|Year : 2022 | Volume
| Issue : 5 | Page : 770-772
A rare case of retroperitoneal mass
Shivam Sharma, Subhash Chawla, Naveen Yadav
Department of Minimally Access Surgery, MMIMSR, Ambala, Haryana, India
|Date of Submission||23-Mar-2020|
|Date of Decision||09-Jun-2020|
|Date of Acceptance||03-Jul-2020|
|Date of Web Publication||19-May-2022|
Dr. Subhash Chawla
Department of Minimally Access Surgery, MMIMSR, Ambala 133- 207, Haryana
Source of Support: None, Conflict of Interest: None
Accessory spleen or splenunculi is a rare entity and usually near the spleen's hilum and in the tail of the pancreas. The accessory spleen may be formed during embryonic life, and they rise from the left side of the dorsal mesogastrium as a result of the imperfect fusion of separate splenic masses. Here, we are presenting a case of retroperitoneal mass who presented with pain in the upper abdomen, evaluated and worked up and was diagnosed as a large retroperitoneal mass along with two small globular structures likely splenunculi. The patient underwent diagnostic laparoscopy and excision of the retroperitoneal mass. The specimen sent for histopathological examination confirmed the diagnosis as splenunculi.
Keywords: Mesogastrium, retroperitoneal mass, splenunculi
|How to cite this article:|
Sharma S, Chawla S, Yadav N. A rare case of retroperitoneal mass. Med J DY Patil Vidyapeeth 2022;15:770-2
| Introduction|| |
Accessory Spleen or Splenunculi is a rare entity and usually near the spleen's hilum and in the tail of the pancreas. Accessory spleen may be formed during embryonic life, they rise from the left side of the dorsal mesogastrium as a result of imperfect fusion of separate splenic masses. Here we are presenting a case of retroperitoneal mass who presented with pain in upper abdomen, evaluated and worked up and was diagnosed as a large retroperitoneal mass along with two small globular structures likely splenunculi. Patient underwent diagnostic laparoscopy and excision of retroperitoneal mass. Specimen sent for histopathological examination confirmed the diagnosis as splenunculi.
| Case Report|| |
28-year-old male presented to surgery outpatient department with chief complaints of pain in left hypochondrium for the last 2 years, which was sudden in onset mild to moderate intensity, which was temporarily relieved on taking oral analgesics and antispasmodics. Since the last 3 months, the patient had a continuous pain abdomen, which was not relived despite treatment. This was not associated with fever, abdominal distension, vomiting, loss of appetite, or weight loss. No history of abdominal trauma. The patient had no significant past medical or surgical history. Per abdomen soft, nontender, no palpable lump. The digital rectal examination did not reveal any abnormality.
Laboratory investigations, including complete blood count (haemoglobin - 14.0 g%, packed cell volume 40.3%, total leukocyte count 7.2 × 1000/cu/mm), liver function test (total protein 7.1 g/%, direct bilirubin 0.10 mg/dl, serum glutamic oxaloacetic transaminase 20 u/l, serum glutamic pyruvic transaminase 32 u/l, alkaline phosphatase 73 u/l, albumin 3.8 g/%, viral markers (nonreactive) international normalized ratio 1.25, Sodium 141, Potassium 4.2, CA 19.9.Ultra sound whole abdomen, lipase 121u/l, amylase 91u/l, CA-19-9 16.09 u/ml, IgG 4 level 75.23 mg/dl.
Ultrasound whole abdomen showed a solitary lymph node at the left renal hilum.
Contrast enhanced computed tomography (CT) abdomen showed well defined lobulated lesions in the retroperitoneal region in relation to the inferior aspect of the tail of pancreas and enhancement characteristics similar to spleen likely ectopic splenic tissue/splenunculus [Figure 1].
|Figure 1: Contrast-enhanced computed tomography abdomen shows lobulated lesion approximately 6 cm × 4 cm in retroperitoneal region|
Click here to view
Positron emission tomography-CT scan showed well-defined enhancing soft tissue mass of size approximately 4.2 cm × 5.4 cm in the retroperitoneal region, another two small similar density soft tissue masses in relation to the upper and lower pole of the spleen are also present likely splenunculi [Figure 2].
