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Case Report
Robot-Assisted Partial Splenectomy for Splenic Epidermoid Cyst
Mubarak Ali kirih , Xiao Liang , Yangyan Xie, Jingwei Cai, Junhao Zheng, Feng Xu,
Shilin He, Liye Tao, and Faisa Ali Abdi
Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou,
Zhejiang Province, China
Correspondence should be addressed to Xiao Liang; srrshlx@zju.edu.cn
Received 30 August 2019; Revised 19 December 2019; Accepted 21 February 2020; Published 7 September 2020
Academic Editor: Dimitrios Mantas
Copyright © 2020 Mubarak Ali kirih et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
The splenic cyst is a rare disease with unknown etiology. The inner wall of the cyst has lining epithelium. The cyst can be unilocular
or multilocular. According to pathology, it can be divided into four types: epidermoid cyst, dermoid cyst, cystic lymphangioma, and
cystic hemangioma. Ultrasound examination is often the first choice for splenic cysts because of its nonradiation, low cost, and
convenient examination. The images are mostly cystic masses with clear borders and dark areas without echoes, after the
detection of splenic space-occupying lesions by ultrasonography, CT, and MRI. Here, we report robot-assisted partial
splenectomy for a splenic cyst. Imaging diagnosis of abdominal CT enhancement: the cystic space-occupying of the spleen is
considered. We should improve the preoperative examination and exclude operative contraindications. During the operation,
there was about 8 cm of the upper pole of the spleen, and the boundary was clear. There was no obvious abnormality in the
exploration of the abdominal viscera. The operation was successful. The operative time was 115 minutes, and the blood loss was
20 ml. On the first day after the operation, the patient took a liquid diet. The time of first anal exhaust was on the second day
after operation. The patient was discharged at the fourth day. Postoperative pathology revealed epidermoid cyst. The therapy
strategy of the splenic cyst is ambiguous. Better understanding of the splenic segmental anatomy and surgical skills has made
minimally invasive partial splenectomy a preferred treatment for splenic cysts. In this paper, we report a case of splenic
epidermoid cyst managed successfully by robot-assisted partial splenectomy.
1. Introduction
Partial splenectomy includes irregular partial splenectomy
and regular partial splenectomy. The latter is based on the
anatomical basis of sectional blood supply in the spleen. After
pretreatment of the two- or three-grade splenic pedicle liga-
ture, the corresponding splenic segment, splenic lobe, or half
spleen can be resected according to the ischemic line of the
spleen surface. Regular splenectomy is much more difficult
than total splenectomy and irregular splenectomy. The main
technical points of regular partial splenectomy are as follows:
(1) fine dissection and ligation of the second and third splenic
pedicle vessels close to the spleen hilum, where each bundle is
as small as possible, while observing the spleen blood circula-
tion; (2) moving 0.5-1.0 cm to the healthy side in the rela-
tively nonvascular plane of the spleen and cutting the
spleen from a part shallow to a deep part with an ultrasound
knife, ligating the blood section (for example, if there are more
blood vessels in the splenic section of the spleen, the incision
and closure device can be used to cut offthe blood vessels);
it can be applied to various bleeding measures such as bleeding
on the section, wet dressing with warm saline gauze, 8-word
suture, adhesives, microwave, and radiofrequency; and (3)
peritoneum or splenic capsule transplantation [1].
In recent years, laparoscopic splenectomy has gradually
replaced open splenectomy as an important method for the
treatment of splenic cysts with the accumulation of laparo-
scopic surgery experience and the improvement of technol-
ogy. Compared with the operation time and prognosis,
laparoscopic splenectomy has less bleeding and shorter hos-
pitalization time. Compared with laparoscopy, the 3D opera-
tion vision and mechanical arm of Da Vinci robotic surgery
Hindawi
Case Reports in Surgery
Volume 2020, Article ID 6245909, 5 pages
https://doi.org/10.1155/2020/6245909
system overcome the limitation of flexibility in vision and
operation instruments, which can greatly enhance the con-
trollability, stability, and accuracy of surgery. Although its
application in clinical practice, especially in splenic surgery,
is in its infancy, it has been reported that robot-assisted par-
tial splenectomy significantly reduces the anatomical time of
the splenic pedicle and overcomes the difficulty of hemostasis
and spleen translocation in traditional laparoscopic partial
splenectomy and reduces the amount of bleeding [2]. In a
research, 24 cases of robot-assisted splenectomy were
reported [3]. Among them, 3 cases were partial splenectomy.
