Splenic Hilum Research Articles

Splenic Epidermoid Cyst arising within an Intrapancreatic Accessory Spleen Masquerading as a Pancreatic Mucinous Cystic Neoplasm-a diagnostic enigma

Abstract Introduction/Objective Accessory spleens are congenital embryological aberrations usually found within the splenic hilum with no clinical significance. An IntraPancreatic Accessory Spleen (IPAS) is an uncommon benign pancreatic lesion encountered clinically. A splenic epidermoid cyst arising within an IPAS is exceedingly rare and is discussed below. Methods/Case Report A 68-year-old male presented with intermittent post-prandial epigastric pain radiating to the left flank for >1.5 years. Radiological imaging identified a 5.2 cm calcified cyst in the pancreatic tail with a differential of mucinous pancreatic neoplasm/ pancreatic pseudocyst. Additionally, a 2.8cm lobulated solid hypoechoic mass was seen at the porta hepatis with a differential of enlarged lymph node/benign neoplasm. Laboratory biochemical tests were within normal limits except for mildly elevated ferritin. Fine needle aspiration biopsy was indeterminate. The patient elected to proceed with surgical resection. A laparoscopic distal pancreatectomy with splenectomy and excision of the hilar mass was performed. The hilar mass was analyzed by hematopathology and revealed a hyaline- vascular variant of Castleman disease. On gross examination of the distal pancreatic/splenectomy specimen, a well- demarcated cystic lesion with brownish fluid was noted within the pancreatic tail. Microscopic examination revealed a nonpathological pancreas separated by a fibrous capsule with a large cyst arising within an intrapancreatic accessory spleen. The cyst was lined with multilayered non-keratinized CK5/6, and p63 positive squamous epithelium with no lymphocytic infiltrates and absent hair/ dermal appendages confirming a splenic epidermoid cyst. Post-operative follow-up at 6 weeks was uneventful. Results (if a Case Study enter NA) NA Conclusion An epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS) is extremely rare thus precluding accurate preoperative diagnosis as this entity shares similar radiological imaging characteristics as other cystic lesions such as mucinous pancreatic cysts. It is important for anatomic pathologists to recognize and consider the intrapancreatic compartment as a possible location for accessory spleens. Accurate preoperative diagnosis can prevent unnecessary surveillance and/or extensive surgical resection.

Evaluation of the presence and severity of spontaneous splenorenal or gastrorenal shunts via four-dimensional flow magnetic resonance imaging: a preliminary study.

