The Wandering Spleen: Laparoscopic Splenectomy in a Pregnant Woman. Case Report and Review of the Literature

The Wandering Spleen: Laparoscopic Splenectomy in a Pregnant Woman. Case Report and Review of the Literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Wandering Spleen: Laparoscopic Splenectomy in a Pregnant Woman. Case Report and Review of the Literature Lorenzo Crepaz, Alberto Di Leo, Giuseppe Borzellino, Paola Pomini, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-615425/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Wandering spleen (WS) is a rare condition, which is characterized by an augmented mobility of the spleen, due to congenital or acquired causes. It’s more frequent in multiparous women, but only a few cases are reported during pregnancy. WS is usually asymptomatic until the onset of ìts possible complications, and this can mislead clinicians in reaching the correct diagnosis. Case Report: We report the case of WS with acute splenic infarction in a pregnant woman and its mininvasive surgical treatment, focusing on the clinical and radiological findings that could mislead or drive clinicians to the right diagnosis, or to a potential disaster. Conclusion: Splenic preservation in WS where it’s safe and possible and is the main goal of the treatment. Clinical and radiological findings are the most relevant elements to drive surgical treatment. WS is an insidious condition, and must be included in differential diagnosis in determined cases, to reach the best and opportune treatment for the patient. wandering spleen pregnancy splenopexy acute abdomen case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Wandering spleen (WS) is a rare and still relatively unknown condition. It is characterized by an augmented mobility of the spleen, due to congenital lack of splenic ligaments or an acquired increased laxity of these structures. This relaxation of the tissues may lead to spontaneous torsions of the splenic hilum, with possible subsequent acute or chronic ischemic infarctions of the spleen, making WS a deceptive and misleading condition. Until 2012 WS cases reported in the medical literature were about 500 worldwide, almost a 0,5% of splenectomy performed [ 1 ]. Since 2012 there have been reported in literature almost 150 new cases. The real incidence of this pathology is surely underestimated because of the healthy carriers, making WS a silent condition until the appearance of its complications, which could also be life-threatening. Most of the cases are reported in child bearing age women, in particular multiparous ones. probably in relation with the augmented laxity of the tissue due to hormonal values acquired during pregnancies. This hypothesis is confirmed by the observation of an asymmetrical distribution of WS in the adult population between female and male, with a proportion approximately of 7:1 [ 2 ]. The second peak incidence is in the pediatric population, with equal distribution between male and female, and a medium age less than 10 years old [ 3 ]. In these cases the WS is probably related to congenital lack of splenic ligaments, giving the organ augmented mobility and subsequent possible acute and/or chronic torsion on its longitudinal axis. In the medical literature there are only few cases of WS during pregnancy [ 4 , 5 ], getting to complex and dangerous clinical pictures, complicated from the coexistence of the fetus. This study is a review of publications regarding WS and a case report of the most advanced gestational age WS during pregnancy, as far as we know in the medical literature. This rare condition was first described by the Van Horne in 1667, while the first scientific report about this pathology was redacted by a Polish doctor, Jozef Dietl, who described this anatomical variation, assuming for the first time the laxity of the ligaments as its possible etiogenesis [ 7 ]. WS rests usually unknown until the appearance of a complication, such as chronic or acute ischemic damage, resulting from the torsion of the vascular axis, leading to potentially life-threatening conditions. For this reason, there are no clear clinical features related to WS, because it depends on the phases of the splenic wandering, and could remain undiagnosed all lifelong. The principal diagnostic tool in these cases is a radiological exam, such as ultrasound, CT scan and MRI [ 8 , 9 , 10 , 11 ], directing clinicians to correct treatment of this condition. Radiological findings of WS are enlarged and hypertrophic splenic vessels, no spleen in left hypochondrium and a mobile mass in the belly. Ultrasound and CT scan with contrast are the most helpful techniques in case of acute torsion or thrombosis of the vascular splenic peduncle. The pathognomonic