|Figure 2: Positron emission tomography-computed tomography report shows splenunculi in retroperitoneal region|
Click here to view
The patient was planned for a diagnostic laparoscopy and proceed, intraoperative finding showed a retroperitoneal mass of approximately of 6 cm × 5 cm in relation to the tail of the pancreas and posteriorly closely related to left kidney medial to the hilum, anteriorly it was in close contact to the greater curvature of the stomach and bowel loops, along with it two small splenunculus were also seen [Figure 3]. Laparoscopically, mass was mobilized through the lesser sac, vessels supplying to mass was ligated, and vein divided between two hemlock clips. Mass dissected from the tail of the pancreas by the harmonic scalpel. Specimen extracted after extending 10 mm port in a disposable bag. The abdominal drain placed in situ and ports closed.
|Figure 3: Intraoperative: large retroperitoneal mass features suggestive of splenunculi|
Click here to view
Postoperative period was uneventful, the patient was kept nil orally for 24 h and started with oral liquids followed by semi-solid diet on the 2nd postoperative day, the abdominal drain was removed on the 2nd postoperative day[Figure 4]. The patient was ambulated and discharged on the 3rd postoperative day. The histopathological report confirmed specimen consistent with splenunculi.
| Discussion|| |
Splenunculi or accessory spleen is a congenital disorder seen in 10%–44% of the population. An accessory spleen arises from the side of the dorsal mesogastrium during the embryological period of development as a result of the imperfect fusion of separate splenic masses. Mostly, we found one accessory spleen (85%) sometimes two (14%) and rarely three or more (1%). Their size is not larger than 2 cm in diameter. Here, we are presenting a 28-year-old male with 3 splenunculi of which two small in size and 1 large size approximately 6 cm × 5 cm.
The most common site is hilum of the spleen in a gastrosplenic ligament (50%), but maybe found behind the tail of the pancreas (30%) or rarely within greater omentum of the stomach, mesentery of the small intestine, mesocolon, intrapancreatic accessory splene, renal fossa mass, and Adnexal mass. Most of the splenunculi are asymptomatic and are discovered incidentally by abdominal ultrasound, CT scan or during laparotomy for other abdominal problems. In some cases, they become symptomatic causing abdominal pain due to torsion and infarction, as was seen in our patient. Accessory spleen needs to be distinguished from splenosis, which is an acquired condition associated with splenic trauma or surgery.
Splenosis presents as numerous nodules (as many as 400) in any intraperitoneal or extraperitoneal location. Splenosis nodules receive their blood supply from newly formed arteries penetrating the capsule. Histologically it is possible to differentiate splenunculi from splenosis. Splenunculi have well-formed capsule, hilum, trabeculae, white pulp with Malpighian follicles having central arteriole and red pulp, whereas splenosis nodule are surrounded by capsule, but Malpighian follices with a central arteriole are not formed. Splenunculi is important in hematological disorders for which splenectomy is the treatment of choice. If the surgeon found difficult to locate or remove them at the time of splenectomy, they will undergo hyperplasia and cause recurrence of the disease. Accessory spleens resemble normal spleen in structure and in immunologic functions. Hence in splenectomy for nonhematologic causes, accessory spleens should be preserved to prevent infection and sepsis after splenectomy. In addition, splenunculi can mimic tumors of the kidney, pancreas, and pelvis. It is important to identify splenunculi either by CT scan or by 99mTc heat-denatured red blood cell scan and confirmed by histopathologic examination to avoid misdiagnosis.
| Conclusion|| |
Splenunculi may present as a large intraabdominal/retroperitoneal mass, the mesenteric cyst should be considered as a differential diagnosis. Asymptomatic cases may not require surgery, but symptomatic splenunculi needs evaluation and may require surgery. Laparoscopic excision and biopsy is possible and is feasible and safe as was done in this patient.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al Ahmadi M, Brundage S, Brody F, Jacobs L, Sakier. Splenosis of the MESO appendix, a case report and review of literature. J R Coll Surg (Edinburgh) 1998;43:200-2.
Hayward I, Mindelzun RE, Jeffrey RB. Intrapancreatic accessory spleen mimicking pancreatic mass on CT scan. J Comput Assisted Tomogr 1992;16:984-5.
Servadio Y, Leibovitch I, Aprer S, Mor Y, Goldwasser B. Symptomatic heterotopic splenic tissue inleft renal fossa. Eur Urol 1994;25:174-6.
Azar GB, Awwad JT, Muffarrij IK. Accessory spleen presenting as adnexal mass. Acta Obstetr Gynecol Scandnevica 1993;72:587-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]