Four-dimensional phase-contrast magnetic resonance imaging (4D flow MRI) is a relatively new type of MRI acquisition technique that provides a unique and comprehensive set of information within a single acquisition, including hemodynamic and anatomical information. This study was designed to noninvasively evaluate the correlation between the presence and severity of spontaneous splenorenal shunt (SRS) or gastrorenal shunt (GRS) and 4D flow MRI-derived parameters. This retrospective case-control study enrolled 70 patients who were diagnosed with hepatocirrhosis portal hypertension and admitted to the Second Affiliated Hospital of Chongqing Medical University. Patients were divided into three groups according to the diameter of the SRS and GRS. 4D flow MRI-derived parameters, including the turbulent kinetic energy, total volume (TV), flow velocity, blood flow volume (BFV), maximum flow (MF), wall shear stress, and relative pressure, were obtained for eight cut planes: proximal to the splenomesenteric confluence and liver hilum of the portal vein (PV1/PV2); the left/right branch of the bifurcation of the PV (LPV/RPV), at the mesosplenic confluence of the splenic vein (SV1), at the splenic hilum of the SV (SV2); at the proximal to the splenomesenteric confluence of the superior mesenteric vein (SMV1), and 5 cm from the splenomesenteric confluence of the SMV (SMV2). Comparisons among the three groups were based on one-way analysis of variance (ANOVA). Logistic regression was used to identify the risk factors for small SRS/GRS (S-SRS/GRS) and for large SRS/GRS (L-SRS/GRS). Receiver operating characteristic curves were used to evaluate the diagnostic performance of the independent risk factors for SRS and GRS. The associations between the clinical data and the 4D flow MRI-derived parameters of GRS and SRS were assessed via Spearman correlation coefficient analysis. The presence of SRS or GRS was correlated with TVLPV (r=-0.302; P=0.035), TVPV1 (r=-0.385; P=0.001), TVPV2 (r=-0.301; P=0.013), BFVPV1 (r=-0.360; P=0.010), BFVSMV2 (r=0.371; P=0.008), MFPV1 (r=-0.341; P=0.004), and MFPV2 (r=-0.291; P=0.017). Meanwhile, the severity of the SRS or GRS was correlated with alanine aminotransferase level (r=-0.535; P<0.001), BFVLPV (r=-0.560; P=0.008), aspartate aminotransferase level (r=-0.321; P=0.038), and model for end-stage liver disease score (r=0.323; P=0.039). TVPV1, TVPV2, BFVPV1, BFVPV2, and MFSMV2 were found to be independent risk factors for L-SRS/GRS, with intermediate diagnostic efficacy, with the area under the curve (AUC)TV PV1=0.706 [95% confidence interval (CI): 0.519-0.853; sensitivity, 61.54%; specificity, 80.77%; P=0.018], AUCBFV PV1 =0.694 (95% CI: 0.507-0.844; sensitivity, 95.00%; specificity, 63.16%; P=0.035), AUCTV PV2 =0.729 (95% CI: 0.544-0.870; sensitivity, 77.78%; specificity, 66.67%; P=0.016), AUCBFV PV2 =0.718 (95% CI: 0.531-0.862; sensitivity, 60.00%; specificity, 82.35%; P=0.017), and AUCMF SMV2 =0.788 (95% CI: 0.608-0.912; sensitivity, 44.00%; specificity, 84.46%; P=0.005), respectively. As the TV of PV1 and PV2 and the BFV of PV1 and PV2 decreased, the risk of L-SRS/GRS increased. As the MF of SMV2 increased, the risk of the presence of L-SRS/GRS increased. 4D flow MRI-derived parameters correlated with the presence and severity of SRS or GRS. Meanwhile, the independent risk factors for the presence of L-SRS/GRS were the TV of LPV, PV1, and PV2; the BFV of PV1 and SMV2; and the MF of PV1 and PV2.

Porto-mesenteric four-dimensional flow MRI: a novel non-invasive technique for assessment of gastro-oesophageal varices

ObjectivesTo assess the role of 4D flow MRI in the assessment of gastro-oesophageal varices and in the prediction of high-risk varices in patients with chronic liver disease.MethodsThirty-eight patients diagnosed with either oesophageal or gastric varices were included in this single-centre prospective study. 4D flow MRI was used to calculate peak flow, average flow and peak velocity at the portal vein confluence (PV1) and hilum (PV2), splenic vein hilum (SV1) and confluence (SV2), and superior mesenteric vein (SMV). PV and SV fractional flow changes were also measured.ResultsROC analysis revealed that both PV2 average flow and PV fractional average flow change had 100% sensitivity to predict high-risk patients with the PV fractional peak flow change having the widest area under the curve (AUC) and the highest specificity (92.3%). SV1 average flow, SV2 average flow, SV2 peak flow, and SV2 peak velocity increased significantly in patients with oesophageal compared to gastric varices included (p = 0.022, < 0.001, < 0.001 and 0.001, respectively).ConclusionBased on certain porto-mesenteric blood flow, velocity, and fractional flow change parameters, 4D flow MRI showed excellent performance in identifying high-risk patients and giving an idea about the grade and location of varices.Critical relevance statementVariceal bleeding is a major consequence of unidentified risky upper GI varices. Thus, by identifying and locating high-risk varices early, either oesophageal or gastric, using a non-invasive method like MRI, adverse events might be avoided.Key Points4D flow MRI can be used as a potential alternative for endoscopy to predict patients with high-risk varices.Based on portal vein fractional flow change, splenic flow and velocity, 4D MRI can predict and locate high-risk varices.Earlier identification of high-risk varices can allow for interventions to prevent adverse events.Graphical

