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Case Report

Incidental finding of multiple splenosis in

patient who had ventral hernia repair
Purav Goel, Mohit Bhatia, Sachin Ambekar
Department of General Surgery, Moolchand Medicity Hospital, New Delhi, India

ABSTRACT
Splenosis in itself is a rare condition and its presence in a patient with ventral hernia can pose an unusual challenge. Ventral
incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair
to various mesh repairs and laparoscopic repair. Splenosis is a benign condition caused by an ectopic autotransplantation of
splenic tissues after splenic trauma or surgery. It is usually diagnosed accidentally and usually occurs within the abdominal and
pelvic cavity. We report a female patient who had undergone splenectomy for abdominal trauma at the age of 12 years and was
diagnosed as a case of abdominal splenosis at the age of 47 years on laparoscopy done for paraumbilical incisional hernia. This
case report intends to share some important aspects of ventral hernia and splenosis and the approach followed in the repair of
ventral hernia in our case.

Key words: Laparoscopy, mesh repair, splenectomy, splenosis, ventral hernia

Introduction Case History

The presence of splenosis in varied clinical scenario
can pose an unusual challenge to the operating surgeon.
The true incidence of this rare condition is unknown,
because splenosis is usually an incidental finding at
imaging or surgery,[1] and in the literature, we could
not find any data throwing light on the repair of ventral
hernia in the presence of splenosis. We report a rare
case of the therapeutic approach followed in the repair
of paraumbilical hernia in a 47‑year‑old female patient
incidentally diagnosed as a case of abdominal splenosis
on laparoscopy done for hernia.
Address for correspondence: Dr. Mohit Bhatia,
1, Bank Colony, Opposite Old Sessions Courts,
Ambala City ‑ 134003, Haryana, India.
E‑mail: drbhatia711@gmail.com
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A 47‑year‑old female patient presented to us with a
moderately sized (6 × 6 cm defect), symptomatic
paraumbilical hernia. The patient had undergone
exploratory laparotomy at the age of 12 years for
abdominal trauma after a road traffic accident leading
to splenectomy as a life‑saving procedure, following
which she had recovered well. Presently, the patient was
planned for a laparoscopic repair of paraumbilical hernia.
Preoperative biochemical investigations (complete
blood count, liver function test, kidney function
test, and blood sugar) were within normal limits.
Considering the scar of the previous laparotomy, an
open technique through the right hypochondrium was
used for creating pneumoperitoneum. On entering the
abdomen, laparoscopy revealed paraumbilical hernial
defect with omentum as its content and small to moderate
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DOI: How to cite this article: Goel P, Bhatia M, Ambekar S. Incidental finding
10.4103/ais.ais_32_18 of multiple splenosis in patient who had ventral hernia repair. Arch Int
Surg 2018;8:78-80.

78 © 2019 Archives of International Surgery | Published by Wolters Kluwer ‑ Medknow

