Splenosis is the heterotropic implantation of splenic fragments onto exposed vascularised peritoneal and intrathoracic surfaces, following splenic injury or elective splenectomy. This can occur anywhere within the abdominal cavity and the resultant splenunculus will receive its blood by parasitizing the surrounding tissue.
There are few previous reports of hepatic splenosis mimicking hepatocellular carcinoma [10, 12, 13]. In most cases, correct diagnosis was only possible on histological examination after a laparotomy and open liver resection [10, 14]. A missed diagnosis of hepatic splenosis can have a significant negative impact on patient's management . Interestingly, in all cases a history of post-traumatic splenectomy was reported and all patients were known to have an underlying chronic liver disease [10, 16, 17]. There are no typical radiological features of intrahepatic splenosis and it is usually difficult to distinguish this condition from other liver tumors. In the presence of chronic liver disease, although mild but raised tumoral markers and strong suspicion of HCC on clinical ground, establishing the correct diagnosis can prove to be difficult.
Distinguishing the nature of a hepatic mass is important because it significantly alters patient management. In this case, if a diagnosis of HCC was confirmed, this patient would be suitable for resection (Child-Pugh class B) or for a liver transplant, satisfying the Milan criteria. Liver cirrhosis, having recent LFT derangement and with the above radiological picture made HCC strongly suspected. However, the pervious history of traumatic splenic rupture and the presence of multiple splenunculi within the abdominal cavity suggested that the best way to proceed would be for a laparoscopic exploration and a secure diffinition of the lesions nature before planning for future management.
Laparoscopy was sufficient in confirming diagnosis of splenosis, as well as excluding coexistent malignancy. This had a significant impact of clinical plans and patients management. It is already recognized that laparoscopy provides a port of minimally invasive entry for the visualisation of suspect masses, and allows access for potential subsequent biopsy or resection.
The abnormal liver function behavior in this case can be explained by an active hepatitis C process, which have improved following further anti viral treatment. Yet, a low threshold for HCC is a must with any similar scenario of suspicious liver function tests and radiological findings.
Laparoscopic resection of symptomatic or suspicious splenosis is a minimally invasive and feasible procedure. This was reported to be a successful diagnostic and interventional tool even in laparoscopically challenging scenarios involving the pancreas [18, 19].
To the best of our knowledge, this is the first case where laparoscopy has been the main tool in difining the correct diagnosis in a case of splenosis, suspected to be an HCC on radiological investingations and strong clinical bases.
We therefore propose that laparoscopic investigation should be part of a new approach for investigating suspect intrahepatic masses.