Delayed Splenic Rupture after Robotic Partial Nephrectomy
Brooke Gogel, BA, Shruti Zaveri, MD, MPH, Elisha Dickstein, MD, Scott Q. Nguyen, MD, Linda P. Zhang, MD, Celia M. Divino, MD, Ketan Badani, MD, Edward H. Chin, MD
Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, New York (Ms. Gogel and Dr. Zaveri). Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dickstein). Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York (Dr. Nguyen, Zhang, Divino, and Chin). Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York (Dr. Badani).
Introduction: Splenic rupture can be classified as traumatic, pathologic, or spontaneous. Spontaneous splenic rupture is rare, and accounts for only 1% of cases. Most cases of spontaneous splenic rupture involve a histopathologically abnormal spleen, but in rare cases, rupture of the spleen can occur in the absence of underlying disease or trauma. We present a case of delayed spontaneous splenic rupture in the postoperative setting following a partial nephrectomy.
Case Description: A 54-y-old man presented with abdominal pain, dysuria, fever, and chills 1 week after a robotic left partial nephrectomy. An initial computed tomography scan showed no evidence of splenic injury, and he was admitted for suspected pyelonephritis. A computed tomography scan was obtained 4 d later for worsening pain and fever and revealed a 14-cm subcapsular hematoma of the spleen extending to the gastrohepatic ligament. He underwent an emergent angiogram and embolization of an actively bleeding splenic artery and inferior phrenic artery. A second embolization was required 2 d later to control ongoing bleeding. He then developed increased abdominal pain with nausea, vomiting, and continued leukocytosis secondary to a completely infarcted and necrotic spleen. A laparoscopic, hand-assisted splenectomy was performed successfully, and he was eventually discharged in stable condition.
Conclusion: Spontaneous splenic rupture is extremely rare, particularly in the postoperative setting. It is possible that some of these cases are in fact secondary to occult trauma to the spleen during surgery. Prompt diagnosis and management, often with emergent splenectomy, is critical in these cases. Minimally invasive surgery is a feasible option for splenic resection in cases of spontaneous splenic rupture.
Key Words: splenic rupture, splenectomy, nephrectomy.