Accessory Splenic Mass Masquerading as Hepatocellular Carcinoma: A Diagnostic Dilemma

The spleen plays a pivotal role in our immune system by facilitating the proliferation and differentiation of lymphocytes and monocytes. Typically located in the left upper quadrant retroperitoneally, splenic tissue found outside of its usual position is termed ectopic spleen. When the tissue maintains its histological architecture and encapsulation and receives blood supply from splanchnic vessels, it is called an accessory spleen. Although it commonly presents near the splenic hilum or pancreatic tail, rare instances have been reported in the gastric, liver, gastrosplenic/lienorenal ligaments, as well as thoracic and gonadal regions. However, the case of an accessory spleen, mimicking a hepatic lesion in the right diaphragm represents a novel observation.

Epidermoid Cyst arising within an Intrapancreatic Accessory Spleen [ECIPAS] mimicking a pancreatic mucinous cystic neoplasm-a case report with literature review

Background: Accessory spleens are congenital embryological aberrations usually found within the splenic hilum with no clinical significance. An Intra Pancreatic Accessory Spleen (IPAS) is an uncommon benign pancreatic lesion encountered clinically. The occurrence of an Epidermoid Cyst arising within an IPAS (ECIPAS) is exceedingly rare and is often misdiagnosed as a pancreatic pathology such as mucinous cystic neoplasm, cystic degeneration within a solid tumor such as a neuroendocrine tumor, or a lymph node. Case report: A 68-year-old male presented with intermittent post-prandial abdominal pain for over 2 years. Abdominal computer tomography identified a 5.2 cm calcified cyst within the pancreatic tail and a mucinous pancreatic neoplasm/pancreatic pseudocyst was considered in the differential diagnosis. The results of endoscopic ultrasound and fine needle aspiration were indeterminate. Due to persistent abdominal pain, the patient underwent a laparoscopic distal pancreatectomy with splenectomy. A gross examination of the distal pancreatic/splenectomy specimen confirmed a well-demarcated cystic lesion with brownish fluid within the pancreatic tail. Microscopic examination revealed a nonpathological pancreas separated by a fibrous capsule with a large cyst arising within an intrapancreatic accessory spleen. The cyst was lined with multilayered non-keratinized stratified squamous epithelium positive for pancytokeratin, CA 19-9, CK5/6, and p63 with no lymphocytic infiltrates and absent hair/ dermal appendages confirming an epidermoid cyst. CD8 outlined the dendritic network of the littoral cells of the splenic tissue in the cyst wall. Post-operative follow-up at 6 weeks was uneventful. Conclusion: The preoperative diagnosis of ECIPAS is extremely difficult as this entity shares overlapping radiological features with other cystic lesions such as mucinous pancreatic cysts. It is important for anatomic pathologists to recognize and consider the intrapancreatic compartment as a possible site for accessory spleen. As histopathology is the final determinant of this diagnosis, increased clinical awareness with an accurate diagnosis of this entity may prevent patients from unnecessary surveillance and/or extensive oncological-based surgical resection.

Spontaneous rupture of a mycotic splenic artery pseudoaneurysm secondary to histoplasmosis: a case report

