LAUSR

A wandering spleen is a rare entity, defined as splenic ectopy as a result of an absence or malformation of the splenic ligamentous attachments due to abnormalities of the dorsal mesogastrium at birth. This condition predisposes the spleen to acute torsion and infarction, which may present as acute abdominal pain, or intermittent and chronic torsion, with resultant splenic vein obstruction, leading to the formation of gastric varices. Herein, the authors report a case of an 18-year-old female, with a wandering spleen complicated by worsening splenomegaly from venous congestion with resultant gastric varices. A previously well 18-year-old female first presented in 2016 with a 2-month history of intermittent left-sided abdominal pain. On examination, she had a palpable splenomegaly about 4 cm below the left costal margin confirmed on computed tomography. Her symptoms resolved with symptomatic treatment and she was keen for observation. In 2018, it was noted that the spleen has significantly enlarged and she had developed new gastric varices with features of portal hypertension on a repeat computed tomography scan (Fig. 1), confirmed on oesophagogastroduodenoscopy (Fig. 2). On repeat examination, the palpable splenomegaly now manifested as a lower abdominal mass. Given the enlarging splenomegaly with the development of new gastric varices, a laparoscopic splenectomy was performed to avoid complications of splenic torsion, rupture and progression of varices. A transumbilical approach was employed to gain access into the abdomen via an open Hasson’s technique. A diagnostic laparoscopy was performed, which confirmed the pelvic location of the spleen, and three working trocars were placed in the left and right periumbilical region, and the right iliac fossa for proper triangulation. Intraoperatively, the spleen was noted to be freely mobile, with engorged veins in the splenic pedicle. Histopathological examination of the spleen revealed splenic congestion of the red pulp and no evidence of any granuloma or malignant infiltrate. Postoperatively, she recovered well, and on follow-up 3 months after surgery, her symptoms and gastric varices have resolved. A wandering spleen occurs as part of an embryological abnormality which results in an abnormally long splenic vascular pedicle, with an absence of the splenic suspensory ligamentous attachments. During the fifth to sixth week of embryological development, a failure of fusion of the dorsal mesogastrium results in an abnormally long splenic vascular pedicle. The lack of fusion also results in lack of fixation of the spleen and formation of the splenorenal and gastrosplenic ligaments, thus allowing the spleen to be extremely mobile in the abdominal cavity. In this patient, she presented with intermittent bouts of abdominal pain, likely secondary to intermittent torsion with subsequent detorsion of the wandering spleen. With prolonged chronic torsion, splenic vein occlusion occurs, with resultant gastric varices. Wandering spleens tend to have a female predisposition, with majority of patients presenting in late adolescent to mid-adulthood. A review of the current literature regarding the management of this rare entity revealed two interesting points. First, almost all Fig. 1. Splenomegaly with wandering spleen (denoted by *) in the pelvis and prominent gastric varices (denoted by the arrow).