radiological appearance of the splenic vessels, called the “Whirlpool sign” [ 12 ], is associated with an absence of flow in the splenic parenchyma, and an augmented enhancement of the splenic capsule [ 11 ]. Treatment of WS, once diagnosis is reached, is strongly correlated with the risk of almost 65% of occurrence of WS complications using conservative treatment, leading clinicians to invasive treatment of this condition once the diagnosis is confirmed [ 13 , 14 , 15 ]. Surgery is the main treatment of WS, and there are two alternative approaches, depending on the WS condition. Treatment of WS is founded on preoperative and intraoperative findings, based on splenic vascular state, grade of acute and/or chronic torsion of its hilum. In case of an asymptomatic patient, in paediatric/young population with no irreversible damage of the splenic parenchyma and function, prevails the need of preserving splenic function, and splenopexy is the most indicated treatment, with many different possible techniques [ 5 , 14 , 16 , 17 ]. From medical publications review, splenopexy offers optimal short and long term results regarding maintenance of vascularization of the splenic parenchyma and correct splenic location, making this technique world-wide accepted in case of elective treatment of WS [ 14 , 17 ]. In an acute case of WS, with ischemic compromission of the splenic parenchyma, urgent splenectomy is the most indicated treatment, acting in a potentially life-threatening clinical situation [ 5 , 7 , 13 ]. Both these techniques can be performed laparoscopic, after evaluation of surgical experience and disposability of surgical material for surgery [ 7 , 13 , 14 , 16 , 17 , 18 ]. The technique allows for relevant diminution of postoperative pain and complications, a minor length of stay and an earlier return to normal activities [ 13 ]. This case report has been reported in line with the SCARE criteria [ 6 ]. Case Report LZ, a 31 years white woman, BMI 20, primigravida, with no pathological history, no pharmacologic chronic therapy nor allergies reported. Mild thrombocytopenia was found in previous blood exams, minimal value of 95 9 platelets/L in 2016, never examined with second level exams. During the first obstetrical ultrasound check, a vascularized and capsulated mobile mass in the abdomen was detected, with a major axis of 12,5 centimetres, characterized from an hypertrophic and elongated hilar vascular axis. In parallel, there was no spleen in the left hypochondrium, confirming WS diagnosis. The WS had some parenchymal calcifical strias, as per previous parcellar ischemic infarctions. This condition was totally asymptomatic, the physical examination was negative for any pathological finding, no palpable masses, no abdominal evocable pain. The result of the multidisciplinary consult executed was an indication of close monitoring of WS through frequent ultrasound examinations and blood exams, with conservative treatment because of the initial weeks of the pregnancy. During week 17th of the pregnancy the patient had blood exams, demonstrating a reduction of PLTs count to 87 9 /L, with stability of the WS in ultrasound check. MRI has been planned in order to have more precise information and set the best treatment for the patient. Some days before the MRI, on October 30, 2019, during the 22th week of pregnancy, the patient got to the ER because of the onset of intense and diffuse abdominal pain during the night, without fever or any other clinical manifestation. Blood exams were in the range of normality, except for further thrombocytopenia, with PLTs count to 74 9 /L. Urgent ultrasound check was performed, observing augmented volume of the WS (diameter 18x8 cm), parenchymal ischemic injury, no vascular signal detected at the splenic hilum with Color-Doppler technique, without free fluid in the belly (Fig. 1 ). For this reason, the patient underwent an urgent surgical procedure. A laparoscopic approach was decided, noticing an hypertrophic mobile spleen in subhepatic space, surrounded by a multitude of ectasic and congested vessels. The principal vascular axis of the WS was also hypertrophic, with a diameter around 4 cm (Fig. 2 ). After initial mobilization of the WS and partial dissection of the perisplenic vessel and isolation of the principal vascular axis, a median mini-laparotomy was performed to dissect and tie the hypertrophic splenic vessels with non resorbable suture (Fig. 3 ). Using laparoscopy, a complete mobilization of the WS was performed from its remaining ligaments. A subsequent extraction of the spleen from the laparotomy was executed from the service laparotomy. Fetal parameters resulted physiological and unaltered after surgery. Post operative course was regular, the PLTs count