Laparoscopic sigmoid colectomy and splenectomy for diverticulitis and splenic sarcoidosis.

Splenectomy together with colectomy is most commonly performed as a result of iatrogenic injury and not as an additional elective procedure. A 50-year-old African American female presented with recurrent episodes of diverticulitis. She had mediastinal, and porta hepatis lymphadenopathy and subcutaneous nodules, but multiple biopsies were unable to establish the diagnosis. On computed tomography scan, innumerable hypodense splenic lesions were noted. The patient underwent combined laparoscopic sigmoid colectomy and splenectomy. First, the severely inflamed sigmoid colon was mobilised followed by descending colon and splenic flexure. The spleen, which showed multiple granulomas, was dissected out and the hilum secured with a stapler. The rectum was now stapled, the Pfannenstiel incision was reopened, the spleen was removed in a retrieval bag and the colon was pulled out. The colorectal anastomosis was created with an end-to-end anastomotic (circular) stapler. Pathology demonstrated multiple non-caseating granulomas indicative for sarcoidosis and acute/chronic diverticulitis. The patient developed a superficial surgical site infection but no other complications. Prednisone and methotrexate were started and her sarcoidosis improved. She was well at her 2 years of follow-up. Only few patients have an indication for elective splenectomy together with segmental colectomy. The procedure can be safely performed using a laparoscopic approach.

INTRODUCTION

Sigmoid diverticulosis is a common finding in the elderly, but only a minority of patients will develop acute diverticulitis.[1] Complicated diverticulitis still requires acute or elective surgical intervention.[2] The hallmarks of modern management of diverticulitis are avoidance of surgery, of a colostomy and an open procedure.[12] Laparoscopic sigmoid colectomy has been shown superior to traditional open surgery.[2]

Concomitant removal of other organs with elective or emergency segmental colectomy is rarely done and may include splenectomy.[34] An elective combined laparoscopic en bloc segmental colectomy, distal pancreatectomy and splenectomy has been previously reported for stage 4 colon cancer;[5] however, splenectomy in addition to colectomy is usually unplanned and performed as a result of iatrogenic injury during mobilisation of the splenic flexure. The overall rate of splenic injury during colorectal surgery has been found to be 0.96%, and recent reports indicate that this may not alter outcome.[6]

Sarcoidosis is a multisystem granulomatous disease of unknown aetiology that manifests with non-caseating granulomas in affected organs, most commonly the lungs. Extrapulmonary sarcoidosis occurs in up to 30% of patients with 6.7% splenic involvement, which is frequently asymptomatic; splenectomy is indicated for abdominal pain as a result of splenomegaly.[7]

We report an elective combined laparoscopic sigmoid colectomy and splenectomy performed for recurrent diverticulitis and multiple splenic nodules of unknown aetiology which were subsequently found to be a manifestation of sarcoidosis.

CASE REPORT

A 50-year-old African American female presented for evaluation for laparoscopic sigmoid resection following the third episode of diverticulitis [Figure 1a]. Her medical history was significant for hypertension, Lyme disease, cardiomyopathy, fibromyalgia and concern for sarcoidosis. She also had undergone an open hysterectomy.

Figure 1

Computed tomography scan: (a) Acute diverticulitis (b and c) splenic granulomas

One year before referral for surgery, the patient developed xerostomia, generalised fatigue, dyspnoea and bilateral parotid gland swelling. Imaging revealed bilateral hilar, mediastinal and porta hepatis lymphadenopathy. Biopsies of parotid gland, hilar lymph nodes and porta hepatis lymph nodes and newly developed subcutaneous nodules were all non-diagnostic. Repeat CT-scan showed innumerable hypodense splenic lesions measuring between 5 and 12 mm in diameter [Figure 1b and c]. She was hospitalised for another episode of acute diverticulitis and started on antibiotics. Laparoscopic splenectomy was offered to the patient to be performed in addition to sigmoid resection.