The median bleeding volume was 75 ml. The average opera-
tion time was 199 minutes. The median hospital stay was
5.5 days after the operation. All patients recovered well after
the operation [4].
2. Case Presentation
The patient, a 28-year-old woman, was admitted to the
Department of General Surgery, Sir Run Run Show Hospital,
for half a month of splenic mass found by physical examina-
tion. Physical examination showed clear, spiritual, nonyellow
skin and sclera, no swelling of superficial lymph nodes, no
difference between cardiopulmonary examination, abdomi-
nal soft, no obvious mass, normal bowel sounds, no tender-
ness and rebound pain in the whole abdomen, negative
mobile voice, negative Murphy’s sign, negativity of renal
percussion pain, no edema in both lower extremities, and
negative pathological signs. In the imaging diagnosis of
abdominal CT enhancement, the cystic space-occupying
lesion of the spleen is considered (Figure 1). We should
improve the preoperative examination and exclude operative
contraindications. During the operation, there was about
8 cm of the upper pole of the spleen, and the boundary was
clear. Figure 2. There was no obvious abnormality in the
exploration of the abdominal viscera. The operation was suc-
cessful. The operative time was 115 minutes, and the blood
loss was 20 ml. On the first day after the operation, the
patient took a liquid diet. The patient had anal exhaust in
the second day and the patient was discharged four days later.
Postoperative pathology revealed an epidermoid cyst.
The patient was placed in an incomplete right lateral
decubitus position. A pneumoperitoneum of 12 mmHg was
established using a Veress needle through a left paraumbilical
incision, and an optical port (5- to 12-mm trocar) was intro-
duced afterward. Under visual control, two robotic 8 mm tro-
cars were placed in the left hypochondriac region and the
epigastrium. An additional 5- to 12-mm accessory port was
placed in the left lumbar region on the middle axillary line
for the side assistant surgeon. The surgical cart with the
robotic arms was positioned on the patient’s left side at a
45
°
angle to the table’s longitudinal axis.
As reported by the European Association for Endoscopic
Surgery clinical practice guidelines, in preoperative imaging,
splenomegaly was defined with a maximum splenic diameter
of more than 15 cm [5]. Postoperative morbidity has been
specified as any complication that occurs within 30 days of
surgery and has been evaluated as in [6].
Dissection was performed with the robotic EndoWrist®
Fenestrated Maryland Bipolar Cautery on the left hand and
HarmonicTM Curved Shears on the right hand. The trocar
position is presented in Figure 3. The table side assistant ele-
vated and moved the spleen or provided suction if needed. In
one case with the large hydatid cyst, it was first inactivated
and evacuated under visual control in order to increase the
working space in the upper abdomen. After dividing the peri-
toneal attachments and the splenic ligaments with the Har-
monicTM Shears, the omental bursa was opened and the
splenic vessels were dissected in the hilum. In the three cases
of subtotal splenectomy, the splenic artery and vein were
ligated with intracorporeal knot tying using EndoWrist®
Needle Holders. After complete mobilization, the splenic
parenchyma was transacted using an Endo GIA Roticulator™
blue cartridge stapler introduced by the side assistant sur-
geon through the accessory port. Vascularization of the
splenic remnant was based on the anastomotic branch of
the left gastroepiploic pedicle.
The specimen was removed in an Endo Catch™II 15 mm
specimen pouch through the accessory port incision. Hemo-
stasis on the transection surface of the splenic remnant was
completed in two cases with a TachoSil® hemostatic sponge.
The drain tube was removed after 1 day. The patient was
discharged on postoperative day 4 with no postoperative
complication. And the final pathological findings showed
epidermoid cyst. We performed a follow-up visit of 1 year,
and no recurrence or abnormal platelet count was found.
