Our Cases

Laparoscopic Partial Splenectomy For Splenic Cyst

Dr. Prashant Jain

A 10-year-old female child presented with intermittent complaints of mild left upper abdomen pain. She was evaluated and was diagnosed with a splenic cyst in the upper pole of the spleen of approximately 4X3.5 cm. She was closely followed up for 2 years with serial ultrasounds which showed progressive increase in the size of the cyst. Contrast enhanced computed tomogram (CECT) abdomen was done which showed a upper pole splenic cyst of size approximately 6X6X5 cm (FIG 1). The cyst was involving the upper one third of the spleen. Because the child was symptomatic, and the size was increasing the child was planned for laparoscopic excision of the cyst. In view of the young age and to avoid the future risk of post splenectomy sepsis, the preferred option was splenic preservation surgery. Although technically challenging, laparoscopic surgery was planned to offer better cosmesis and faster recovery.

To plan for partial splenectomy and to avoid the risk of hemorrhage, it was important to understand the vascular anatomy of the spleen. CECT angiogram revealed a separate upper polar vessel branching from the hilum and supplying the cystic area.

On laparoscopy, the large cystic mass was identified in the upper pole of the spleen (FIG 2). A careful dissection of the hilum was done, and the upper polar branch splenic artery was identified and secured. This created a well-defined avascular plane which further facilitated the resection of the cyst with minimal blood loss.

Postoperatively, the child was stable and was discharged on second postoperative day. Histopathology was suggestive of epidermoid cyst of the spleen. After 2 years of follow up the child is asymptomatic and there is no recurrence of the cyst.

Congenital epidermoid cyst are rare and comprises 2.5% of all splenic cyst in childhood. Traditionally total splenectomy has been advocated for large cyst but it has high incidence of post appendectomy sepsis. Partial splenectomy preserving at least at least 25% splenic parenchyma can prevent risk of pneumococcal bacteremia.

Symptomatic patients and patients with cyst size more than 5 cm should be considered for surgical excision. Better understanding of the splenic segmental anatomy on imaging, need of splenic conservation, and advances in laparoscopic skills has made laparoscopic partial splenectomy a preferred treatment for splenic cysts. Laparoscopy although technically difficult and challenging, but with proper planning, is a safe and feasible option. It offers the advantage of minimal scars and early recovery.

Fig 1; CECT abdomen showing large upper pole splenic cyst.
Fig 2: Laparoscopic view of splenic cyst.

Minimal Access Management Of Adrenal Masses - Case 1

7 year old male child, presented with c/o pain abdomen for 10- 15 days. He was evaluated and USG abdomen and CECT abdomen showed a large, well capsulated right adrenal mass of size approximately 6X7 cm. The evaluation was suggestive of a benign non functioning adrenal mass. He underwent successful laparoscopic excision of the adrenal mass. The biopsy was suggestive of benign adrenal mass (Ganglioneuroma). Post operative period was uneventful.

Laparoscopic approach for adrenal mass is preferred and safe option for management of such tumors.

It avoids large incision and morbidity of open surgery.

It ensures early recovery with excellent outcome.

Laparoscopic excision of Bilateral Adrenal Pheochromocytoma - Case 2

Tumours of the adrenal gland, other than neuroblastoma, are extremely rare in children. Pheochromocytomas are catecholamine secreting tumors derived from the adrenal gland which presents with symptoms of palpitation, sweating and headache.

A 12 year old boy was admitted in emergency with c/o abnormal limb movements and severe headache. He was evaluated and was found to have high blood pressure. The child was stabilized and BP was controlled. The child was then evaluated and CECT abdomen/MIBG scan were suggestive of Bilateral Pheocromocytoma. The child underwent Laparoscopic bilateral adrenalectomy after adequate preoperative preparation. The child is on regular follow up with normal blood pressure.

Pheochromocytomas are rare adrenal functioning tumors. They need extensive preoperative evaluation and management. Minimal access surgery has many advantages in the management. It minimises intraopertaive and postoperative complications. Also it avoids large incision especially in cases of bilateral tumors.

A multidisciplinary team of Pediatric Surgeon, Pediatric intensivist and Pediatric endocrinologist is required for successful planning and management of such cases.

Pediatric Urology - Case 1

A case of Severe Hypospadias

Penoscrotal hypospadias with severe chordee
Stage 1: Chordee correction and free preputial graft
Stage II: Urethroplasty

Pediatric Urology - Case 2

A case of Distal hypospadias

Single stage repair with foreskin reconstruction (Preputioplasty)
After 3 weeks

Pediatric Urology - Case 3

Undescended Testis

Laparoscopic fixation (orchidopexy) in undescended Testis

Pediatric Urology - Case 4

Endoscopic fulgaration of Posterior Urethral Valve in below Two KG newborn

A 1 month old, 1.6 KG, 33 wks preterm, newborn presented with urinary dribbling and retention of urine.
Investigations revealed bilateral dilatation of kidneys and ureter.
Mictuirating cystourethrogram was showing dilated posterior part of urethra and reflux on the left side.
This was suggestive posterior urethral valve. The child was stabilised and endoscopic fulgration was done.
Presently child is doing fine and passing good steam of urine. Dilatation of kidney is reduced on ultrasound.

Pediatric Laparoscopy

Thoracoscopic repair of Congenital Diaphragmatic Hernia

Thoracoscopic repair of diaphragmatic defect