The patient was placed in lithotomy and 5 mm trocars were placed in the right upper quadrant and umbilicus and a 10–12 mm port in the right lower quadrant. A lighted left ureteral stent had been inserted. The sigmoid colon was mobilised off the left lateral abdominal wall [Figure 2a]; the lighted stent was visualised. A window was created through the sigmoid mesentery and widened towards proximal rectum and descending colon using an EnSeal [Figure 2b]. Again the lighted stent was visualised [Figure 2c]. A 15 mm trocar was placed in the patient's previous Pfannenstiel incision. The lesser sack was opened through the gastrocolic ligament, and the short gastric vessels were divided [Figure 2d]. The splenocolic ligament was divided and the spleen, which showed multiple granulomas was mobilised out of the retroperitoneum [Figure 2e]. The hilum was secured with an Echelon stapler with vascular loads [Figure 2f]. The splenic flexure was completely mobilised and the colon divided below the rectosigmoid junction. The old Pfannenstiel incision was opened from the 15 mm trocar and widened to 5 cm, and the spleen within a retrieval bag was removed. The colon was brought out and divided at an area of good perfusion as determined by indocyanine green (ICG) dye. A 29 end-to-end anastomotic device (circular stapler) (EEA) anvil was tied into the colon conduit, the Pfannenstiel incision was closed and the colorectal anastomosis was created with an EEA stapler. The anastomosis was examined with air testing. Good perfusion was demonstrated again with ICG dye from the abdominal side and transrectally. A pelvic drain looping up into the splenic bed was inserted. Macroscopic examination showed diverticulitis and multiple granulomas throughout the spleen [Figure 3]. Pathology demonstrated multiple non-caseating splenic granulomas establishing the diagnosis of sarcoidosis and the sigmoid colon demonstrated acute/chronic diverticulitis.

Figure 2

Intraoperative findings: (a-c) Mobilisation of the sigmoid colon (a) dissection of the colon off the lateral abdominal wall (b) window created through sigmoid mesentery (c) after colonic mobilisation lighted left ureter stent is visible (arrow) (d-f) mobilisation and resection of the spleen (d) the lesser sack has been opened exposing the gastric back wall (e) the mobilised spleen shows granulomatous disease (f) the splenic hilum is secured with a vascular load of the Echelon stapler

Figure 3

Specimens: Sigmoid colon with signs of acute and chronic diverticulitis; spleen with multiple granulomas

The patient tolerated the procedure well, but the Pfannenstiel incision had to be opened for a superficial surgical site infection (SSSI) after 1 week; she had no other complications. The patient was started on prednisone and methotrexate, and her sarcoidosis symptoms improved. She is alive and well at the 2 years’ follow-up.

DISCUSSION

We report the rare case of a combined laparoscopic splenectomy and sigmoid colectomy for unrelated conditions. Colectomy was indicated due to her multiple bouts of the complicated diverticular disease.[1] We opted for laparoscopy as this approach has been shown to be associated with reduced post-operative ileus, pain and hospital stays when compared to open surgery.[2] Splenectomy together with colectomy is typically performed as a result of iatrogenic injury. Predictive risk factors for splenic injury during colorectal surgery have been found to include open operations, type of resection (transverse, left or total colectomy) and resections performed for malignancy and diverticulitis.[8] Laparoscopic colorectal surgery has a decreased need for incidental splenic procedures thought to be secondary to better visualisation and avoidance of unnecessary traction.[8] Splenic procedures including splenectomy, splenorrhaphy and partial splenectomy performed during colorectal surgery used to be associated with increased length of total hospital stays, re-operation requirement, transfusion requirement and sepsis[8] but this may be much more common in open colectomies.

A single report of combined elective laparoscopic sigmoid resection and splenectomy has been published in the literature,[5] and this was done as an en bloc resection together with distal pancreatectomy. Our patient experienced an SSSI, but no other complications and recovered well form the combined procedure. The splenectomy yielded a diagnosis of sarcoidosis whereas previous biopsies of skin lesions, mediastinal and liver hilar lymphadenopathy had been inconclusive. This case highlights the value of laparoscopic splenectomy performed in addition to sigmoidectomy as a safe procedure. Indications for such a combined procedure are uncommon.

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.

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Conflicts of interest

There are no conflicts of interest.