normalized in a few weeks, with a media of 300 9 /L. Subsequent blood exams confirmed normalization of PLTs values (Fig. 4 ).Patient had natural childbirth at week 39th with no complications. Patient subsequently received Streptococcus Pneumoniae , Haemophilus Influenzae and Neisseria Meningitidis vaccinations, as standard prevention for most frequent severe infections after splenectomy. Conclusion WS is a rare and insidious condition, with many different possible manifestations, from asymptomatic patients to urgent and emergency situations, requiring prompt and opportune diagnosis and treatment, making this condition very challenging for clinicians. WS is a diagnosis that must be included in differential diagnosis in particular cases, such as multiparous women with abdominal palpable mass or recurrent and vague abdominal pain. Increase in WS diagnosis is supported by a constant and rapid improvement in radiological technique, getting more easily and accurately diagnosed in elective and acute examination. Surgical splenic preservation is mandatory for the patient’s safety, with many possible laparoscopic and laparotomic treatments, depending on the surgeon’s ability and hospital’s available resources. Splenectomy instead must be preferred when splenic vascularization is compromised, and the risk of splenic rupture is very high and risky for the patient. WS knowledge is principally based on an increasing number of single case reports, such as this one, driving clinicians to manage this rare and complex diagnosis, both in emergency and in elective surgery. A better understanding of WS etiopathogenesis is important to reach a complete comprehension of its pathological mechanisms, to get a better diagnostic and therapeutic ability, preventing a possible life-threatening condition. Further studies are necessary to obtain a full understanding of WS’s genesis, to get a unique and standard diagnostic and therapeutic guideline, making WS best known and less dangerous condition. Declarations i. Funding No funding were received for this study ii. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. iii. Ethics approval Not applicable iv. Consent to participate Fully informed written consent were obtained for surgery v. Consent for publication Fully informed written consent were obtained for publication vi. Availability of data and material All data and material are available from main author vii. Code availability Not applicable viii. Authors' contributions Lorenzo Crepaz and Alberto Di Leo wrote the manuscript. Lorenzo Crepaz, Giuseppe Borzellino and Paola Pomini took part to surgical procedure. Lorenzo Crepaz, Michele Genna managed preoperative and postoperative indications. References Puranik, A. K., Mehra, R., Chauhan, S., & Pandey, R. (2017). Wandering spleen: a surgical enigma. Gastroenterology report , 5 (3), 241–243. https://doi.org/10.1093/gastro/gov034 National Organization for Rare Disorders (NORD), Wandering spleen. https://rarediseases.org/rare-diseases/wandering-spleen/. Accessed 01 April 2021. Radillo, L., Taddio, A., Ghirardo, S., Bramuzzo, M., Pederiva, F., Maschio, M., & Barbi, E. (2016). The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature. Pediatric emergency care , 32 (9), 619–622. https://doi.org/10.1097/PEC.0000000000000642 Parvaiz, A., Chandran, S., Karim, A., Kumar, K., Jeffrey, P., & Lagattolla, N. R. (2004). Torted and ruptured wandering spleen presenting as a surgical emergency in pregnancy. TheScientificWorldJournal , 4 , 1035–1037. https://doi.org/10.1100/tsw.2004.208 Yücel, E., Kurt, Y., Ozdemir, Y., Gun, I., & Yildiz, M. (2012). Laparoscopic splenectomy for the treatment of wandering spleen in a pregnant woman: a case report. Surgical laparoscopy, endoscopy & percutaneous techniques , 22 (2), e102–e104. https://doi.org/10.1097/SLE.0b013e318246beb5 Agha, R. A., Borrelli, M. R., Farwana, R., Koshy, K., Fowler, A. J., Orgill, D. P., & SCARE Group (2018). The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines. International journal of surgery (London, England) , 60 , 132–136. https://doi.org/10.1016/j.ijsu.2018.10.028 Magowska A. (2013). Wandering spleen: a medical enigma, its natural history and rationalization. World journal of surgery , 37 (3), 545–550. https://doi.org/10.1007/s00268-012-1880-x Buckley, O., Ward, E. V., Doody, O., & Torreggiani, W. C. (2007). MRI of the wandering spleen. Clinical radiology , 62 (5), 504. https://doi.org/10.1016/j.crad.2006.11.018 Clark, J. K., Gorman, J., Lee, M. H., Barbick, B. C., & Marks, R. M. (2014). Dynamic MRI in the diagnosis and post surgical evaluation of wandering spleen. Journal of radiology case reports , 8 (10), 15–22. https://doi.org/10.3941/jrcr.v8i10.1969 Mohammadi, A., & Ghasemi-Rad, M. (2015). Wandering