Laparoscopic removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy.

The clinical success of therapeutic splenectomy for idiopathic thrombocytopenic purpura depends on the complete removal of all functional splenic tissue. Among reasons for poor response to splenectomy, failure to remove accessory spleens is mentioned. We present our experience with laparoscopic removal of accessory spleen from retroperitoneal space in a patient with relapse of ITP 30 years after classical splenectomy. A 45-year-old female patient underwent in 1972 classical splenectomy for ITP. Progressive decline in thrombocyte count was observed 7 years ago. Scintigraphy, CT, and ultrasound revealed residual splenic tissue. A laparoscopic approach was proposed. Four trocars placed along left costal margin were used. After dissection of all the adhesions behind the pancreatic tail deep in the retroperitoneal space a round structure 4 cm in diameter, macroscopically resembling splenic tissue, was found. The accessory spleen was removed intact. The patient recovered well; 2 months later steroids were discontinued while the thrombocyte level was 251 x 10(9)/L. Identification of accessory spleen seems to be major intraoperative problem. We believe that accessory spleen can be safely removed laparoscopically, avoiding a major open procedure, and a satisfactory postoperative result could be expected.