Emergency laparoscopic splenectomy for torsion of wandering spleen in a geriatric patient: A case report

Highlights • Wandering spleen is rare in geriatric / elderly population.• Wandering spleen torsion may present as acute abdomen.• Imaging is needed to diagnose wandering spleen.• Imaging is essential in assessing splenic perfusion in case of torsion.• Non-viable spleen can be managed by laparoscopic splenectomy.


Presentation of case
We present the case of a 69-year-old female with WS torsion. She has complained of intermittent right lower quadrant abdominal pain since a month ago, and the pain worsened over the previous five days. She did not feel feverish and denied any gastrointestinal symptoms. She did not experience symptoms of urinary tract infection. No family history of connective tissue disease or malignancy was identified. She bore to two children three decades ago via vaginal deliveries. Last year, she underwent an open cystectomy for a symptomatic functional ovarian cyst.
Upon examination, we noted an intra-abdominal mass at the right lower quadrant of the abdomen, measuring roughly 10 cm × 7 cm. The smooth-surfaced mass was mobile, firm, and tender upon palpation. Other physical examinations were normal.
We proceeded with an abdominal ultrasonography, revealing a heterogeneous mass within the right abdominal cavity and absence of the spleen in its normal position (Fig. 1). The features pointed towards a WS. Thus, a contrast-enhanced computed tomographic (CT) scan of the abdomen was ordered, revealing a   12.4 cm × 3.5 cm × 7.4 cm ectopic spleen in the abdominal cavity occupying the right lumbar, iliac, and pelvic regions (Fig. 2). Subsequently, an abdominal CT angiography was performed, which demonstrated anticlockwise torsion of the elongated splenic vascular pedicle in a whirlpool disposition with splenic infarction characteristics (Fig. 3). Laboratory investigations of the patient were normal.
Soon after, an emergency exploratory laparoscopy was planned for the patient. Intra-operatively, the enlarged spleen was found in the right iliac fossa, displaced from the left hypochondrium (Fig. 4). The ptotic spleen had twisted anticlockwise around its elongated vascular pedicle and had no ligamentous attachments. Peri-splenic adhesions to the anterior abdominal wall were found. After adhesiolysis and detorsion, the spleen was deemed non-viable (Fig. 5).  Due to the intra-operative findings, a laparoscopic splenectomy was performed. From the subsequent histopathological examination of the spleen, extensive infarctions were inferred. The patient had an uneventful recovery. Vaccines including pneumococcal, meningococcal, and Haemophilus influenza type b were given to the patient post-operatively.

