Sub capsular splenectomy for delayed spontaneous splenic rupture in a case of sickle cell anemia

Many pathological conditions of spleen predispose it to spontaneous rupture, diagnosis of which can be delayed due to its unusual presentation. Splenectomy is often required for splenic rupture, both for its acute and chronic presentations. Chronic splenic rupture may be associated with dense peri splenic adhesions making this surgery a difficult one. In such a scenario, avoidance of iatrogenic trauma to neighboring organs is of paramount importance. Sub capsular Splenectomy (from within the pseudo capsule formed due to inflammation) is an alternative technique and allows a safe splenectomy in cases having dense peri splenic adhesions.KSM, a 50 year old man presented with severe pain over left hypochondrium and left lower chest wall, moderate fever on and off for one month. Pain increased on deep inspiration and radiated to left shoulder. There was no history of trauma or any disease process. On examination, only positive sign was some tenderness over left hypochondrium. Ultrasonography revealed chronic rupture of spleen with some hemoperitonem in the perisplenic area and small pleural effusion. (Figure 1) Biochemical workup did not show any abnormality, except a positive test for sickle cell trait. Patient was taken up for splenectomy because of severe pain. On exploratory laparotomy left quadrant was found cordoned off by omental adhesions. On taking down the adhesions, 250 ml of darkish blood was drained form the area around the spleen. Dense adhesions prevented separation of spleen from diaphragm, left lobe of liver, stomach and left flexure of colon. Attempt was made to ligate splenic vessels, by opening the lesser sac, but dense adhesions prevented success of this step. Sub capsular splenectomy (SCS, from within the pseudo capsule formed due to inflammation) starting from near the diaphragm, was performed so as to avoid inadvertent iatrogenic trauma to neighboring structures. (Figure 2) Splenic vessels were identified inside the capsule and ligated by transfix