Laparoscopic removal of an accessory spleen for recurrent idiopathic thrombocytopenic purpura 5 years after laparoscopic splenectomy

Hugo Bonatti, MD, Daniel Medina, MD, Stephen Kavic, MD. University of Maryland.

Background: Treatment of idiopathic thrombocytopenic purpura (ITP) refractory to medical management consists of splenectomy with a high success rate. Recurrent ITP may be due to regrowth of a missed accessory spleen.

Case report: A 59 year old female had undergone laparoscopic splenectomy for ITP refractory to medical management five years ago. After several years of stable platelet count, her platelet count started to drop to as low as 1K/ml and she developed purpura. On liver/spleen scan and CT-scan a 5x5cm mass containing splenic tissue was found close to the tail of the pancreas. We recommended laparoscopic removal. The patient was placed supine with her left side elevated at 45 degrees. A Verres needle in the left upper quadrant was used to establish pneumoperitoneum and a 5mm visiport was placed under the left ribcage. Under visual control another 5mm trocar and a 10-12mm trocar were placed in the laft flank and above the umbilicus, respectively. Dense adhesion of the omentum to the abdominal wall and the stomach were divided. The colon was now identified and the lesser sack opened through the gastrocolic ligament. The splenic flexure was taken down and the stomach was lifted anteriorly and medially to expose the tail of the pancreas. In the area of the previous splenic hilum the mass was identified and carefully dissected off the pancreas. Dorsally it was lifted off the left kidney and adrenal gland. To the medial adhesions to the stomach were divided. Blood supply for the mass originated from a side branch of the splenic artery and splenic vein at the tip of the tail of the pancreas. We used an endo GI with a white load to divide this structure and this was secured with an endoloop around the tip of the tail of the pancreas to achieve hemostasis and secure a potential leak of the pancreatic duct. The accessory spleen was placed into an endobag, cut in small pieces and removed through the 10-12mm port. The patient recovered well from the procedure without any complications and her platelet count normalized within few weeks.

Discussion: Regrowth of splenic tissue causing recurrent ITP is a rare condition. Laparoscopic re-splenectomy can be safely done.

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