Discussion
A WS is also known as a displaced, ectopic, pelvic, or ptotic spleen [1,4,6,7,10,13,16]. Limited literature was found regarding this uncommon clinical entity, most including case reports and series [2]. Only around 500 cases of WS, which presented with abdominal pain, were reported [1,5,7]. The incidence rate of WS is 0.05%-0.5% [7,9,10,13]. The majority of the patients presenting with WS are children under 10 years old, especially those under 1 year old and young adults 20-40 years old, predominantly fertile females [1,4,6,9,10]. Statistically, WS is 6-7 times more common in females than males above 10 years old, but interestingly, there is a male predominance for those under 1 year old with the ratio of 2.5:1 [1,6,[9][10][11]. No gender predominance exists in the group comprising 1-to 10-year-olds [6]. The incidence is rare in the elderly population [5]. McFee et al. [5] discovered only 13 reported cases of WS with patients aged above 61 years, whereas our review yielded only three cases of WS involving older patients, of which only two were geriatric patients (> 65 years) and the other patient is a 64-year-old man [2,5,9]. Of the three case reports, one patient had thalassemia with splenomegaly on presentation [9]. In our case, the patient is a 69-year-old elderly woman without any comorbidity.
The pathophysiology of WS is characterised by the hypermobility of the spleen secondary to the absence or excessive laxity of the following primary splenic suspensory ligaments: gastrosplenic, splenorenal, splenocolic, splenophrenic, pancreaticosplenic, and pre-splenic folds [1,4,[6][7][8][9][10]13,16]. Due to the abnormality or absence of these ligaments, the splenic vascular pedicle in WS is susceptible to elongation and torsion [1,7,8,12]. The aetiology of WS is considered to be multifactorial and broadly divided into congenital anomalies and acquired conditions [1,6,7]. Congenital WS is secondary to the failure of fusion or incomplete fusion between the dorsal mesogastrium and posterior abdominal wall during foetal development [1,3,6,[8][9][10][11]. Acquired WS might be due to trauma or other underlying conditions, such as multiparity, splenomegaly, connective tissue diseases, and enlargement or absence of a kidney [1,2,[6][7][8][9]11]. Hormonal changes during pregnancy contribute to the increased laxity of the ligaments, which could explain the higher prevalence of WS in fertile females [7,8,10,11]. Our patient had two previous pregnancies, which might be a contributing factor.
Most patients with WS are asymptomatic [10]. Commonly, WS is detected incidentally in physical examination as an abdominal mass or in imaging studies performed for other conditions [3,[6][7][8][12][13][14]. Paediatric WS patients usually present with acute abdominal pain, whereas abdominal mass is the most common complaint in adult WS patients [6]. Clinical features of WS are usually attributed to the consequences of splenic vascular pedicle torsion [1,3,8,10]. Initially, the abdominal pain might be intermittent due to splenic congestion with recurrent torsion and spontaneous detorsion of the splenic vascular pedicle, but the patient might develop an acute abdomen secondary to acute torsion with splenic infarction or rupture [3,[7][8][9]11,13]. Chronic torsion of the splenic vascular pedicle and splenic sequestration resulted in splenomegaly and presented as an abdominal mass [6,8,10]. Other reported unspecific symptoms are nausea, vomiting, and fever [2,6,13]. Recurrent acute pancreatitis is a rare presentation and complication of WS, where the tail of the pancreas is twisted along with the splenic vascular pedicle at the splenic hilum, causing pancreatic inflammation [2,3,11]. Laboratory investigations might reveal thrombocytopenia or Howell-Jolly bodies in some patients due to sequestration, hypersplenism, or functional asplenia, but otherwise are non-specific in diagnosing WS [1,3,5,6,10]. Our patient experienced intermittent abdominal pain prior to presenting an acute abdomen, and her laboratory investigations were not significant.
Moreover, 65% of asymptomatic WS patients treated conservatively developed complications, such as torsion, compression of other organs, and susceptibility of the spleen to trauma; thus, nonoperative management is inadvisable [1,6,7]. A WS only accounted for 0.1%-2% of all splenectomies [1,2,4,5,[9][10][11]14]. Splenectomy is recommended for a non-viable spleen, splenic infarction or rupture, thrombosis, and splenomegaly [3,. Otherwise, splenic function preservation with splenopexy is preferred in uncomplicated WSs to avoid risk of an overwhelming post-splenectomy infection, especially in young patients [2,3,6,8,14]. Laparoscopic approaches are considered more ideal compared to laparotomies because they are less painful and have better cosmetics, lower wound complications, shorter hospitalisation, lesser morbidity, and earlier return to normal activity [1,8,17]. A laparoscopic approach is technically feasible because WS is relatively free from attachments and other organs [1]. However, Benevento et al. [17] discovered only five reported cases of a laparoscopic approach to WS, whereas our review yielded one case of laparoscopic splenectomy for WS [14]. In our case, an emergency laparoscopy was offered, and we decided on splenectomy, as the spleen was deemed non-viable even after detorsion. Intraoperatively, peri-splenic adhesions were encountered, possibly from recurrent ischaemic events of the spleen.

Conclusion
Ultimately, due to potentially life-threatening consequences and the rarity of such cases, a thorough history, detailed physical examination, and objective investigation are the pillars to attain a prompt diagnosis of WS for appropriate management to be conducted as soon as possible to minimise complications.

Ethical approval
Ethical approval has been exempted by our institution as this publication is a case report and not a randomized trial or a case series, provided that the patient gave her written consent both for operation and the publication of this case.

Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contribution
Novia A. Nastiti is the first author of this paper. Muhammad S. Niam is the surgeon in charge. Novia A. Nastiti and Muhammad S. Niam were involved in the surgery. Phong Jhiew Khoo is the corresponding author and performed critical revision to this paper. Novia A. Nastiti, Muhammad S. Niam, and Phong Jhiew Khoo participated in the writing of this paper. All authors read and approved the final manuscript.

Registration of research studies
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Provenance and peer review
Not commissioned, externally peer-reviewed.

Declaration of Competing Interest
No conflicts of interest.