Ruptured spleen: an unusual complication of laparoscopy

Abstract

Introduction

Splenic rupture is a well-known complication of open surgery but is much less common at laparoscopic surgery.

Case outline

A 45-year-old man underwent laparoscopy for perforated duodenal ulcer. The abdominal cavity was washed out and the ulcer was sutured. He was discharged on the fifth postoperative day but was readmitted because of a sharp pain in the left upper quadrant radiating to the left shoulder. He then developed haemorrhagic shock. Urgent laparotomy revealed a diffuse haemoperitoneum consequent upon a posterior subcapsular haematoma of the spleen.

Discussion

There are four previous case reports of splenic rupture at laparoscopy. In the present case, a posterior subcapsular haematoma arose during lavage of the left subdiaphragmatic area. Such a haematoma is undetectable during laparoscopy.

Introduction

Laceration of the spleen or splenic rupture is a well-known risk of operations on the stomach and left colon or during emergency laparotomy for peritonitis. At laparoscopic surgery, injuries of the liver, digestive tract, retroperitoneal vessels, urinary tract and abdominal wall vessels can all occur either during access or during dissection ¹,²,³,⁴,⁵, but splenic rupture or injury has rarely been reported.

Case report

A 45-year-old man was admitted with a perforated duodenal ulcer causing generalised peritonitis. Laparoscopy undertaken immediately through one 10-mm umbilical trocar and three 5-mm trocars in the epigastrium, right flank and left flank confirmed the diagnosis. The abdomen was washed out under laparoscopy, including the left subphrenic quadrant that was exposed by tacking down a wide gastrosplenic ligament to see the left diaphragm and the anterior edge of the spleen. The duodenal perforation was closed with two sutures reinforced with fibrin glue. There was no bleeding at the end of the procedure. Recovery was uneventful, and the patient was discharged on the fifth postoperative day with treatment to eradicate Helicobacter pylori.

The patient was readmitted several hours later because of the acute onset of a sharp pain in the left upper quadrant of the abdomen and left loin radiating to the left shoulder and inhibiting deep breathing. On physical examination, there was moderate tenderness in the left upper quadrant without guarding. Chest X-ray showed elevation of the left diaphragm, the white cell count was raised at 18.2×10 /L and the haemoglobin was 1.78mmol/L (11.5 g/dl). The patient was admitted for observation but he developed another episode of sharp abdominal pain with hypotension, tachycardia and a fall of haemoglobin to 1.24 mmol/L (8 g/dl). He was operated urgently through a midline laparotomy with the diagnosis of ruptured spleen. There was a diffuse haemoperitoneum with clot surrounding the spleen. A posterior subcapsular haematoma located at the site of the adhesion of the spleen to the posterior peritoneum had dissected the capsule over the dome of the spleen, and had ruptured into the peritoneum. Splenectomy was undertaken. The postoperative recovery was uneventful, and the patient was discharged 8 days later.

Discussion

Four cases of splenic rupture have been reported since the beginning of laparoscopy ⁶,⁷,⁸,⁹. In one case, the combination of laparoscopy and preoperative trauma to the left upper quadrant of the abdomen was responsible ⁹. In the other three cases, the pneumoperitoneum tore on some adhesions between spleen, omentum and lateral abdominal wall ⁶,⁷,⁸. In the present case, pulling on the gastrosplenic ligament during lavage of the left sub-diaphragmatic area appears to have torn the spleen at the site of its attachment to the posterior peritoneum. This mechanism produced a posterior expanding subcapsular haematoma of the spleen that remained asymptomatic (with normal haemoglobin) until it ruptured. In the previous reports, the splenic capsule ruptured during or immediately after laparoscopy, so that haemoperitoneum and haemorrhagic shock appeared 4-10 h postopera-tively and there was no subcapsular haematoma of the spleen ⁶,⁷,⁸,⁹. By contrast, in the present case, haemoperitoneum and bleeding shock appeared on day 5 when the subcapsular haematoma ruptured into the peritoneum. Whereas the diagnosis of operative site bleeding was made after the original laparoscopy and splenic rupture was discovered during urgent laparotomy in the previous reports, in the present case the pain in the left upper quadrant and the elevation of the left diaphragm allowed the diagnosis of splenic rupture before urgent laparotomy that confirmed the diagnosis.

Splenic rupture is an unusual but serious complication of laparoscopic exploration and laparoscopic surgery. It has to be diagnosed and treated if possible during the original laparoscopic procedure. The detection of an injury of the anterior edge or the inferior pole of the spleen is possible during laparoscopy if the spleen is observed at the end of the procedure. The detection of a posterior subcapsular haematoma of the spleen is impossible during laparoscopy and cannot be suspected if there is no bleeding from the spleen at the end of the procedure. Such a haematoma is not detectable after laparoscopy as long as the patient remains asymptomatic, and symptoms occur when the haematoma ruptures. Ultrasound and CT scan can be helpful to diagnose such a haematoma but these explorations are unlikely to be performed in the absence of either postoperative or intraoperative concern about the spleen.