BackgroundA splenic artery pseudoaneurysm is a rare pathology that occurs mainly secondary to pancreatitis, abdominal trauma, peptic ulcers, pancreatic and gastric cancers, and infections. It is best diagnosed using computed tomography angiography and typically treated using endovascular embolization and, in some cases, open or laparoscopic surgery. In this report, we present a case of a ruptured mycotic splenic artery pseudoaneurysm containing Histoplasma capsulatum, which to our knowledge is the first case to report a mycotic splenic artery pseudoaneurysm of this nature.Case presentationWe report a case of a 42-year-old white male with past medical history of Hepatitis C and IV drug abuse who presented to the Emergency Department with a 24-h history of severe diffuse abdominal pain. He was tachycardic and peritonitic on exam. Work-up demonstrated leukocytosis and lactic acidosis. Computed tomography of the abdomen and pelvis with intravenous contrast showed hemoperitoneum and active extravasation of contrast from the splenic artery into the splenic hilum, associated with a surrounding hematoma measuring 5.3 × 5.0 cm, concerning for ruptured splenic artery pseudoaneurysm. The patient was taken emergently for exploratory laparotomy, where a large intraperitoneal hematoma was evacuated. A ruptured splenic artery pseudoaneurysm was identified, isolated, and controlled, followed by completion splenectomy. Final pathology demonstrated a 3.0 × 1.3 × 0.3 cm pseudoaneurysm wall and a 14 × 9.5 × 5.5 cm spleen containing multiple necrotizing granulomata positive for the presence of Histoplasmosis species. The patient recovered appropriately and was discharged on post-operative day five.ConclusionsThis case demonstrates a successful approach to a ruptured mycotic splenic artery pseudoaneurysm resulting in a positive outcome. It is a unique case as it highlights, to our knowledge, the first report of splenic artery aneurysm secondary to Histoplasma capsulatum infection. This report helps further the understanding of the pathophysiology as well as the natural history of mycotic splenic pseudoaneurysms.

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

BackgroundDuring laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel.MethodsThis is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our“five-step process”(n = 34) between January 2021 and July 2023 were included.ResultsThe vessels can be effectively exposed using the aforementioned “five-step process.” It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein.ConclusionWe have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer

Discrepancies in Splenic Size Measurement: A Comparative Analysis of Ultrasound and Computed Tomography.

The accurate measurement of splenic size is essential for the diagnosis and management of various gastrointestinal and hematological conditions. While ultrasound (US) and computed tomography (CT) are widely used imaging modalities for assessing splenic size, discrepancies between their measurements have been observed in clinical practice. This study aimed to analyze the measurement differences between US and CT and identify factors influencing these differences. A retrospective analysis of 598 asymptomatic patients who underwent both abdominal US and CT was conducted. Measurements of splenic size obtained from US, axial CT, and coronal CT scans were compared, and various factors such as patient demographics, operator experience, and imaging parameters were evaluated to elucidate their impact on the measurement discrepancies. The results revealed that US consistently underestimated splenic size compared to CT. The magnitude of the discrepancy was influenced by factors such as patient age, body mass index (BMI), depth of the spleen from skin on US and that on CT, visibility of the splenic hilum on US, sonic window quality, and operator experience. This study underscores the importance of considering these factors when interpreting splenic measurements obtained from different imaging modalities in clinical practice.

Robotic resection for splenic artery aneurysm associated with neurofibromatosis type 1: a case report

BackgroundNeurofibromatosis type 1 is an autosomal-dominant disease characterized by café-au-lait spots and neurofibromas, as well as various other symptoms in the bones, eyes, and nervous system. Due to its connection with vascular fragility, neurofibromatosis type 1 has been reported to be associated with vascular lesions, such as aneurysms. However, there have been few reports of abdominal visceral aneurysms associated with neurofibromatosis type 1. Furthermore, there have been no reports of robotic treatment of aneurysms associated with neurofibromatosis type 1. In this report, we describe the case of a patient with neurofibromatosis type 1 with a splenic artery aneurysm who was successfully treated with robotic surgery.Case presentationThis report describes a 41-year-old Asian woman with a history of neurofibromatosis type 1 who was referred to our hospital for evaluation of a 28 mm splenic artery aneurysm observed on abdominal ultrasound. The aneurysm was in the splenic hilum, and transcatheter arterial embolization was attempted; however, this was difficult due to the tortuosity of the splenic artery. Thus, we suggested minimally invasive robotic surgery for treatment and resection of the splenic artery aneurysm with preservation of the spleen. The postoperative course was uneventful, and the patient was discharged on the eighth day after surgery. At 1 year of follow-up, the patient was doing well, with no evidence of recurrence.ConclusionWe encountered a rare case of splenic artery aneurysm in a patient with neurofibromatosis type 1 who was successfully treated with robotic surgery. There is no consensus on treatment modalities for neurofibromatosis-related aneurysms, and endovascular treatment is considered safe and effective; however, surgery remains an important treatment modality. Especially in patients with stable hemodynamic status, robotic surgery may be considered as definitive treatment. To our knowledge, this is the first successfully treated case of a splenic artery aneurysm in a patient with neurofibromatosis type 1.