Spleen: Whirlpool Appearance in Color Doppler Ultrasonography. A Case Report. Maedica , 10 (1), 58–60 Aguirre Pascual, E., Fontanilla, T., Pérez, Í., Muñoz, B., Carmona, M. S., & Minaya, J. (2016). Wandering spleen torsion-use of contrast-enhanced ultrasound. BJR case reports , 3 (1), 20150342. https://doi.org/10.1259/bjrcr.20150342 Ben Ely, A., Zissin, R., Copel, L., Vasserman, M., Hertz, M., Gottlieb, P., & Gayer, G. (2006). The wandering spleen: CT findings and possible pitfalls in diagnosis. Clinical radiology , 61 (11), 954–958. https://doi.org/10.1016/j.crad.2006.06.007 Nastiti, N. A., Niam, M. S., & Khoo, P. J. (2019). Emergency laparoscopic splenectomy for torsion of wandering spleen in a geriatric patient: A case report. International journal of surgery case reports , 61 , 91–95. https://doi.org/10.1016/j.ijscr.2019.07.021 Soleimani, M., Mehrabi, A., Kashfi, A., Fonouni, H., Büchler, M. W., & Kraus, T. W. (2007). Surgical treatment of patients with wandering spleen: report of six cases with a review of the literature. Surgery today , 37 (3), 261–269. https://doi.org/10.1007/s00595-006-3389-0 Thompson, J. S., Ross, R. J., & Pizzaro, S. T. (1980). The wandering spleen in infancy and childhood. Clinical pediatrics , 19 (3), 221–224. https://doi.org/10.1177/000992288001900309 Palanivelu, C., Rangarajan, M., Senthilkumar, R., Parthasarathi, R., & Kavalakat, A. J. (2007). Laparoscopic mesh splenopexy (sandwich technique) for wandering spleen. JSLS : Journal of the Society of Laparoendoscopic Surgeons , 11 (2), 246–251 Schaarschmidt, K., Lempe, M., Kolberg-Schwerdt, A., Schlesinger, F., Hayek, I., & Jaeschke, U. (2005). The technique of laparoscopic retroperitoneal splenopexy for symptomatic wandering spleen in childhood. Journal of pediatric surgery , 40 (3), 575–577. https://doi.org/10.1016/j.jpedsurg.2004.11.020 Hirose, R., Kitano, S., Bando, T., Ueda, Y., Sato, K., Yoshida, T., Suenobu, S., Kawano, T., & Izumi, T. (1998). Laparoscopic splenopexy for pediatric wandering spleen. Journal of pediatric surgery , 33 (10), 1571–1573. https://doi.org/10.1016/s0022-3468(98)90503-6 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-615425","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":124917785,"identity":"3f762da8-c0d6-4245-b8fb-de5abce670c1","order_by":0,"name":"Lorenzo 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Case Report and Review of the Literature\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWandering spleen (WS) is a rare and still relatively unknown condition. It is characterized by an augmented mobility of the spleen, due to congenital lack of splenic ligaments or an acquired increased laxity of these structures.\u003c/p\u003e \u003cp\u003eThis relaxation of the tissues may lead to spontaneous torsions of the splenic hilum, with possible subsequent acute or chronic ischemic infarctions of the spleen, making WS a deceptive and misleading condition.\u003c/p\u003e \u003cp\u003eUntil 2012 WS cases reported in the medical literature were about 500 worldwide, almost a 0,5% of splenectomy performed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since 2012 there have been reported in literature almost 150 new cases.\u003c/p\u003e \u003cp\u003eThe real incidence of this pathology is surely underestimated because of the healthy carriers, making WS a silent condition until the appearance of its complications, which could also be life-threatening.\u003c/p\u003e \u003cp\u003eMost of the cases are reported in child bearing age women, in particular multiparous ones. probably in relation with the augmented laxity of the tissue due to hormonal values acquired during pregnancies.\u003c/p\u003e \u003cp\u003eThis hypothesis is confirmed by the observation of an asymmetrical distribution of WS in the adult population between female and male, with a proportion approximately of 7:1 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe second peak incidence is in the pediatric population, with equal distribution between male and female, and a medium age less than 10 years old [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In these cases the WS is probably related to congenital lack of splenic ligaments, giving the organ augmented mobility and subsequent possible acute and/or chronic torsion on its longitudinal axis.\u003c/p\u003e \u003cp\u003eIn the medical literature there are only few cases of WS during pregnancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], getting to complex and dangerous clinical pictures, complicated from the coexistence of the fetus.\u003c/p\u003e \u003cp\u003eThis study is a review of publications regarding WS and a case report of the most advanced gestational age WS during pregnancy, as far as we know in the medical literature.