Idiopathic spleen rupture after laparoscopic appendectomy

Abstract text (incl. references and figure legends)
Case history and clinical findings

54-years-old woman underwent a laparoscopic appendectomy for an acute appendicitis. Three days after the surgery the patient developed generalized abdominal pain and hypovolemic shock.

Investigation/Results

A CT-scan revealed active bleeding confined to the splenic capsule and a parenchymal laceration involving segmental arteries

Diagnosis

Idiopathic rupture of the spleen after appendectomy was the presumed diagnosis.

Therapy and Progressions

The patient underwent emergency open splenectomy. She had an uneventful post-operatory recovery and was discharged clinically improved, at the 3rd day post-op.

Comments

Atraumatic rupture of the spleen is a rare event, with a mortality rate of up to 12%. In 93% of the cases, this condition is related to underlying pathologic conditions like malignancy or infectious. In the remain 7% of the cases there is no identifiable cause. There are also a number of case reports that described splenic ruptures after laparoscopic surgery such as Nissen fundoplication and repair of perforated duodenal ulcer.

The traction forces transmitted to the spleen at the induction of the pneumoperitoneum trough the splenic ligament or the presence of adhesions between the spleen and the colon may favour ruptures. In our case the patient had no previous surgical history, the histologic analysis revealed a normal spleen and there were no surgical manoeuvres performed in the sub-phrenic space. Furthermore, during the second intervention the presence of intra-peritoneal adhesions was ruled out.

Since the rupture occurred three days after the appendectomy, it is likely that the two events are related.

Idiopathic splenic ruptures are rare but should be remembered as a potential source of postoperative haemorrhage with no obvious etiology.

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