Spleen anatomic variations in the context of morphology

The immune and hematopoietic systems in the human body depend on the spleen. The understanding of anatomical and morphological variations of the spleen and its arterial vascular segments (AVS) is crucial for performing whole or partial splenectomy in the treatment of splenomegaly and splenic rupture. The aim of this study was to compare the anatomical differences in the spleen and its AVS in Thai cadavers of both sexes. This cadaveric study was performed on 77 cadaveric spleens (males = 38 and females = 39) from the Gross Anatomy Laboratory at the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University. The average morphological measures of the observed spleens were 9.11±1.40 cm in length, 6.57±1.46 cm in width, 3.11±0.67 cm in thickness in male cadavers, and 8.77±1.87 cm in length, 5.91±1.35 cm in width, and 2.90±0.78 cm in thickness in female cadavers. The variations in spleen form were 7.79% oval, 16.88% tetrahedral, 28.57% triangular, and 46.75% wedge. The mean splenic hilum length was 5.14±1.10 cm in males and 5.12±1.22 cm in females. The mean lobar branch to hilum distance was 2.26±0.98 cm in males and 2.29±1.05 cm in females. Females were more likely than males to have two lobar arteries. Three lobar arteries, however, were more prevalent in males. The occurrence of accessory spleens was 2.63% for males and 7.50% for females. According to the data, there were significant differences in the number of lobar arteries and spleen size between male and female Thai cadavers.

Appraisal of surgical outcomes and oncological efficiency of intraoperative adverse events in robotic radical gastrectomy for gastric cancer.

Surgical quality control is a crucial determinant of evaluating the tumor efficacy. To assess the ClassIntra grade for quality control and oncological outcomes of robotic radical surgery for gastric cancer (GC). Data of patients undergoing robotic radical surgery for GC at a high-volume center were retrospectively analyzed. Patients were categorized into two groups, the intraoperative adverse event (iAE) group and the non-iAE group, based on the occurrence of intraoperative adverse events. The iAEs were further classified into five sublevels (ranging from I to V according to severity) based on the ClassIntra grade. Surgical performance was assessed using the Objective Structured Assessment of Technical Skill (OSATS) and the General Error Reporting Tool. This study included 366 patients (iAE group: n = 72 [19.7%] and non-iAE group: n = 294 [80.3%]). The proportion of ClassIntra grade II patients was the highest in the iAE group (54.2%). In total and distal gastrectomies, iAEs occurred most frequently in the suprapancreatic area (50.0% and 54.8%, respectively). In total gastrectomy, grade IV iAEs were most common during lymph node dissection in the splenic hilum area (once for bleeding [grade IV] and once for injury [grade IV]). The overall survival (OS) and disease-free survival of the non-iAE group were significantly better than those of the iAE group (Log rank P < 0.001). Uni- and multi-variate analyses showed that iAEs were key prognostic indicators, independent of tumor stage and adjuvant chemotherapy (P < 0.001). iAEs in patients who underwent robotic radical gastrectomy significantly correlated with the occurrence of postoperative complications and a poor long-term prognosis. Therefore, utilization and inclusion of ClassIntra grading as a crucial surgical quality control and prognostic indicator in the routine surgical quality evaluation system are recommended.

