Laparoscopic partial splenectomy in the treatment of splenic ectopic pregnancy

Introduction

Ectopic pregnancy is a pregnancy that occurred outside the uterus, usually in the fallopian tube, followed by other abdominal pregnancies. Ectopic pregnancy could not develop normally to term and requires sufficient evaluation and intervention with medication or surgery in most cases (1). As a rare form of abdominal pregnancy (2), splenic ectopic pregnancy could be treated by drug treatment (3) or surgical interventions, including laparotomy and laparoscopy, which focused on total splenectomy (4,5). A previous study (6) indicated that laparoscopic partial splenectomy for selected patients was safe and feasible. Due to the fragile texture of the spleen, the suture method during laparoscopic partial splenectomy was technically demanding since it might encounter higher risk of splenic vascular hemorrhage than total splenectomy. Hence, few reports focused on the treatment of splenic ectopic pregnancy via laparoscopic partial splenectomy (7). In order to avoid the potential severe complications such as hemoperitoneum (8) caused by drug treatment alone, and to avert impaired hematopoietic and immune function caused by total splenectomy, we herein presented a case (Video 1) of a 30-year-old woman (gravida 2, para 1) undergoing laparoscopic partial splenectomy performed by hepatobiliary surgeons to treat splenic ectopic pregnancy.

Case presentation

Preoperative examinations and treatment

A blood test showed that a serum level of β-human chorionic gonadotropin (β-hCG) was 34,229 U/mL. The patient had 64 days of menolipsis medical history with occasional minor left upper abdominal pain, which indicated a highly probable ectopic pregnancy. Preoperative imaging examination was used to show an approximately 5.4 cm × 4.5 cm × 3.9 cm gestational sac located at the inferior pole of the spleen (Figure 1A). Two days later after admission, the patient was treated with mifepristone and methotrexate to terminate pregnancy.

Figure 1 Preoperative and postoperative examinations. (A) Preoperative magnetic resonance imaging showed a gestational sac located at the lower pole of the spleen. (B) Postoperative pathology examination indicated a fetus with a length of 4 cm, 3 cm × 3 cm grimy placenta tissue and an 8-cm umbilical cord. (C) Histopathological examination confirmed a splenic ectopic pregnancy: chorionic villi within the splenic tissue (H&E staining, ×100). (D) Abdominal computed tomography and blood tests one year after surgery showed a residual spleen with favorable function.

Surgical procedure

Similar to previous reports regarding the surgical technique details (9-12), an ultrasonic scalpel was performed to dissociate gastrosplenic and gastrocolic ligaments. The splenic artery was observed at the upper edge of pancreas. The splenic artery was pre-occluded with a vascular clamp to temporarily block blood flow. The ligaments around the spleen were dissociated, the splenic pedicle was exposed, and the arteries and veins of the inferior pole of the spleen were dissected and clamped with a vascular clip. Then, the ischemic line of the inferior pole of the spleen was defined. The embryo was observed within it. The spleen parenchyma was transected by ultrasonic scalpel along the removal line meticulously. A bipolar electrocoagulation hemostatic device was used to stop bleeding. We performed continuous suture method to facilitate hemostasis on the transected surface. The abdominal cavity was irrigated thoroughly. Biological hemostatic materials were placed. A drainage tube was placed in the splenic recess and then extracted through the trocar hole.

Perioperative and follow-up outcomes

The operation duration was 220 min, the intraoperative blood loss was 300 mL and no perioperative blood transfusion occurred. The abdominal drainage tube was removed on the fourth day after surgery. The patient was discharged on the sixth postoperative day without postoperative complications. Postoperative pathology examination indicated that there was a fetus with a length of 4 cm, a 3 cm × 3 cm grimy placenta tissue and an 8-cm umbilical cord (Figure 1B). Histopathological examination confirmed a splenic ectopic pregnancy: chorionic villi within the splenic tissue (Figure 1C). No positive β-hCG values were observed 1 month after the operation. Abdominal computed tomography and blood tests one year after surgery showed a residual spleen with favorable function (Figure 1D). All procedures performed in this article were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Informed consent was obtained from the patient for whom identifying information is included in this article.

Discussion

Ectopic pregnancy is defined as the implantation of a fertilized ovum outside of the uterine cavity. Its incidence is about 19.7/1,000 (3,13). According to previous reports, 95.5% of the ectopic pregnancies were in the fallopian tube, only 1.3% were at abdominal (2,3). To the best of our knowledge, the spleen is one of the rarest sites for abdominal pregnancies, which carried a high risk of potentially uncontrollable, life-threatening intraperitoneal bleeding at early gestation.

