Giant Splenic Cyst with Hypersplenism: Laparoscopic Splenectomy

Mohamed E Abd Ellatif

Mohamed E Abd Ellatif, General Surgical Department, Faculty Of Medicine, Mansoura University, Mansoura, Egypt

Correspondence to: Mohamed E Abd Ellatif, MD, General Surgical Department, Faculty Of Medicine, Mansoura University, Mansoura, Egypt.
Received: September 27, 2012
Revised: November 2, 2012
Accepted: November 6, 2012
Published online: April 21, 2013


Splenic cysts are rare lesions with approximately 800 cases reported in the world literature. Splenic cysts associated with hypersplenism are even rarer and only few cases have been described. They have been classified as "true" or "pseudo" cysts based on the presence or absence of an epithelial lining. We report a case of giant true splenic cyst. A 29-year- old Saudi woman presented with one year history of abdominal pain and sensation of fullness in her left upper abdomen. She gave a vague history of abdominal trauma one year back. Abdominal ultrasonography and Computed Tomography (CT) revealed a giant splenic cyst almost replacing the splenic parenchyma and abutting the splenic hilum. Laboratory tests revealed a picture of hypersplenism. She was treated successfully by laparoscopic splenectomy. The pathological examination confirmed a true cyst with epithelial lining. Postoperative recovery was uneventful, and the blood count returned normal.

Key words: Epithelial cyst; Hypersplensim; Laparoscopic splenectomy

© 2013 The Author. Published by ACT Publishing Group Ltd.

Abd Ellatif M. Giant Splenic Cyst with Hypersplenism: Laparoscopic Splenectomy. Journal of Gastroenterology and Hepatology Research 2013; 2(4): 549-551 Available from: URL: http://www.ghrnet.org/index./joghr/


Splenic cysts have been classified as "true" or "pseudo" cysts based on the presence or absence of an epithelial lining. True cysts have a cellular lining that can be caused by congenital events or parasitic infection (Echinococcus). Pseudocysts have no cellular lining and may be of hemorrhagic, serous, inflammatory, or degenerative origin. Congenital nonparasitic cysts of the spleen are rarely met in clinical practice, representing approximately 10% of all splenic cysts[1]. They are also called true, congenital, epidermoid or epithelial cysts. We report the case of a giant epithelial cyst of the spleen, which was diagnosed before surgery as pseudocyst.


A 29-year-old Saudi woman presented to our clinic with one year history of a progressively painful lump and sensation of fullness in the left upper quadrant of the abdomen which increased mainly among the last 3-months. A vague history of trauma to abdomen was present. On examination, the patient was pale and all vital parameters were stable. A mass measuring 10-15 cm with smooth surface and cystic consistency was palpated in left hypochondrium. Laboratory investigations showed thrombocytopenia (81×103), leukopenia (2.6×103) and anaemia (Hb=8.2 gm%). Peripheral smear showed pancytopenia and a reticulocyte count of 2.5%. Bone marrow was hypercellular with erythroid hyperplasia. Echinococcus IgG antibody test was negative and oesophago-gastric-duodeno-scopy did not show any evidence of portal hypertension.

Ultrasonography (US) and Computed tomography (CT) indicated the presence of a normal sized spleen with a cyst located on the medial surface and upper pole of the spleen (Figure 1). The mass was well circumscribed and homogeneous. The pancreas and both kidneys were normal. Polyvalent pneumococcal vaccine was administered.

The procedure started placing the patient in right semi-lateral position and 30° right lateral table tilt and reverse Trendelenberg position. Three ports were placed (Figure 2). There was a giant cyst at the medial surface and the upper pole of the spleen, involving the hilum, separable from stomach and pancreas. Plenty of thick adhesions between the cyst and the parietal peritoneum were present. Aspiration of the cyst was necessary and yield 1 400 mL of yellowish thick fluid (Figure 3).

We chose the “infero-lateral approach”, dividing the phreno-colic, splenocolic and lino-renal ligaments using Ligasure instrument followed by dissection of the gastro-splenic ligaments with short gastric vessels (Figure 4). Splenic vessels were ligated at the hilum with 2-0 Vicryl double ligature. A drain was placed and kept for one day. The spleen was taken out through 3-4 cm Pfannenstiel incision ( Figures 5, 6).

Light-microscopical examination showed interior lining of tubulocolumnar, pseudostratified (mesothelial line) epithelium that was consistent with the diagnosis of an epithelial cyst (Figure 7). Fluid culture showed no growth. Postoperative recovery was uneventful, and blood parameters returned normal. The patient was discharged on postoperative day 3.


Splenic cysts are rare lesions. Pathogenesis of the true cysts is not entirely clarified and there are many theories by different authors. It has been suggested that they are derived from inclusions of the mesothelial lining of the splenic surface in the splenic parenchyma during development[2]. Patients with congenital splenic cysts are younger than those with false cysts, and marked female preponderance is observed[2,3]. They are usually discovered incidentally because of the lack of typical clinical symptoms, and are generally diagnosed after compression of neighboring organs. Diagnosis is easily made by noninvasive imaging. Cysts arising from adjacent organs, especially from the tail of the pancreas, can be differentiated by ultrasonic examination[2,4,5].

Diagnosis of splenic cysts is generally based on radiological examination (US, CT, magnetic resonance imaging)[5]. Aspiration of the cyst content will not further differentiate true from false cysts or subclassify the congenital cyst[1]. By histology, it is possible to know whether the cyst is primary or secondary (no cellular lining) and to determine its precise nature.

Surgery is primarily recommended for the prevention or treatment of complications. Decisions about the exact surgical procedure are based on the size of the cyst, its relation to the splenic hilar vessels and parenchyma, and the amount of healthy splenic tissue remaining[6].

The recent options of management consist of percutaneous aspiration or percutaneous drainage[7], partial splenectomy with a stapler or with harmonic scalpel, total cystectomy, marsupialization or cyst decapsulation (unroofing)[8], laparoscopic puncture and creation of a cyst peritoneal window[4]. Access can be either via laparotomy or laparoscopy. Partial splenectomy should preserve more than 25% of the splenic parenchyma, which is the minimal splenic tissue to ensure immunologic protection without increasing the risk of recurrences[9].

Although literature offers the possibility of providing conservative or semiconservative treatment, in our case, the cyst was bigger than the residual splenic parenchyma, which was reduced to a small remnant, so it would have been impossible to perform a simple cystectomy or partial splenectomy to preserve the spleen. Furthermore, the cyst encompassed the hilum of the spleen. Total splenectomy, vaccination, and long-term antibiotic prophylaxis is a viable alternative when needed.

Few cases of hypersplenism associated with true splenic cyst have been reported. Increased destruction of red blood cells and pooling of blood in the enlarged spleen are considered responsible for hypersplenism associated with cyst of spleen[10].

Our case suggests that laparoscopic splenectomy is an effective method of management for such cyst involving the hilar region of the spleen or almost replacing the splenic parenchyma. Intraoperative suction of such cysts under laparoscopic guidance greatly facilitates laparoscopic splenectomy. The use of Pfannenstiel incision for specimen retrieval significantly reduces operating time as compared to piecemeal removal of the specimen by enlarging one of the ports.


Laparoscopic splenectomy is an effective method of management for cysts involving the hilar region of the spleen or almost replacing the splenic parenchyma.


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Peer reviewer: Gianluca Pellino, MD, General Surgery Unit, Second University of Naples, Via Giotto, 60, 81031, Aversa (CE), Italy.


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