PMC3114453_01
(a, b) Plain chest X-ray showing the elevation of the left hemidiaphragm (a). Abdominal ultrasound (US) showing a large, round hypoechoic lesion with internal echoes and regular thin wall surrounded by a peripheral rim of splenic tissue (b).
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fig1
(a)-(d) Preoperative abdominal CT, (a) axial (b) and coronal (c) T2 weighted MRI shows a giant rounded cystic mass anterior to the spleen, which is significantly displaced posteriorly. Axial T1 weighted fat saturated MRI postgadolinium administration shows a thin peripheral enhancement of the splenic mass:possibly representing a capsule:and no internal enhancement consistent with its cystic nature (d).
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The abdominal computed tomography scan (CT scan) demonstrated a well-circumscribed, large nonenhancing unilocular (17 cm x 12 cm x 15, 5 cm), hypoattenuated cystic (approximately 8 Hounsfield Units) lesion in the upper pole of the spleen lacking internal septa and therefore not favouring a parasitic origin (Figure 2(a)). T1 and high T2 signal intensity images was detected. There was a thin, mild peripheral enhancement possibly representing a capsule, and there was no enhancement centrally after intravenous administration of gadolinium (Figures 2(b), 2(c), and 2(d)).
Port positions. A 10-mm umbilical port for laparoscopy (a), a 10 mm on the right upper quadrant below the right costal margin on the midclavicular line (b), a 5 mm trocar in the sub-xiphoid region (c), a 12 mm trocar paraumbilical in the left mid-clavicular line (d) and a 10 mm trocar in the left midaxillary line (e).
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fig3
Due to the large size of the cyst that caused displacement of adjacent organs and structures, additional trocars were placed as shown in Figure 3: one 12 mm trocar paraumbilical in the left midclavicular line, one 10 mm trocar in the left midaxillary line, one 5 mm trocar in the subxiphoid region and another 10 mm on the right upper quadrant on the midclavicular line. 
(a)-(f) Laparoscopic view of the splenic cyst during operation. A large splenic cyst located at the upper pole of the spleen was found, and its contents were aspirated laparoscopically (a & b). Laparoscopic resection of the cyst wall and partial decapsulation with a large window was performed (c & d). The resected cyst wall was removed in an ENDOBAG (e). A drain was placed in the cyst remaining cavity (f).
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The omentum attached over the spleen was dissected and pulled down revealing an anterior cyst at the upper pole of the spleen (Figure 4(a)). Afterwards, with the same precautions as when dealing with a parasitic cyst, the cyst was punctured with a needle at the most protruding area (Figure 4(b)). Using the LigaSure vessel sealing system, cyst wall was almost completely resected except for the wall adjoining to the residual splenic parenchyma, with excellent hemostasis while respecting the lower pole of the spleen (Figures 4(c) and 4(d)). Afterwards, the resected cyst capsule was removed with an ENDO CATCH bag (Figure 4(e)), and a drain was placed in the left subphrenic space with the tip in the remaining cystic cavity (Figure 4(f)).
(a, b) Axial enhanced CT postsurgical decapsulation of the splenic cyst (3rd post-operative day) reveals an intact and homogeneously enhanced splenic parenchyma (a). The hypodense area at the anatomic region of the decapsulated cyst anterior to the spleen (a) that contains loculation of air in its center (a) represents the remnants of the cystic wall that have partially collapsed after laparoscopic surgical decapsulation together with perisplenic pockets of fluid (b).
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A follow-up abdominal CT scan at the 3rd postoperative day showed perisplenic fluid accumulation and an air-filled cavity contiguous with the splenic parenchyma, while the parenchyma of the splenic remnant was falsely misinterpreted as having perfusion defects, especially in the margins of the cystic wall left in situ (Figures 5(a) and 5(b)).
The surgical specimen after total splenectomy containing the spleen and the cystic remnant. The trabecular architecture characteristic of a nonparasitic congenital splenic cyst and the intact spleen are clearly seen.
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fig6
The intact resected spleen was retrieved (Figure 6), and a drain was placed in the left subphrenic space, and all incisions were closed in the usual way.