According to previous studies, splenic ectopic pregnancy can be treated by drug treatment (3) or surgical interventions, including laparotomy and laparoscopy, which focused on total splenectomy (4,5). It is generally acknowledged that the traditional approach to treating splenic surgical disease has been total splenectomy. Recently, recognition of the significance of the spleen as a critical organ of the human immune system and the potential threat of perioperative bleeding and postoperative complications such as enhanced arteriosclerosis, postoperative thrombosis and overwhelming postsplenectomy infection (14) have led surgeons to prefer to perform parenchyma-preserving surgical procedures, for instance laparoscopic partial splenectomy (15).

Since the gestational sac is located at the lower pole of the spleen, if the patient was treated by drug alone, it may contribute to potential complications such as gestational sac rupture, abdominal infection or bleeding. Ruptured splenic ectopic pregnancy could even result in patient death. Although the lesion may be completely removed after performing total splenectomy, we cannot ignore the probability of experiencing impaired hematopoietic and immune function, further contributing to related complications, for instance, postoperative thrombosis. Therefore, laparoscopic partial splenectomy was performed.

A previous research (16) indicated that laparoscopic partial splenectomy is safe and effective in patients with focal benign splenic lesion. Laparoscopic partial splenectomy for some benign splenic diseases has been carried out in our center and the results showed that it was a technically safe and feasible approach.

Conclusions

Laparoscopic partial splenectomy for splenic ectopic pregnancy may be feasible and be associated with preserved hematopoietic and immune function. Further large samples studies are required to validate our outcomes.

Acknowledgments

Funding: This work was supported by grant from the New Clinical Technology Project Foundation of the Southwest Hospital, Third Military Medical University (No. SWH2016JSTSYB-50).

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-584/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-584/coif). The authors report that this work was supported by grant from the New Clinical Technology Project Foundation of the Southwest Hospital, Third Military Medical University (No. SWH2016JSTSYB-50). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this article were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Informed consent was obtained from the patient for whom identifying information is included in this article.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Lee IT, Barnhart KT. What Is an Ectopic Pregnancy? JAMA 2023;329:434. [Crossref] [PubMed]
2. Julania S, Tai R. Heterotopic simultaneous splenic and intrauterine pregnancy after spontaneous conception and review of literature. J Obstet Gynaecol Res 2013;39:367-70. [Crossref] [PubMed]
3. Kalof AN, Fuller B, Harmon M. Splenic pregnancy: a case report and review of the literature. Arch Pathol Lab Med 2004;128:e146-8. [Crossref] [PubMed]
4. Yagil Y, Beck-Razi N, Amit A, et al. Splenic pregnancy: the role of abdominal imaging. J Ultrasound Med 2007;26:1629-32. [Crossref] [PubMed]
5. Wu L, Jiang X, Ni J. Successful diagnosis and treatment of early splenic ectopic pregnancy: A case report. Medicine (Baltimore) 2018;97:e0466. [Crossref] [PubMed]
6. Liu G, Fan Y. Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review. World J Surg 2019;43:1505-18. [Crossref] [PubMed]
7. Wang M, Mo S, Yao Y, et al. Laparoscopic surgery with spleen preservation to treat primary splenic pregnancy: Case report and literature review. J Obstet Gynaecol Res 2019;45:1932-5. [Crossref] [PubMed]
8. Greenbaum A, Miskimins R, Coffman B, et al. Management of splenic ectopic pregnancy presenting with massive haemoperitoneum. BMJ Case Rep 2016;2016:bcr2016218291. [Crossref] [PubMed]
9. Xing D, Li P, Yang Y, et al. Retrospective assessment of the clinical efficacy of laparoscopic partial splenectomy. Exp Ther Med 2023;25:210. [Crossref] [PubMed]
10. Namikawa T, Araki K, Utsunomiya M, et al. Laparoscopic partial splenectomy in a patient with splenic hemangioma after distal gastrectomy for a neuroendocrine tumor. Clin J Gastroenterol 2024;17:29-33. [Crossref] [PubMed]
11. Cai L, Zhang C, Zhong KH, et al. Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device. J Vis Exp 2022; [Crossref] [PubMed]
12. Fedele S, Bizzoca C, Aquilino F, et al. Laparoscopic partial splenectomy for symptomatic benign cystic lesions: technical notes. Updates Surg 2022;74:1153-6. [Crossref] [PubMed]
13. From the Centers for Disease Control and Prevention. Ectopic pregnancy--United States, 1990-1992. JAMA 1995;273:533. [Crossref] [PubMed]
14. Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis Clin North Am 1996;10:693-707. [Crossref] [PubMed]
15. Han XL, Zhao YP, Chen G, et al. Laparoscopic partial splenectomy for splenic hemangioma: experience of a single center in six cases. Chin Med J (Engl) 2015;128:694-7. [Crossref] [PubMed]
16. Wang X, Wang M, Zhang H, et al. Laparoscopic partial splenectomy is safe and effective in patients with focal benign splenic lesion. Surg Endosc 2014;28:3273-8. [Crossref] [PubMed]