they are known to become symptomatic as a consequence of enlargement , infection , or rupture , the latter being an exceedingly rare complication traditionally treated with open splenectomy .
we herein report a unique case of a giant epidermoid splenic cyst that ruptured spontaneously and was successfully treated with the laparoscopic approach .
laparoscopic surgery may be considered an initial treatment option in cases of very large epidermoid cysts even when rupture occurs .
laparoscopic splenectomy is an established therapeutic option for the elective treatment of nonparasitic splenic cysts .
we herein report a case of a ruptured giant epidermoid splenic cyst that was successfully treated with the laparoscopic method .
a 32-year - old woman was urgently admitted to our department with acute onset of pain in the left upper quadrant that radiated to the left shoulder . she had no history of antecedent abdominal trauma ; however , she did have a 2-month history of mild abdominal pain and left shoulder discomfort . on physical examination ,
tenderness in the left upper quadrant , diminished bowel sounds , and abdominal guarding were noted .
computerized tomography of the abdomen revealed a large cystic lesion , evolving from the spleen measuring 16 cm x 14 cm with features indicative of intra- and extrasplenic rupture .
also , a significant amount of free peritoneal fluid was present ( figure 1 ) . with the imaging diagnosis of ruptured splenic cyst , the patient underwent a successful laparoscopic splenectomy .
computerized tomography of the abdomen , demonstrating the giant ruptured epidermoid splenic cyst and the intraperitoneal fluid .
after the induction of general anaesthesia and endotracheal intubation , the patient was placed in the full , right lateral decubitus position with the table tilted at 20 to 30 and in a moderate reverse trendelenburg position .
pneumoperitoneum was established with the open method ( hassan technique ) through the umbilicus up to the level of 15 mm hg .
four 10-mm trocars were subsequently inserted along the left costal margin , allowing for bimanual operative manipulations .
splenic mobilization commenced with division of the splenocolic ligament , ligation of inferior polar vessels and division and ligation of short gastric vessels by using ligasure ( ussc , autosuture co , norwalk , ct ) .
the next operative step was the hilar control , which was accomplished by multiple firings of the endogia ( ussc , autosuture co , norwalk , ct ) applied directly to the splenic vascular pedicle .
once the hilum was controlled , the ligamentous posterior peritoneal attachments were divided , preserving though the phrenic attachments .
subsequently , a specially designed retrieval bag was inserted through the left lower trocar site . after the entry of the spleen into the bag , the end of the bag was brought outside the abdomen through the umbilical trocar site .
histologic examination revealed multiple splenic fragments with a total weight of 160 g and dimensions of 18 cm x 14 cm x 7 cm . the bigger splenic fragment contained an empty cyst with dimensions of 9 cm x 6 cm with a fibrotic wall bearing epithelial lining ( figures 2 and 3 ) .
this report describes a rare case of a giant epidermoid splenic cyst that ruptured spontaneously and was successfully treated with laparoscopic splenectomy .
nonparasitic splenic cysts are rare splenic lesions occurring in all age groups , probably resulting from a developmental anomaly , during which primitive mesothelium becomes entrapped within the splenic parenchyma
cysts , in which no lining can be demonstrated . however , the absence of an epithelial lining can be a spurious observation , so failure to identify scant remnants of this lining may lead to erroneous classification of a cyst . of the true splenic cysts ,
epidermoid cysts comprise 90% , whereas dermoid cysts are less common and comprise the remaining 10% .
clinically , true splenic cysts may be completely asymptomatic , constituting an incidental finding during physical or radiologic examination or manifested with minor , non - specific symptoms , such as pain and abdominal distention due to cyst enlargement . complications including infection and rupture are extremely rare ; in a recent review , the reported overall complication rate was 5.2% , involving 6 cases of cyst rupture and 4 cases of cyst infection .
therefore , our case of spontaneous rupture of the giant splenic cyst is an exceedingly rare condition .
nonoperative treatment is recommended for small cysts , up to 5 cm in diameter , if they are totally asymptomatic and the imaging characteristics are absolutely typical . when a splenic cyst is symptomatic or if the diagnosis is in doubt , operative therapy is warranted .
elective treatment options for nonparasitic splenic cysts include total splenectomy or some spleen - conserving variants , such as removal of the cyst in its entirety along with a remnant of adjoining spleen ( partial splenectomy ) or leaving a small remnant of the cyst still affixed to the spleen ( cystectomy or splenic decapsulation or partial cystectomy ) .
other limited treatments , such as percutaneous catheter drainage and sclerosis , have also been described ; however , they are associated with high rates of recurrence or infection and have largely been abandoned .
total splenectomy is the only method of operative treatment in the reported cases of ruptured epidermoid splenic cysts .
interestingly enough , although the application of the laparoscopic method is well documented in elective cases , it seems quite restricted in the urgent setting .
actually , no report has been published in the english literature about laparoscopic treatment of a ruptured epidermoid splenic cyst .
because our patient was hemodynamically stable , we opted for the laparoscopic approach , which was successfully completed .
it seems reasonable that acute rupture of an epidermoid splenic cyst does not constitute a contraindication for laparoscopic repair per se , and laparoscopic splenectomy may be attempted as an initial treatment option .
 background : epidermoid splenic cysts are uncommon lesions of the spleen . 
 they are known to become symptomatic as a consequence of enlargement , infection , or rupture , the latter being an exceedingly rare complication traditionally treated with open splenectomy . 
 we herein report a unique case of a giant epidermoid splenic cyst that ruptured spontaneously and was successfully treated with the laparoscopic approach.conclusion:laparoscopic surgery may be considered an initial treatment option in cases of very large epidermoid cysts even when rupture occurs . 