A Case of Splenic Rupture: A Rare Event After Laparoscopic Cholecystectomy

Girolamo Geraci; Antonino Picciurro; Andrea Attard; Giuseppe Modica; Massimo Cajozzo; Carmelo Sciumè

Disclosures

BMC Surg. 2014;14(106) 

In This Article

Case Presentation

A 77 years old woman with a recent history of constant right upper quadrant pain radiating to the right shoulder was referred to our hospital for symptomatic gallbladder microlithiasis. No relevant past medical history was referred and pre-operative tests did not show any pathological findings (at ultrasonography (US), spleen diameter 101 mm).

We performed a LC by 4 ports "French" technique. The pneumoperitoneum was established with open "Hasson" technique respecting an insufflating volume of 5 l/min.

We used one 10-mm trocar into umbilicus, with a 10-mm 30° laparoscope, two 5 mm trocars, respectively on the left of the midline and in the right side, and one 10 mm epigastric trocar, setting the pneumoperitoneum at 12 mmHg. No specific peritoneal adhesions around the gallbladder have been identified.

The total operative time was about 75 minutes, without any intraoperative complications or bleeding. The abdomen was normal without tenderness or guarding; no analgesic was required and there was a normal intestinal function 6 hours after surgery; normal values of postoperative (6 hours after surgery) blood tests have been found; post-operative drainage in Winslow was silent.

During the first postoperative day, at about 12 hours after the operation, she experienced self limiting lipotimic episode (pulse of 120 beats/minute, blood pressure of 80/40 mm Hg), with cold and clammy peripheries and referred a sudden upper abdominal pain. The abdominal examination showed a distended abdomen characterized by tenderness in the left upper quadrant, guarding, and rebound tenderness, Blumberg's sign and shallow breathing.

Immediately blood tests were performed showing a severe anemia (hypovolemic shock): the Hemoglobin decreased from preoperative 10.4 gr/dl to 5.3 gr/dl and red blood cell from 3.6×106/μl to 1.7×106/μl. We performed an urgent computed tomography (CT) that showed severe haemoperitoneum with two major blood collections localized respectively along the course of hepato-gastric ligament (16×5 cm) and in the left sub-phrenic space (with active spreading of contrast medium) (Figure 1).

Figure 1.

CT showing severe haemoperitoneum with two major blood collections localized respectively along the course of hepato-gastric ligament (a) and in the left sub-phrenic space (b).

We did not consider the embolization of splenic artery before surgery because of the hemodynamic instability. The patient was urgently operated through a midline laparotomy and we found a 3-cm sub-capsular splenic haematoma ruptured into the peritoneum. We then performed splenectomy, intra-abdominal lavage (draining about 1.5 liters of blood and clots) and two drainages were placed (the first one in the splenic root and the second one in Douglas' root). We did not perform partial splenectomy or conservation of spleen in the suspect of more complex splenic lesion.

During the operation five blood unit transfusions, 9 plasma and 8 platelet units have been practiced. Twenty hours after the splenectomy blood tests were performed, showing a stable Hb of 9 gr/dl. No further transfusions were needed. The histological examination showed a subcapsular haematoma dissecting the capsula and rupted (in peritoneum), with normal surrounding splenic pulp (Figure 2). The remote history of the patient was negative for any kind of trauma during the preceding year, or for hematologic syndrome such as myeloproliferative or myelodisplastic disease or thrombotic thrombocytopenic purpura. The patient was discharged on the 7th postoperative day in good clinical condition, after hospitalization of 4 days in intensive care unit.

Figure 2.

Histological examination showing subcapsular haematoma dissecting the capsula (red circle), with normal surrounding splenic pulp.

She received the standard vaccinations against encapsulated organisms (pneumococcal, meningococcal, and haemophilus influenzae).

One week after the discharge the patient performed an abdomen US scan which was negative for any intra-abdominal fluid collection.

All data reported in the manuscript have been visualized and then approved by our University Hospital Ethics Committee and all procedures carried out on the patients were in compliance with the Helsinki Declaration.

Moreover, the patient has given written explicit, express and unequivocal consent to publish her sensible data on our manuscript.

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