Laparoscopic splenectomy for haemangioma of the spleen.

Splenic haemangioma is a rare disorder but remains the most common benign neoplasm of the spleen. It accounts for 0.1 to 14% of many large autopsy series. Most haemangiomas tend to be discovered in adults in the age group 30-50 years. In 80% of cases splenic haemangioma is usually found incidentally. Spontaneous rupture has been reported to occur in as many as 25% of these patients especially when the diameter of the tumour is more than 4 cm necessitating splenectomy as the only modality of treatment. We report a case of splenic haemangioma in a 23-year female. Laparoscopic splenectomy was undertaken and spleen removed through a small left inguinal hand port incision. Post-operative period was uneventful and histopathological examination report showed splenic haemangioma. She remains well three years post-operative.

INTRODUCTION

Splenic haemangioma is a rare disorder. Being usually asymptomatic diagnosis is incidental. For fear of rupture treatment is splenectomy. We report a patient with splenic haemangioma who underwent laparoscopic splenectomy.

CASE REPORT

A 23 year female had chronic pain in upper abdomen since 3 years with acute exacerbations off and on, once in 4 to 6 months, lasting for 8 days responding to analgesics. On examination, apart from tenderness in left hypochondria and lumbar region there were no positive findings. Spleen was not palpable. Hematological findings were normal. Routine sonography showed moderate splenomegaly 178 mm in craniocaudal direction, with a large mass at the lower pole, which was predominantly hyperechoic. The mass approximately measured 110 mm by 90 mm by 75 mm in size.

Computed tomography showed that the spleen is enlarged, measuring 178 mm in craniocaudal length with a large heterogenous mass lesion, growing exophytically along anteroinferior border of the spleen. The mass measured 118 mm by 97 mm by 78 mms in size and appeared hypo dense on non-contrast CT. Post contrast study showed peripheral enhancement with gradual central dissipation of contrast on delayed phases. The fat planes surrounding the mass are well preserved. Bowel loops were separate from the mass [Figure 1]. The gradual central filling of contrast was highly suggestive of haemangioma.

Figure 1

CT scan showing large hemangioma in the spleen

After ruling out other causes of pain in abdomen other than splenic haemangioma, patient was undertaken for laparoscopic splenectomy through a 4 port trocar entry with patient in semi lateral position. Operative findings showed perisplenitis in the lower pole with minimal adhesions near the splenic flexure [Figure 2]. Dissection of the ligaments and clipping of the splenic vessels were carried out in the conventional manner. The specimen was removed in toto through a small left inguinal incision. Operative time was 150 min. and bleeding was approximately 30 ml. Post-operative was uneventful and patient was discharged on 3rd post-operative day as against the conventional 8-10 days in open surgery with large subcostal incision.

Figure 2

Laparoscopic view of the splenic hemangioma

DISCUSSION

Hodge reported the first case of splenic haemangioma treated successfully by surgery in 1895. Less than 100 cases have been reported in the medical literature so far. The clinical presentation is variable and mostly the diagnosis is incidental.

Autopsy series states its incidence between 0.02 to 16%[2 4] they are the most common benign neoplasms of the spleen.[1] A haemangioma is a slow growing neoplasm consisting of an overgrowth of new blood vessels. It is found mostly when a patient is being screened for another illness. Benign growth usually implies that the organ affected would not require removal, but because of the concentration of blood vessels located within the spleen and its susceptibility to blunt trauma[2] splenectomy is recommended irrespective of its size.[3]

Though they are labeled as tumors, they are dysplasias with excessive vascular proliferation. Diffuse hemangiomatosis of the spleen is a very rare variant. Here the normal architecture of the spleen is replaced by blood vessels of varying caliber and associated with generalized angiomatosis of other haematopoietic organs like bone marrow and liver.[5] Though reported as benign, potential for angiosarcoma is known, especially when the spleen is big in size[6] these lesions are usually asymptomatic in 80% of cases. Presentation is with abdominal pain, dyspnoea, diarrhea and constipation. Hematological abnormalities are seen in only diffuse hemangiomatosis.[7] Clinically, splenomegaly is present in 10% of cases. Complications like spontaneous rupture with life-threatening hemorrhage can occur in 25% of patient especially when the tumour size exceeds 4 cm.

Pathologically they are usually small cavernous haemangiomas. Their morphological spectrum can range widely from being solid to cystic. On histopathology, they comprise of non-capsulated proliferation of vascular channels containing slow flowing blood of variable size, ranging from capillary to cavernous, and are lined with a single layer endothelium without mitosis. Thrombosis and infarction are known. When completely organized it may even resemble a fibroma.

The treatment options available ranges from splenectomy to anti-angiogenic therapy. The risk of a large hemangioma is its possible rupture with severe hemorrhage. Despite the successful treatment with embolisation of the specific splenic arterial branch to the hemangioma or with radiotherapy and with antiangiogenic therapy, the best results are achieved with splenectomy either by laparotomy or laparoscopy.[8] Partial splenectomy is offered at some centers when the lesion is small and localized to the poles of the spleen.[9] Alternate treatment are found to be effective in the younger age group. Since our patient was an adult with a big lesion involving 2/3rd of the spleen, total splenectomy was considered a laparoscopic splenectomy is the preferred method of removal for optimum recovery.[10] Traditional surgery involves a large incision and longer recovery time with a greater risk of infection after the operation. Most patients undergoing laparoscopic surgery are able to leave the hospital within 2 days after the surgery.

CONCLUSION

Hematological disorders constitute 96% of all indications for splenectomy. Amongst the non-hematological disorders splenic hemongioma accounts for less than 1% of the total indications. Once this rare disorder is diagnosed splenectomy, partial or complete, is the treatment of choice. Splenic artery embolisation, antiangiogenic therapy are also tried depending upon the age of the patient and the site and size of the lesion. Laparoscopic approach is preferred to the conventional open surgery.