Feasible Laparoscopic Retroperitoneal Splenopexy and Gastropexy Using a Needle Grasper for Wandering Spleen with Gastric Volvulus: A Case Report of a 3-Year-Old Boy

Background: Wandering spleen is a rare clinical condition characterized by splenic hypermobility that results from the absence or maldevelopment of the splenic suspensory ligaments.1 As a result, the spleen is predisposed to torsion and subsequently infarction. Laparoscopic splenopexy for wandering spleen has often been reported in the literature, but few reports have described the use of a small-diameter instrument, called a “needle grasper.”2–5 We herein report a case in which laparoscopic retroperitoneal splenopexy was performed for wandering spleen using a needle grasper. Case Presentation: Patient was a 3-year-old boy with neurodevelopmental delay and autism. He presented with left upper epigastric pain and vomiting for 2 days and visited the previous hospital. At that hospital, upper gastrointestinal fiberscopy was performed, showing duodenal torsion at the superior duodenal angle, which made it impossible for the endoscope to be passed. For a further examination, he was referred to our hospital. Enhanced computed tomography showed gastric volvulus and dislocation of the spleen without splenic ischemia. Preoperative diagnosis was gastric volvulus accompanied by wandering spleen. Because his symptoms were not relieved completely by conservative therapy, we decided to perform laparoscopic splenopexy and gastropexy. Operative Findings and Procedure: Under general anesthesia, the patient was placed in the right semilateral position. A 5-mm 30° laparoscope was inserted through an umbilical incision using the open 5-mm Hasson trocar method. Pneumoperitoneum was established by carbon dioxide insufflation (5 L/min, 8 mm Hg). One working trocar was inserted to left of the umbilicus (5 mm, operator's right hand for dissection and needle driving) and one in right upper abdomen (2.1 mm, operator's left hand). The operator used a needle grasper (BJ needle®; NITI-ON, Chiba, Japan) with the left hand. The ligamentum teres hepatis was elevated using a loop needle device (LAPA-HER-CLOSURE®; Hakko, Co. Ltd., Tokyo, Japan) to obtain a sufficient surgical view and working space. On laparoscopic exploration, the gastric volvulus was found to have resolved spontaneously, and the spleen was not twisted, although it lacked suspensory ligaments. The retroperitoneum was incised using bipolar scissors (Aesculap, Inc., Center Valley, PA, USA) and dissected using a vessel sealing system (LigaSure Maryland®; Medtronic, Inc., Dublin, Ireland) to create a sufficiently large retroperitoneal pocket. After dissecting the upper and lower portions of the splenic mesentery, the spleen was carefully placed into the retroperitoneum pocket. In this process, care was taken to avoid injuring the spleen with the left hand's needle grasper. It is important not to grasp the spleen directly with the needle grasper. The retroperitoneal defect was closed by interrupted sutures using 3-0 nonabsorbable braid sutures (Ethibond®; Ethicon, Somerville, NJ, USA). In addition, anterior gastropexy was also performed using 3-0 nonabsorbable braid sutures. All ligatures were made by Roeder's knot. Results and Conclusion: No intra- or postoperative complications occurred. The postoperative course was uneventful. The patient was discharged on postoperative day 6. The operative scars were minimal and resulted in an excellent cosmetic appearance. Laparoscopic retroperitoneal splenopexy and gastropexy using needle grasper was feasible for pediatric patient, although caution is required when handling spleen. Acknowledgments: We thank Brian Quinn for his comments and help with the article. Ethics Approval and Consent to Participate: Approval was obtained from the appropriate ethics review board of our institution. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure; patient anonymity has been preserved, and personal information has been protected. No competing financial interests exist. Runtime of video: 4 mins 31 secs