Nodal recurrence mapping and clinical target volumes after resection of intrahepatic cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma

BackgroundScarce evidence exists for clinical target volume (CTV) definitions of regional lymph nodes (LNs) in intrahepatic cholangiocarcinoma (iCCA) or combined hepatocellular-cholangiocarcinoma (cHCC-CCA). We investigated the mapping pattern of nodal recurrence after surgery for iCCA and cHCC-CCA and provided evidence for the nodal CTV definition. MethodsWe retrospectively reviewed the medical records of patients with iCCA or cHCC-CCA who underwent surgery between 2010 and 2020. Eligibility criteria included patients pathologically diagnosed with iCCA or cHCC-CCA after surgery and a first recurrent event in regional LNs during follow-up. All recurrent LNs were registered onto reference computed tomography images based on the vascular structures to reconstruct the node mapping. Fifty-three patients were eligible. LN regions were classified into four risk groups. ResultsHepatic hilar and portal vein-vena cava were the most common recurrent regions, with recurrence rates of 62.3 % and 39.6 % (high-risk regions), respectively. Recurrence rates in the left gastric, diaphragmatic, common hepatic, superior mesenteric vessels, celiac trunk, and paracardial regions ranged from 15.1 % to 30.2 % (intermediate-risk regions). There were fewer recurrences in the para-aortic (16a1, a2, b1) and splenic artery and hilum regions, with rates <10 % (low-risk regions). No LN recurrence was observed in the para-oesophageal or para-aortic region (16b2) (very low-risk regions). Based on node mapping, the CTV should include high- and intermediate-risk regions for pathologically negative LN patients during postoperative radiotherapy. Low-risk regions should be included for pathologically positive LN patients. ConclusionWe provide evidence for CTV delineation in patients with iCCA and cHCC-CCA based on recurrent LN mapping.

Wandering Spleen with Tortion – A Case Report

A 16-year-old male presented with abdominal pain over 12 months, that had acutely worsened over the 5 days pre-presentation. Preliminary outpatient investigations revealed thrombocytopaenia 90(platelets per microliter), and a pelvic spleen on abdominal ultrasound. Contrast enhanced CT of the abdomen and pelvis in the portal venous phase confirmed a pelvic spleen with torsion of the splenic hilum. The spleen appeared hypoechoic on ultrasound. On CT, the spleen had heterogeneous enhancement with some irregularly shaped regions of hypoenhancement. There was a swirl (at least two complete turns) in the splenic vascular pedicle in the left abdomen. The splenic artery demonstrated some enhancement, but no enhancement of the splenic vein. The pancreatic tail was also involved in the torted vascular pedicle. No pancreatic duct dilation, and no infarct of pancreatic parenchyma were found. A small amount of free fluid around the spleen was found with no free gas. The portal vein enhanced normally. Lack of convincing enhancement of the splenic vein and heterogenous appearance of the spleen were suspicious for early splenic ischaemia. Laparotomy revealed an engorged twisted spleen around its pedicles. The spleen was identified in the pelvis with a torted vascular pedicle, which was subsequently detorted and manipulated back into the left upper quadrant (LUQ), with a pre-peritoneal space formed in the LUQ, the spleen was inserted into this pocket.

Surgical Approach to the Upper Side of the Gastrosplenic Ligament During Laparoscopic Total Gastrectomy for Proximal Gastric Cancer: Operative Techniques and Initial Results.

Background: Laparoscopic gastrectomy for gastric cancer has become widespread as minimally invasive surgical treatment, but use of laparoscopic total gastrectomy (LTG) remains limited because of the technical difficulty and complexity of lymphadenectomy at the splenic hilum. Surgical techniques and initial experiences with the surgical approach to the upper side of the gastrosplenic ligament during LTG are introduced. Materials and Methods: Between January 2019 and December 2022, 57 patients with proximal gastric cancer underwent LTG using this approach. Results: Regarding the extent of lymphadenectomy, D1+, D2, spleen-preserving D2 + 10, and D2 + 10 with splenectomy were performed in 31, 18, 4, and 4 patients, respectively. Operative time was 341 (192-724) minutes, and estimated blood loss was 30 (0-515) g. There were no conversions to laparotomy and no postoperative complications of Clavien-Dindo grade ≥III. Conclusions: The present procedure is safe and feasible and provides an excellent operative view at the splenic hilum, making it easier to determine exactly the extent of lymphadenectomy in accordance with cancer progression.

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery.

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

Early mobilization and delayed arterial ligation (EMDAL) as a surgical technique for splenectomy and shunt surgery in portal hypertension.

