appendectomy sepsis. Partial splenectomy preserving at least at least 25% splenic parenchyma can prevent risk of pneumococcal bacteremia. Symptomatic patients and patients with cyst size more than 5 cm should be considered for surgical excision. Better understanding of the splenic segmental anatomy on imaging, need of splenic conservation, and advances in laparoscopic skills has made laparoscopic partial splenectomy a preferred treatment for splenic cysts. Laparoscopy although technically difficult and challenging, but with proper planning, is a safe and feasible option. It offers the advantage of minimal scars and early recovery.

Fig 2: Port Placement for laparoscopic splenectomy

Fig 3: Laparoscopic view of splenic cyst