\u003c/p\u003e \u003cp\u003eThis rare condition was first described by the Van Horne in 1667, while the first scientific report about this pathology was redacted by a Polish doctor, Jozef Dietl, who described this anatomical variation, assuming for the first time the laxity of the ligaments as its possible etiogenesis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWS rests usually unknown until the appearance of a complication, such as chronic or acute ischemic damage, resulting from the torsion of the vascular axis, leading to potentially life-threatening conditions.\u003c/p\u003e \u003cp\u003eFor this reason, there are no clear clinical features related to WS, because it depends on the phases of the splenic wandering, and could remain undiagnosed all lifelong.\u003c/p\u003e \u003cp\u003eThe principal diagnostic tool in these cases is a radiological exam, such as ultrasound, CT scan and MRI [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], directing clinicians to correct treatment of this condition.\u003c/p\u003e \u003cp\u003eRadiological findings of WS are enlarged and hypertrophic splenic vessels, no spleen in left hypochondrium and a mobile mass in the belly.\u003c/p\u003e \u003cp\u003eUltrasound and CT scan with contrast are the most helpful techniques in case of acute torsion or thrombosis of the vascular splenic peduncle. The pathognomonic radiological appearance of the splenic vessels, called the \u0026ldquo;Whirlpool sign\u0026rdquo; [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], is associated with an absence of flow in the splenic parenchyma, and an augmented enhancement of the splenic capsule [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment of WS, once diagnosis is reached, is strongly correlated with the risk of almost 65% of occurrence of WS complications using conservative treatment, leading clinicians to invasive treatment of this condition once the diagnosis is confirmed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgery is the main treatment of WS, and there are two alternative approaches, depending on the WS condition.\u003c/p\u003e \u003cp\u003eTreatment of WS is founded on preoperative and intraoperative findings, based on splenic vascular state, grade of acute and/or chronic torsion of its hilum.\u003c/p\u003e \u003cp\u003eIn case of an asymptomatic patient, in paediatric/young population with no irreversible damage of the splenic parenchyma and function, prevails the need of preserving splenic function, and splenopexy is the most indicated treatment, with many different possible techniques [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom medical publications review, splenopexy offers optimal short and long term results regarding maintenance of vascularization of the splenic parenchyma and correct splenic location, making this technique world-wide accepted in case of elective treatment of WS [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn an acute case of WS, with ischemic compromission of the splenic parenchyma, urgent splenectomy is the most indicated treatment, acting in a potentially life-threatening clinical situation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth these techniques can be performed laparoscopic, after evaluation of surgical experience and disposability of surgical material for surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The technique allows for relevant diminution of postoperative pain and complications, a minor length of stay and an earlier return to normal activities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case report has been reported in line with the SCARE criteria [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eLZ, a 31 years white woman, BMI 20, primigravida, with no pathological history, no pharmacologic chronic therapy nor allergies reported.\u003c/p\u003e\n\u003cp\u003eMild thrombocytopenia was found in previous blood exams, minimal value of 95\u003csup\u003e9\u003c/sup\u003e platelets/L in 2016, never examined with second level exams.\u003c/p\u003e\n\u003cp\u003eDuring the first obstetrical ultrasound check, a vascularized and capsulated mobile mass in the abdomen was detected, with a major axis of 12,5 centimetres, characterized from an hypertrophic and elongated hilar vascular axis. In parallel, there was no spleen in the left hypochondrium, confirming WS diagnosis.\u003c/p\u003e\n\u003cp\u003eThe WS had some parenchymal calcifical strias, as per previous parcellar ischemic infarctions.\u003c/p\u003e\n\u003cp\u003eThis condition was totally asymptomatic, the physical examination was negative for any pathological finding, no palpable masses, no abdominal evocable pain.