An Accessory Spleen Found During Emergency Splenectomy for Blunt Abdominal Trauma: A Rare Intraoperative Finding

INTRODUCTION

Blunt abdominal trauma frequently involves the spleen due to its anatomical position and friable parenchyma, making it the most commonly injured intra-abdominal organ in such settings.^[1] The severity of splenic injury is commonly graded using the American Association for the Surgery of Trauma (AAST) organ injury scale, which guides management decisions.^[1] Non-operative management is preferred in haemodynamically stable patients, while surgical intervention is indicated in cases of haemodynamic instability or failure of conservative management.^[2,3]

Accessory spleens are congenital nodules of splenic tissue resulting from incomplete fusion during embryological development and are reported in 10–30% of the population.^[4] They are most commonly located near the splenic hilum, tail of the pancreas, or within the gastrosplenic ligament.^[5] Identification and preservation of accessory spleens during splenectomy may contribute to residual splenic immune function and reduce the risk of overwhelming post-splenectomy infection (OPSI).^[6,7] We report a case of blunt splenic trauma requiring emergency splenectomy with incidental intraoperative identification and preservation of an accessory spleen.

CASE REPORT

A 35-year-old male presented to the emergency department with an alleged history of a fall from a motorcycle six hours prior to admission. He complained of upper abdominal discomfort associated with left-sided chest and back pain. There was no history of loss of consciousness or bleeding from the ear, nose, or throat.

On examination, the patient was conscious and oriented with a Glasgow Coma Scale score of 14/15(E3V5M6). Vital signs revealed tachycardia (120 beats/min), hypotension (90/70 mmHg), tachypnoea (25 breaths/min), and oxygen saturation of 98% on room air. Chest examination revealed equal bilateral air entry. Abdominal examination showed distension in the epigastric region; however, the abdomen was soft and non-tender with no signs of peritonitis. Neurological examination was unremarkable.

Initial resuscitation with one litre of crystalloid resulted in transient haemodynamic improvement (blood pressure 110/80 mmHg). Chest radiography showed no evidence of haemothorax or pneumothorax. Contrast-enhanced computed tomography (CECT) of the abdomen demonstrated a Grade II splenic injury with associated haemoperitoneum, consistent with blunt splenic trauma.^[1] Despite initial response to resuscitation, the patient subsequently developed worsening tachycardia, tachypnoea, and a declining haemoglobin level, indicating ongoing intra-abdominal bleeding. In view of haemodynamic deterioration, emergency surgical intervention was planned in accordance with established trauma management guidelines.^[2,3]

Management

The patient underwent emergency exploratory laparotomy and splenectomy under general anaesthesia through a midline incision. Haemoperitoneum was evacuated, and splenic injury was confirmed intraoperatively. Splenectomy was performed due to ongoing haemorrhage and haemodynamic instability.

During exploration, a 1 × 1 cm blue-coloured nodular structure was identified within the gastrosplenic ligament [Figures 1 and 2], consistent with an accessory spleen based on its appearance and location.^[4,5] The accessory spleen was carefully preserved. Deep lacerations noted on the spleen [Figures 3 and 4]. The remainder of the procedure was uneventful.

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Figure 1: Intraoperative image showing the accessory spleen (yellow arrow).

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Figure 2: Intraoperative image showing the accessory spleen (yellow arrow).

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Figure 3: Intraoperative image showing laceration on spleen.

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Figure 4: Intraoperative image showing laceration on spleen.

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DISCUSSION

Non-operative management of blunt splenic injury has become the standard of care in haemodynamically stable patients, with reported success rates exceeding 80%.^[2,3]

However, delayed haemodynamic deterioration may occur due to ongoing haemorrhage, necessitating prompt surgical intervention, as seen in the present case.

Accessory spleens are relatively common and are usually asymptomatic, often detected incidentally on imaging or during surgery.^[4,5,8] Their identification during splenectomy is clinically significant, as preserved accessory splenic tissue may maintain partial splenic function and reduce susceptibility to infections following splenectomy.^[6,7] This case underscores the importance of careful intraoperative inspection for accessory spleens during splenectomy in trauma patients.

CONCLUSION

Blunt splenic injury may demonstrate delayed haemodynamic deterioration despite initial response to resuscitation. Emergency splenectomy remains the definitive treatment in unstable patients. Incidental identification and preservation of an accessory spleen during splenectomy may help retain residual splenic immune function and should be considered whenever feasible.