Splenectomy is the most frequently performed procedure as definitive management or as part of shunt surgery or devascularization in portal hypertension. Splenectomy is technically challenging because of the frequent coexistence of multiple collateral varices, splenomegaly, poor liver function, and thrombocytopenia. Early arterial ligation and late mobilization (EALDEM) is the traditional method for splenectomy in portal hypertension. Early spleen mobilization offers good control of the hilum. We aim to compare the effect of the early mobilization and delayed arterial ligation (EMDAL) technique with that of the conventional splenectomy technique in patients with portal hypertension. During the study period from September 2011 to September 2022, 173 patients underwent surgical intervention for portal hypertension at our institution. Among these patients, 114 underwent the conventional method of splenectomy (early arterial ligation and late splenic mobilization) while 59 underwent splenectomy with the EMDAL technique. Demographics were compared between the two groups. Intraoperative and postoperative outcomes were analyzed using the Mann-Whitney test in each group. A minimum follow-up of 12 months was performed in each group. Demographics and type of surgical procedure were comparable in the two surgical method groups. Median blood loss was higher in the conventional group than in the EMDAL method. The median duration of surgery was comparable in the two surgical procedures. Clavien-Dindo grade III/IV complications were reported more frequently in the conventional group. The splenic hilum can be controlled well and bleeding can be minimised with early mobilization and delayed arterial ligation.

Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer.

Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.

Ex-situ Open Approach Spleen Preserving Splenic Hilum Lymphadenectomy.

Background: multiple studies showed important benefices arising from splenic preservation in patients with digestive cancer in general and gastric cancer in particular. The minimally invasive approach remains controversial in locally advanced gastric cancer cases whilst the open approach still has an important role. This paper's aim is to describe and present the feasibility of an open surgical technique that allows removing stations 10 together with 11p and 11d with spleen and splenic vessels preservation in pacients operated upon by open surgery. Material and Methods: We present an open "Ex-situ" spleen and pancreas preserving surgical technique that removes the anterior and posterior ganglia from the splenic hilum, the splenic vessels and the distal pancreas in locally advanced gastric cancer cases of the upper two thirds of the stomach. Forty-three consecutive patients since 2003 were operated upon by the author in multiple centers. during upper two thirds gastric cancer resections requiring no. 10 lymphadenectomy. Results: no splenectomy was needed . All the spleens were viable at postoperative Doppler echography and CT scans. No spleen migrated nor caused mechanical complications. No clinically significant pancreatic leaks were noticed. Two patients died during hospital stay, one of miocardial infarction and one of massive stroke. Pertinent follow up data and survival were not available. Conclusions: The method enables the surgeon to remove the lymph nodes no. 10 along with 11p and 11d without needing to sacrifice the spleen. All spleens were reattached sucessfully using the preserved spleno-renal ligament fold, no wandering spleen was noticed.

Histopathological appraisal of splenic hilum lymphadenectomy during distal pancreatectomy for pancreatic cancer: predefined subanalysis of the diploma trial

Histopathological appraisal of splenic hilum lymphadenectomy during distal pancreatectomy for pancreatic cancer: predefined subanalysis of the diploma trial

Splenic mesothelial cyst: a case report

Splenic cyst was first described by Andral in 1929. Splenic cysts are divided into 2 groups as parasitic and non-parasitic. Splenic mesothelial cyst (SMC) is a rare form of splenic cysts, and its incidence is not known exactly. It is frequently observed in children and young adults. In this case report, a 21-year-old male patient who underwent laparoscopic splenectomy with a diagnosis of symptomatic splenic cyst is discussed. Total splenectomy was decided because of the splenic cyst localization in the splenic hilus. Laparoscopic splenectomy was performed to the patient. SMC is a rare primary splenic cyst and is usually asymptomatic. It is often detected incidentally by imaging modalities. Symptomatic cysts with a size of more than 5 cm should be treated. Spleen sparing techniques are accepted as the current treatment option. In this case report, a young adult patient who underwent laparoscopic splenectomy for symptomatic SMC is discussed in the light of the literature.