\u003c/p\u003e\n\u003cp\u003eThe result of the multidisciplinary consult executed was an indication of close monitoring of WS through frequent ultrasound examinations and blood exams, with conservative treatment because of the initial weeks of the pregnancy.\u003c/p\u003e\n\u003cp\u003eDuring week 17th of the pregnancy the patient had blood exams, demonstrating a reduction of PLTs count to 87\u003csup\u003e9\u003c/sup\u003e/L, with stability of the WS in ultrasound check.\u003c/p\u003e\n\u003cp\u003eMRI has been planned in order to have more precise information and set the best treatment for the patient. Some days before the MRI, on October 30, 2019, during the 22th week of pregnancy, the patient got to the ER because of the onset of intense and diffuse abdominal pain during the night, without fever or any other clinical manifestation.\u003c/p\u003e\n\u003cp\u003eBlood exams were in the range of normality, except for further thrombocytopenia, with PLTs count to 74\u003csup\u003e9\u003c/sup\u003e/L.\u003c/p\u003e\n\u003cp\u003eUrgent ultrasound check was performed, observing augmented volume of the WS (diameter 18x8 cm), parenchymal ischemic injury, no vascular signal detected at the splenic hilum with Color-Doppler technique, without free fluid in the belly (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eFor this reason, the patient underwent an urgent surgical procedure.\u003c/p\u003e\n\u003cp\u003eA laparoscopic approach was decided, noticing an hypertrophic mobile spleen in subhepatic space, surrounded by a multitude of ectasic and congested vessels. The principal vascular axis of the WS was also hypertrophic, with a diameter around 4 cm (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAfter initial mobilization of the WS and partial dissection of the perisplenic vessel and isolation of the principal vascular axis, a median mini-laparotomy was performed to dissect and tie the hypertrophic splenic vessels with non resorbable suture (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eUsing laparoscopy, a complete mobilization of the WS was performed from its remaining ligaments.\u003c/p\u003e\n\u003cp\u003eA subsequent extraction of the spleen from the laparotomy was executed from the service laparotomy. Fetal parameters resulted physiological and unaltered after surgery. Post operative course was regular, the PLTs count normalized in a few weeks, with a media of 300\u003csup\u003e9\u003c/sup\u003e/L. Subsequent blood exams confirmed normalization of PLTs values (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).Patient had natural childbirth at week 39th with no complications.\u003c/p\u003e\n\u003cp\u003ePatient subsequently received \u003cem\u003eStreptococcus Pneumoniae\u003c/em\u003e, \u003cem\u003eHaemophilus Influenzae\u003c/em\u003e and \u003cem\u003eNeisseria Meningitidis\u003c/em\u003e vaccinations, as standard prevention for most frequent severe infections after splenectomy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWS is a rare and insidious condition, with many different possible manifestations, from asymptomatic patients to urgent and emergency situations, requiring prompt and opportune diagnosis and treatment, making this condition very challenging for clinicians.\u003c/p\u003e \u003cp\u003eWS is a diagnosis that must be included in differential diagnosis in particular cases, such as multiparous women with abdominal palpable mass or recurrent and vague abdominal pain.\u003c/p\u003e \u003cp\u003eIncrease in WS diagnosis is supported by a constant and rapid improvement in radiological technique, getting more easily and accurately diagnosed in elective and acute examination.\u003c/p\u003e \u003cp\u003eSurgical splenic preservation is mandatory for the patient\u0026rsquo;s safety, with many possible laparoscopic and laparotomic treatments, depending on the surgeon\u0026rsquo;s ability and hospital\u0026rsquo;s available resources.\u003c/p\u003e \u003cp\u003eSplenectomy instead must be preferred when splenic vascularization is compromised, and the risk of splenic rupture is very high and risky for the patient.\u003c/p\u003e \u003cp\u003eWS knowledge is principally based on an increasing number of single case reports, such as this one, driving clinicians to manage this rare and complex diagnosis, both in emergency and in elective surgery.\u003c/p\u003e \u003cp\u003eA better understanding of WS etiopathogenesis is important to reach a complete comprehension of its pathological mechanisms, to get a better diagnostic and therapeutic ability, preventing a possible life-threatening condition.\u003c/p\u003e \u003cp\u003eFurther studies are necessary to obtain a full understanding of WS\u0026rsquo;s genesis, to get a unique and standard diagnostic and therapeutic guideline, making WS best known and less dangerous condition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ei. Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding were received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eii. Conflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiii. Ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eiv. Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFully informed written consent were obtained for surgery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ev. Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFully informed written consent were obtained for publication\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003evi. Availability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and material are available from main author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003evii. Code availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eviii. Authors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLorenzo Crepaz and Alberto Di Leo wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eLorenzo Crepaz, Giuseppe Borzellino and Paola Pomini took part to surgical procedure.\u003c/p\u003e\n\u003cp\u003eLorenzo Crepaz, Michele Genna managed preoperative and postoperative indications.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePuranik, A. K., Mehra, R., Chauhan, S., \u0026amp; Pandey, R. (2017). Wandering spleen: a surgical enigma. \u003cem\u003eGastroenterology report\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(3), 241\u0026ndash;243. https://doi.org/10.1093/gastro/gov034\u003c/li\u003e\n\u003cli\u003eNational Organization for Rare Disorders (NORD), Wandering spleen. https://rarediseases.org/rare-diseases/wandering-spleen/. Accessed 01 April 2021.\u003c/li\u003e\n\u003cli\u003eRadillo, L., Taddio, A., Ghirardo, S., Bramuzzo, M., Pederiva, F., Maschio, M., \u0026amp; Barbi, E. (2016). The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature. \u003cem\u003ePediatric emergency care\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(9), 619\u0026ndash;622. https://doi.org/10.1097/PEC.0000000000000642\u003c/li\u003e\n\u003cli\u003eParvaiz, A., Chandran, S., Karim, A., Kumar, K., Jeffrey, P., \u0026amp; Lagattolla, N. R. (2004). Torted and ruptured wandering spleen presenting as a surgical emergency in pregnancy. \u003cem\u003eTheScientificWorldJournal\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e, 1035\u0026ndash;1037. https://doi.org/10.1100/tsw.2004.208\u003c/li\u003e\n\u003cli\u003eY\u0026uuml;cel, E., Kurt, Y., Ozdemir, Y., Gun, I., \u0026amp; Yildiz, M. (2012). Laparoscopic splenectomy for the treatment of wandering spleen in a pregnant woman: a case report. \u003cem\u003eSurgical laparoscopy, endoscopy \u0026amp; percutaneous techniques\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(2), e102\u0026ndash;e104. https://doi.org/10.1097/SLE.0b013e318246beb5\u003c/li\u003e\n\u003cli\u003eAgha, R. A., Borrelli, M. R., Farwana, R., Koshy, K., Fowler, A. J., Orgill, D. P., \u0026amp; SCARE Group (2018). The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines. \u003cem\u003eInternational journal of surgery (London, England)\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e, 132\u0026ndash;136. https://doi.org/10.1016/j.ijsu.2018.10.028\u003c/li\u003e\n\u003cli\u003eMagowska A. (2013). Wandering spleen: a medical enigma, its natural history and rationalization. \u003cem\u003eWorld journal of surgery\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(3), 545\u0026ndash;550. https://doi.org/10.1007/s00268-012-1880-x\u003c/li\u003e\n\u003cli\u003eBuckley, O., Ward, E. V., Doody, O., \u0026amp; Torreggiani, W. C. (2007). MRI of the wandering spleen. \u003cem\u003eClinical radiology\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(5), 504. https://doi.org/10.1016/j.crad.2006.11.018\u003c/li\u003e\n\u003cli\u003eClark, J. K., Gorman, J., Lee, M. H., Barbick, B. C., \u0026amp; Marks, R. M. (2014). Dynamic MRI in the diagnosis and post surgical evaluation of wandering spleen. \u003cem\u003eJournal of radiology case reports\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(10), 15\u0026ndash;22. https://doi.org/10.3941/jrcr.v8i10.1969\u003c/li\u003e\n\u003cli\u003eMohammadi, A., \u0026amp; Ghasemi-Rad, M. (2015). Wandering Spleen: Whirlpool Appearance in Color Doppler Ultrasonography. A Case Report. \u003cem\u003eMaedica\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 58\u0026ndash;60\u003c/li\u003e\n\u003cli\u003eAguirre Pascual, E., Fontanilla, T., P\u0026eacute;rez, \u0026Iacute;., Mu\u0026ntilde;oz, B., Carmona, M. S., \u0026amp; Minaya, J. (2016). Wandering spleen torsion-use of contrast-enhanced ultrasound. \u003cem\u003eBJR case reports\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), 