excluding trauma , immune thrombocytopenic purpura ( itp ) is the most common indication for splenectomy , being an attractive therapeutic option for those patients with no response after 46 weeks of medical therapy with steroids or other agents 1 . at least 15% of patients treated with splenectomy will develop recurrence of itp after surgery . the prevalence of accessory spleen tissue is about 1040% of autopsies 2 and does not require treatment unless it is associated with hematological diseases . in the context of immune thrombocytopenic purpura , accessory spleens can cause recurrent or persistent disease after splenectomy , and , in this cases , exeresis of accessory spleen is indicated in order to maintain an acceptable platelet count and to reduce the pharmacological treatment . a 44yearold woman , with a medical history of primary biliary cirrhosis and asymptomatic hbv infection , was admitted to our clinic because of development of thrombocytopenia ( platelet count of 19.000/microl ) and skin purpura since one year . the patient did not show any alteration on physical examination , except for the isolated skin purpura in upper extremities , abdomen without mases , and low platelet count with no other disorder in blood sample . the imaging tests we performed before establishing the medical treatment were an abdominal ultrasonography and computed tomography ( ct ) , demonstrating no spleen or liver disorders . firstline treatment with orally steroids was started , showing a transitory response in her platelet count , with thrombocytopenia relapse in few months . considering the lack of response with high dose of steroid treatment , surgery was proposed as next step . then , laparoscopic splenectomy ( pneumoperitoneum was created using a veress needle , and four trocars were placed in left subcostal region ) was accomplished successfully without intraoperative evidence of accessory spleen ( abdominal cavity was explored in order to search for the presence of accessory spleens in their most common locations ) , and the specimen was introduced into a retrieval bag ( 800 ml ) for removal by morcellation . after surgery , the patient showed a platelet increase in the first few weeks with subsequent relapse in platelet count with < 20.000 platelets / microl after 45 days of procedure , requiring treatment with thrombopoietic drugs ( eltrombopag ) in order to maintain platelet count and to avoid bleeding symptoms . research of the cause of itp recurrence started 3 months after surgery with nuclear medicine scintigraphy using heatdamaged tc99mlabeled red blood cells , revealing two images of uptake in left subdiaphragmatic region ( fig . 1 ) , compatible with two accessory spleens , not previously diagnosed in preoperative studies . gammagraphic study with red blood cells and tc99 m with image of abdominal computed tomography overlapped . a second intervention was proposed and the patient underwent intraoperative gammaprobe guidance surgery after injection of tc99mlabeled denatured erythrocytes , through left subcostal minilaparotomy . systematic scan of the left upper quadrant was performed , with care taken to angle the probe away from the liver so as to avoid interference . higher activity was noted next to the tail of the pancreas where the exploration revealed a soft red mass embedded in the pancreatic tail ( fig . resection of two accessory spleens was completed and no complications were described after the procedure . the patient did not present an immediate increase in platelet count , so thrombopoietic treatment was needed again for 3 months . nowadays , with lower doses of steroids treatment , platelet count remains stable . an estimated 1530% of patients show relapse after surgery , and at least onethird of these relapse is due to accessory splenic tissue 1 . the sensitivity and specificity of ct scan for the detection of accessory spleen are 60 and 95.6% . intrapancreatic accessory spleens are relatively uncommon and can be difficult to distinguish from pancreatic neuroendocrine tumors on ct scan and magnetic resonance imaging . tc99 m heatdenatured red blood cells can distinguish accessory spleens from neoplasia because of prominent physiological uptake in functioning splenic tissue , being useful in order to avoid unnecessary biopsy or major abdominal surgery if pancreatic neoplasia is not suspected 4 . intrapancreatic accessory spleens , as other accessory splenic tissue , can cause recurrence of itp and , if the study with nuclear medicine confirms the diagnosis , excision in this case is indicated . accessory splenectomy should be considered in any patient with recurrence of itp if studies are suggestive of residual functional splenic tissue . it appears that response rates after laparoscopic removal of retained splenic tissue are at least comparable with an open approach 5 . results in clinical response show that less than onequarter of these patients will have a longterm remission after the removal of an accessory spleen , and this is probably due to increased destruction of platelets by accessory parts of the reticuloendothelial system other than the spleen 6 . the most common benefit after removal of accessory spleen seems to be the reduction of dose in medical treatment . in literature , we find different results after accessory splenectomy . in case of open splenectomy , akwari et al . 7 described nine patients undergoing open accessory splenectomy for recurrent itp , showing complete remission in six patients . in laparoscopic propose that surgical accessory splenectomy allows a transitory remission of the disease , after a study with two patients who underwent laparoscopic accessory splenectomy for recurrence of itp . the first patient had a diseasefree period of 2 months and the second one of 1 month . both patients restarted immunosuppressive therapy . in our case , minilaparotomy was the selected approach due to the rare location of accessory spleen that we suspected in preoperative imaging studies . a minilaparotomy in the left subcostal region allowed us to use the gammaprobe to detect the splenic tissue and to remove it through the same incision . evolution in our patient shows a moderate response after the removal of accessory spleens , which is a result often described as the most common situation after the surgical management of accessory spleen in the context of itp . based on literature and on our case , we recommend the excision of accessory spleen in case of recurrence in hematological disease , because a minimally invasive approach removal ( laparoscopic or even minilaparotomy with gammaprobe guidance ) is safe and can be beneficial to patients with recurrent itp and documented accessory splenic tissue , although response usually is not durable and satisfactory . accessory spleen diagnosis can be safely achieved with scintigraphy using heatdamaged tc99mlabeled red blood cells .
key clinical messageaccessory splenectomy should be considered in any patient with recurrence of immune thrombocytopenic purpura , if studies ( scintigraphy using heatdamaged tc99mlabeled red blood cells ) are suggestive of residual functional splenic tissue . 
 the most common benefit after removal of accessory spleen seems to be the reduction of dose in medical treatment .