With the popularization and application of ultrasound,
abdominal CT and magnetic resonance imaging in clinical
practice, and the awareness of public health examination,
the number of splenic cysts diagnosed in recent years has
increased significantly. According to the etiology, splenic
cysts can be divided into two categories: nonparasitic cysts
and parasitic cysts. In nonparasitic cysts, splenic pseudocysts
and splenic true cysts can be classified according to the pres-
ence or absence of lining epithelium in the cyst wall. Pseudo-
cysts are more common. Most of them are formed after
trauma secondary to subcapsular hematoma of the spleen.
They are also called secondary splenic cysts. The wall of the
cyst is only a fibrous tissue without lining epithelium. The
cyst contains blood or serous fluid. The splenic cyst is a rare
disease with unknown etiology. The inner wall of the cyst has
lining epithelium. The cyst can be unilocular or multilocular.
According to pathology, it can be divided into four types: epi-
dermoid cyst, dermoid cyst, cystic lymphangioma, and cystic
hemangioma. Ultrasound examination is often the first
choice for splenic cysts because of its nonradiation, low cost,
and convenient examination. The images are mostly cystic
masses with clear borders and dark areas without echoes.
After the detection of splenic space-occupying lesions by
ultrasonography, CT, MRI, and other imaging examinations
can further understand the size, shape, and type of splenic
cysts. The number, characteristics of cyst cavity and wall,
and adjacent relationship with surrounding organs are of
great value.
Surgical treatment is the main method for a splenic cyst.
Clinically, nonparasitic splenic cysts less than 2.0 cm in
diameter and without any symptoms can be observed
2 Case Reports in Surgery
regularly. When the diameter of splenic cyst is more than
5.0 cm, the follow-up of the outpatient department increases
rapidly or complications such as compression of surrounding
organs, rupture, and infection occur; timely surgical treat-
ment is advocated. At present, the main surgical methods
depend on the size and location of the cyst, including fenes-
tration and drainage of splenic cyst, total splenectomy,
splenectomy with preservation of accessory spleen, hemisple-
nectomy, and partial splenectomy. As the main immune
organ of the human body, the spleen plays the role of regulat-
ing immune function and clearing senile blood cells. If total
splenectomy is performed, the chance of overwhelming post-
splenectomy infection will increase, and complications such
as platelet elevation and venous thrombosis will be more
likely to occur. Therefore, it is advocated that surgery should
preserve the function of the spleen as far as the patient is
concerned, such as the presence of a cyst on the upper pole
of the spleen or the presence of a cyst at the lower part of
the spleen. The diameter of the spleen is less than 50% of
the total volume of the spleen. The partial splenectomy or
partial splenectomy can be performed according to the
specific conditions of the patients.
3. Discussion
Splenic cysts are classified into true cyst (primary) and pseu-
docysts (secondary), on the basis of the presence of an epithe-
lial lining inside the cyst [7]. Splenic true cysts are typically
classified as cystic lymphangiomas, cystic hemangiomas,
and epidermoid and dermoid cysts. The current consensus
(a) (b) (c)
Figure 1: Abdominal CT-enhanced images: (a) shows plain scan; (b) shows arterial phase; and (c) shows venous phase. The upper part of the
spleen is about 7-8 cm with slightly low-density shadow.
(a) (b)
(c) (d)
Figure 2: Intraoperative findings: (a) splenic space occupied during operation; (b) free secondary vessels of the splenic pedicle; (c) after
disconnection of secondary vessels of the splenic pedicle, ischemic line on the surface of the spleen can be seen; and (d) along the ischemic
line, the spleen of an affected side can be removed.
3Case Reports in Surgery
is that splenic cysts with a diameter greater than 5 cm or
rapid growth rate should be treated surgically to avoid the
risk of multiple complications, such as rupture, infection
with abscess, and intracavitary bleeding [8].