20150342. https://doi.org/10.1259/bjrcr.20150342\u003c/li\u003e\n\u003cli\u003eBen Ely, A., Zissin, R., Copel, L., Vasserman, M., Hertz, M., Gottlieb, P., \u0026amp; Gayer, G. (2006). The wandering spleen: CT findings and possible pitfalls in diagnosis. \u003cem\u003eClinical radiology\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e(11), 954\u0026ndash;958. https://doi.org/10.1016/j.crad.2006.06.007\u003c/li\u003e\n\u003cli\u003eNastiti, N. A., Niam, M. S., \u0026amp; Khoo, P. J. (2019). Emergency laparoscopic splenectomy for torsion of wandering spleen in a geriatric patient: A case report. \u003cem\u003eInternational journal of surgery case reports\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e, 91\u0026ndash;95. https://doi.org/10.1016/j.ijscr.2019.07.021\u003c/li\u003e\n\u003cli\u003eSoleimani, M., Mehrabi, A., Kashfi, A., Fonouni, H., B\u0026uuml;chler, M. W., \u0026amp; Kraus, T. W. (2007). Surgical treatment of patients with wandering spleen: report of six cases with a review of the literature. \u003cem\u003eSurgery today\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(3), 261\u0026ndash;269. https://doi.org/10.1007/s00595-006-3389-0\u003c/li\u003e\n\u003cli\u003eThompson, J. S., Ross, R. J., \u0026amp; Pizzaro, S. T. (1980). The wandering spleen in infancy and childhood. \u003cem\u003eClinical pediatrics\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(3), 221\u0026ndash;224. https://doi.org/10.1177/000992288001900309\u003c/li\u003e\n\u003cli\u003ePalanivelu, C., Rangarajan, M., Senthilkumar, R., Parthasarathi, R., \u0026amp; Kavalakat, A. J. (2007). Laparoscopic mesh splenopexy (sandwich technique) for wandering spleen. \u003cem\u003eJSLS : Journal of the Society of Laparoendoscopic Surgeons\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(2), 246\u0026ndash;251\u003c/li\u003e\n\u003cli\u003eSchaarschmidt, K., Lempe, M., Kolberg-Schwerdt, A., Schlesinger, F., Hayek, I., \u0026amp; Jaeschke, U. (2005). The technique of laparoscopic retroperitoneal splenopexy for symptomatic wandering spleen in childhood. \u003cem\u003eJournal of pediatric surgery\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(3), 575\u0026ndash;577. https://doi.org/10.1016/j.jpedsurg.2004.11.020 \u003c/li\u003e\n\u003cli\u003eHirose, R., Kitano, S., Bando, T., Ueda, Y., Sato, K., Yoshida, T., Suenobu, S., Kawano, T., \u0026amp; Izumi, T. (1998). Laparoscopic splenopexy for pediatric wandering spleen. \u003cem\u003eJournal of pediatric surgery\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(10), 1571\u0026ndash;1573. https://doi.org/10.1016/s0022-3468(98)90503-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"wandering spleen, pregnancy, splenopexy, acute abdomen, case report","lastPublishedDoi":"10.21203/rs.3.rs-615425/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-615425/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Wandering spleen (WS) is a rare condition, which is characterized by an augmented mobility of the spleen, due to congenital or acquired causes. It’s more frequent in multiparous women, but only a few cases are reported during pregnancy. WS is usually asymptomatic until the onset of ìts possible complications, and this can mislead clinicians in reaching the correct diagnosis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCase Report: \u003c/strong\u003eWe report the case of WS with acute splenic infarction in a pregnant woman and its mininvasive surgical treatment, focusing on the clinical and radiological findings that could mislead or drive clinicians to the right diagnosis, or to a potential disaster.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSplenic preservation in WS where it’s safe and possible and is the main goal of the treatment. Clinical and radiological findings are the most relevant elements to drive surgical treatment.\u003c/p\u003e\u003cp\u003eWS is an insidious condition, and must be included in differential diagnosis in determined cases, to reach the best and opportune treatment for the patient.\u003c/p\u003e","manuscriptTitle":"The Wandering Spleen: Laparoscopic Splenectomy in a Pregnant Woman. Case Report and Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-02 16:57:17","doi":"10.21203/rs.3.rs-615425/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"945b4750-1f46-457a-bf7a-b8c221b65697","owner":[],"postedDate":"August 2nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-09-07T05:51:46+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-02 16:57:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-615425","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-615425","identity":"rs-615425","version":["v1"]},"buildId":"wLkW0s4AflPzk-lpfg-fK","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}