Recurrent Autoimmune Hemolytic Anemia Fifteen Years After Laparoscopic Splenectomy

David A Santos, MD, Edward H Phillips, MD FACS. Cedars Sinai Medical Center

OBJECTIVE: To present an unusual case of recurrent auto-immune hemolytic anemia and the laparoscopic approach to identify and remove multiple accessory spleens.

DESCRIPTION: A 60 year old woman presented with recurrent autoimmune hemolytic anemia 15 years after a successful laparoscopic splenectomy during which two accessory spleens were seen and removed. Her recent work up included a CT scan and Technetium 99 liver-spleen scintigraphy. The CT scan showed 4 masses that were consistent with accessory spleens but the liver-spleen scan showed only two with uptake.

RESULTS: The video demonstrates a systematic laparoscopic exploration of the upper abdomen and removal of accessory spleens. Histology confirmed splenic tissue. The patient has had no recurrence of autoimmune hemolytic anemia to date. Literature review suggests that accessory spleens are present in 10% of the population. The most common locations for accessory spleens are near the splenic hilum and pancreatic tail, but accessory spleens may migrate anywhere in the abdomen or pelvis. Only 25% of accessory spleens less than 1cm in diameter are detected by CT scans. Laparoscopic exploration during splenectomy can miss 13 – 25% of accessory spleens and may lead to reoperation in hematologic disease.

CONCLUSIONS: We report a case of recurrent automimmune hemolytic anemia due to the presence of accessory spleens. Imaging is helpful in locating accessory spleens, but extensive operative exploration is critical in this subset of patients and can be accomplished laparoscopically.