In recent years, mounting splenic cysts are diagnosed due
to the development of modern diagnostic technology. And
multiple surgical approaches have been applied in the ther-
apy, especially spleen preserving minimally invasive proce-
dures based on splenic vascular anatomy, which can
preserve more than 25% of splenic parenchyma [4]. Partial
splenectomy (PS) is now increasingly being promoted, which
can reserve the spleen with maximum function to reduce
postoperative complications such as thrombocytosis, intra-
abdominal abscess, and infections in total splenectomy.
Laparoscopic splenectomy has gradually replace open
splenectomy for its safety and minimal invasion. However,
a systematic review involving 20 articles elucidated that no
statistical differences were observed in many parameters,
such as blood loss, time of drainage removal, and incidence
of complications between laparoscopy and laparotomy [2].
As a new mini-invasive technique, robotic surgery has
shown its superiority in many disease therapies, which is
gradually applied in splenology. A robotic surgery system
allows for an exquisite dissection due to the high definition
and stereoscopic vision and tremor reduction along with per-
fect maneuverability. These characteristics make it possible
to perform complex and advanced surgical procedures. Some
surgeons have published their experience with the robot-
assisted PS [9, 10].
With regard to the laparoscopic technique, most data
focus on laparoscopic decapsulation, while in the literature
the feasibility of laparoscopic partial splenectomy for splenic
cysts has been well established [10, 11].
A total of 21 cases of the nonparasitic splenic cyst were
compared with laparoscopic partial splenectomy. The results
showed that intraoperative hemorrhage in the robotic group
was significantly less than that in the laparoscopic group.
There were no postoperative complications in the robotic
group, while 2 cases occurred in the laparoscopic group (left
pleural effusion and operative area effusion). In this case, the
robot-assisted regular partial splenectomy was performed to
prevent the patients from having low comprehensive immu-
nity and more precise excision of the lesion. The procedure
was smooth, the field of vision was clear, and the bleeding
was less. In practice, it is found that the magnification effect
of the robotic surgical system is stronger than that of laparos-
copy. It has more advantages for the fine anatomy of the two-
degree splenectomy vascular pedicle and can better perform
regular partial splenectomy. As a new minimally invasive
technique, it has more room for development, though there
are still many problems. With problems and controversies,
but with the continuous updating of surgical instruments
and equipment, the continuous progress of basic and clinical
research of spleen, the accumulation of surgical experience,
and the improvement of surgical skills, this method of oper-
ation will be applied more and more.
While it might be difficult technically to manage partial
laparoscopic splenectomy and bleeding from the cut edge of
spleen, it can be performed safely with the understanding of
the spleen’s vascular anatomy. The spleen is divided primar-
ily into two lobes on the basis of vascular distribution. In our
case, the demarcation line was formed when the upper lobe
vessels were ligated. It is easily accessible without loss of
blood for partial splenectomy.
The robot-assisted technique may be the most appropriate
for partial splenectomy, as it enables great dissection. The
value of partial splenectomy for selected benign diseases in
preserving the immune function has been well demonstrated.
The comparison of complete and partial laparoscopic splenec-
tomy in children They found that laparoscopic partial splenec-
tomy was as successful as complete laparoscopic splenectomy,
although more pain, longer time for oral intake, and longer
hospital stay were present inthe partial category. The technical
challenge associated with partial laparoscopic splenectomy is
another factor to consider. The robotic approach is able to
overcome the limitations inherent in laparoscopy, especially
for hilar dissection and vascular isolation. A partial splenec-
tomy requires effective splenic branch dissection, and in our
experience, 3D vision robotic technology and the wrist-like
equipment allow good vascular control. In comparison, by
applying pledgets, the hemostasis of the cut segment after
the parenchymal transection can be performed well. The robot
can also be helpful for this challenging task.
4. Conclusion
In conclusion, robot-assisted PS is a promising option for the
treatment of splenic cysts, which provides an alternative
method to the standard laparoscopic approach especially in
difficult cases. However, more series and prospective studies
are required to further compare the effects of laparoscopic
and robotic approaches.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
R2
Camera
R1
VLS
Figure 3: Position of trocars in robotic splenectomy. R1 and R2:
robotic arms; VLS: laparoscopic assistance.
4 Case Reports in Surgery
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5Case Reports in Surgery
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