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Goel, et al.: Incidental multiple splenosis
sized multiple reddish blue masses all over the anterior
abdominal wall and in the omental fat [Figures 1 and 2].
Histological examination of these masses had confirmed
splenosis postoperatively.
Intraoperatively, the paraumbilical defect was subjected
to further adhesiolysis, and all the hernial contents were
reduced; however, the dilemma occurred about doing an
intraperitoneal onlay mesh (IPOM) repair since the area
surrounding the hernial defect was studded with multiple
reddish blue masses as mentioned above. To avoid
disintegration of these masses and consequent bleeding,
we planned to abandon further laparoscopic intervention
and performed an open hernia mesh repair. Instead of the
parietex composite mesh that was supposed to be used
for IPOM repair, we used a polypropylene mesh for open
hernia repair. We did not do any therapeutic procedure for
splenosis. The patient recovered well after surgery.
Discussion
The repair of ventral hernia in the presence of splenosis
can pose an unusual challenge to the operating surgeon
depending on whether splenosis is an incidental diagnosis
at laparoscopy or a definitive diagnosis preoperatively.
This discussion will focus on some important aspects of
ventral hernia and splenosis, the definitive preoperative
versus incidental diagnosis of the latter, and the surgical
approach followed in repair of ventral hernia in our case.
Ventral incisional hernia is an important complication
of abdominal surgery. Its repair has progressed from a
primary suture repair to various prosthetic mesh repairs
and laparoscopic repair. Prosthetic material may be placed
as an onlay patch to buttress a tissue repair, interposed
between the fascial defect, sandwiched between tissue
planes, or put in an intraperitoneal position.[2] Laparoscopic
Figure 1: Incidental finding of mass (splenosis) along with hernia
content
Archives of International Surgery / Volume 8 / Issue 2 / April-June 2018
ventral hernia repair is being used with increasing
frequency in everyday surgical practice.[3] But it goes
without saying that this approach has to be modified in
certain coexistent conditions; the one encountered in our
case was splenosis.
Splenosis is an uncommon benign condition resulting
from heterotopic autotransplantation of splenic tissues
onto exposed vascularized intra‑ and extraperitoneal
surfaces following splenic trauma and surgeries.
Generally, the splenic implants are numerous and
are located within the peritoneal cavity; however,
extra‑abdominal splenosis does occur. The implants are
rarely clinically significant and are incidental findings
at autopsy or at abdominal operation, although they can
seldom present as a vague abdominal or testicular pain,
intestinal obstruction from adhesions, gastrointestinal
bleeding, and spontaneous rupture. When present as an
incidental imaging mass, it has been reported on to mimic
renal, adrenal, or abdominal tumors, accessory spleens,
endometriosis, hemangiomas, metastasis, lymphoma,
and ectopic testicles.
Any incidental finding of splenosis during an operation
for another indication should be sent for histopathology
examination.[4] The therapeutic approach followed in the
management of various conditions in the presence of
splenosis may alter depending on accurate preoperative
versus incidental diagnosis of the latter. Therefore, a
high index of suspicion should be maintained for the
diagnosis of splenosis. Nuclear scintigraphy using
Technetium‑99m heat‑damaged erythrocytes (red blood
cell) or Indium‑111‑labeled platelets is more sensitive and
specific for splenic uptake, making these tests the current
diagnostic tools of choice.
Figure 2: Hernia content adjacent to the splenosis
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Goel, et al.: Incidental multiple splenosis
Splenosis does not require any additional treatment if
the patient does not present with symptoms. Minimally
invasive surgery such as laparoscopy is the ideal treatment
for patients with symptomatic splenosis.[5]
We could not find previous experience (published and
unpublished) regarding how to proceed with multiple
splenic implants present at the site of recommended mesh
placement while performing a laparoscopic IPOM repair
for a ventral hernia, that is, either to place the mesh over
these implants or to first excise the splenic implants and
then place the mesh over the hernial defect, or to abandon
the laparoscopy and rather perform an open hernia mesh
repair. Placing the mesh over these implants may not be
feasible due to the size and location of the implants, and
excision of these implants to facilitate mesh placement
may lead to significant bleeding and disintegration of
these implants leading to further seeding of the peritoneal
cavity with splenic tissue. Also, as already mentioned, no
treatment is indicated for asymptomatic splenosis. Due to
these reasons, in our case we abandoned laparoscopy and
performed an open hernia mesh repair. It is also obvious
that the therapeutic approach as in our case may also alter
with accurate preoperative diagnosis of splenosis and in
symptomatic versus asymptomatic splenosis.
Anomalies like splenosis may present to us in varied
clinical scenario in future and we need appropriate
documentation of these cases and research work to deal
with these kinds of cases in future.
80
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Gupta K, Ahluwalia A, Jain T, Saggar K. Abdominal splenosis
mimicking peritoneal deposits – A case report. Pan Afr Med
J 2014;17:269.
2. Towsend C, Beauchamp R, Evers B, editors. Sabiston
Textbook of Surgery: The Biological Basis of Modern Surgical
Practice. 18th ed. Philadelphia, PA: Saunders Elsevier; 2008.
p. 1173.
3. Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas A.
Current trends in laparoscopic ventral hernia repair. JSLS
2015;19.doi: 10.4293/JSLS.2015.00048.
4. Smolar M, Lucan J, Dedinska I, Hosala M, Laca L. Splenosis as
a rare cause of abdominal pain. Rozhl Chir 2016;95:168‑71.
5. Park SY, Kim JY, Lee JH, Choi JS, Ko JH, Park SH. Laparoscopic
management of pelvic splenosis. Obstet Gynecol Sci
2014;57:89‑91.
Archives of International Surgery / Volume 8 / Issue 2 / April-June 2018