Accessory spleen misdiagnosed as left adrenal tumor causing complications

A 58-year-old female patient came to our hospital for physical examination. CT scan: a round, well-dened and isoechoic nodule has been found in the left adrenal with a clear boundary and scaled about 2.0cm × 1.7 cm. She underwent laparoscopic resection, sequentially occurred complications of the pancreas and renal impairment. Discussion: In general, the accessory spleen is asymptomatic and most were found by ultrasonography in physical examination. Usually, accessory spleen located in the helium or inferior pole of the spleen, rarely in the superior pole or other organs like adrenal. Clinically, it can be misdiagnosed or even caused complications in some serious cases. cannulas and after gasbag dilatation. The perirenal fascia is dissociated to dome diaphragm along the side of the kidney and then separated from pole to the ventral side of the The adrenal was found at the pole of the On no obvious was observed among the upper to the diaphragmatic apex, lower to the renal hilum anterior to the parietal peritoneum and posterior the medial margin of the psoas major. The left adrenal gland and surrounding adipose tissue were completely placed into a specimen bag.

revealed that the 8 AM blood cortisol was slightly lower(6.66, 6.7-22.6), signi cantly decreased urinary cortisol (15.69, 58-403)  During the physical examination, the left adrenal mass has been discovered, then the patient went to the urology department of the local hospital for treatment, did not make further examination and consultation, and underwent the surgeon. After anesthesia, the right side-lying position took, laying routine disinfection towels. A 2 cm incision was made above the midaxillary iliac ridge and separated into the retroperitoneal cavity. Then performed puncture cannulas with a diameter of 5 mm and 10 mm under the anterior and posterior costal margin of the axilla, respectively and the laparoscope was placed after gasbag dilatation. The perirenal fascia is dissociated to the dome diaphragm along the dorsal side of the kidney and then separated from the upper pole to the ventral side of the kidney. The adrenal tissue was found at the upper pole of the kidney. On scrutiny, no obvious mass was observed among the abdominal cavity upper to the diaphragmatic apex, lower to the renal hilum anterior to the parietal peritoneum and posterior to the medial margin of the psoas major. The left adrenal gland and surrounding adipose tissue were completely removed and placed into a specimen bag.
Continue to separate from the dome diaphragm to the ventral side, and carefully investigate. One brownyellow round mass was observed at the lateral edge of the splenic artery, and about 2.0cm × 1.7 cm. Using a blood vessel clamp at the base for hemostasis, then carefully separated and removed the mass completely from the original incision with an ultrasound knife. The excised tissue was put into a specimen bag, removed, and sent for pathological examination. After thorough hemostasis under laparoscopy, the wound surface was ushed, and no active bleeding was detected. Two drainage tubes were placed, the puncture cannula was pulled out, and the puncture incision was sutured in sequence. After the operation, the patient returned safely to the ward. Postoperatively, the patient is generally normal.
On day 10 after the operation, the uid was about 100 ml per day, which was considered as lymphatic leakage. CT scan showed the left adrenal mass still existed( Fig. 2A) with a similar CT value with the spleen, and consistent with spleen after enhancement (Fig. 2B). Hence accessory spleen was considered.
The patient was discharged with catheters on the same day.
On day 14 after the operation, approximately 500 ml of colorless uid was expelled from one of the drainage tubes. Pancreatic leakage was considered and readmitted for treatment.
On day 15 after the operation, about 500 ml bright red blood drained out, and bleeding was considered. Acute arteriography revealed splenic artery hemorrhage, then underwent arterial embolization (Fig. 3).
On day 17 after the operation, the patient developed abdominal discomfort. The upper abdominal muscles were found to be slightly tense, tender, and without rebound pain. The local uid was found on CT examination (Fig. 4), and an emergency laparotomy was performed. Hemoperitoneum around the retroperitoneal pancreas was observed,following cleared and double cannula and peritoneal drainage were placed.
After the operation, symptomatic treatment was given. The drainage tube was drained with colorless liquid of about 200 ml per day. The drainage uid decreased and on day 40 after the secondary operation, no hydrops was found on CT examination. Pulled out the tubes and the patient was cured and discharged.
The patients were followed up for half a year without special discomfort. CT showed the formation of a pseudocyst of the pancreas (Fig. 5A) and ischemia of the upper pole of the left kidney (Fig. 5B).

Discussion
The accessory spleen is caused by the fusion failure of the splenic anlage located in the dorsal mesogastrium in the fth week of fetal life [4] or developed from the deciduous part of the main spleen [5].
The incidence of the accessory spleen is about 10%-35%[6, 7] and the younger the age, the higher the incidence. It mainly occurs in the splenic hilum and the tail of the pancreas (more than 70%), and a few can occur in the gastrosplenic ligament and lienocolic ligament, or the greater omentum, ureter, ovary and pelvic cavity [8,9]. The accessory spleen can link to the main spleen or form a separate nodule in most cases. The nodule is composed of brous tissue with a clear boundary, and its internal structure is similar to that of the normal spleen. Therefore, the same circumstance on their internal echo [10]. Therefore, the accessory spleen may have lesions related to the main spleen, such as infarction, rupture, tumor, cyst, and even pedicle torsion, and its internal echo may change correspondingly [11].
Since the blood supply of the heterotopic accessory spleen comes from the external membranous micro artery or the small branch of the splenic artery, the left liver accessory spleen was misdiagnosed as liver cancer, focal liver hyperplasia and other liver diseases [12,13]. The accessory spleen on the tail of the pancreas was misdiagnosed as pancreatic cancer [14], islet cell tumor, or solid pseudopapillary of the pancreas [15], which leads to unnecessary surgery. Normally, the accessory spleen has little chance of lesions and acts no impact on human health. However, its related misdiagnosis or miss-diagnosis will cause unnecessary surgery or secondary surgery, which suggests that clinicians should increase their knowledge of the accessory spleen, especially the heterotopic accessory spleen so that to reduce the rate of misdiagnosis and missed diagnosis of the accessory spleen.

Conclusion
The case reported above indicated that the left adrenal mass was found in a physical examination and underwent surgery without a clear diagnosis. During the surgery, the pancreas has been impaired and inadequate post-injury management, which caused serious complications and pains to the patient.
We concluded three lessons in this case: 1. When unidenti ed mass found in the abdominal cavity, should consider the possibility of the accessory spleen. In this case, if the tumor was found in the CT and there was no abnormality in the general biochemical examination, no further examination was performed, and laparoscopic surgery was performed boldly. The funding body had no role in the design of the study, data collection/ analysis, interpretation of data, and the writing of the manuscript.  On day 15 after surgery, the patient underwent arterial embolization after diagnosed as splenic artery hemorrhage by acting acute arteriography.