Laparoscopic resection of retroperitoneal lymphangioma around the pancreas: a case report and review of the literature
© Sato et al. 2015
Received: 23 June 2015
Accepted: 5 November 2015
Published: 10 December 2015
Lymphangiomas are rare, benign tumors. An intra-abdominal location of these lesions is rarer still and there are only a few reports describing laparoscopic resection for retroperitoneal lymphangiomas, especially in tumors that mimic pancreatic tumors.
We present the case of an asymptomatic 30-year-old Japanese woman in whom a cystic tumor was found incidentally in close approximation to the pancreas. Because the tumor was located in the retroperitoneal space and the body of the pancreas was compressed, we were unable to distinguish a cystic lymphangioma from cystic pancreatic tumors. We started the procedure laparoscopically with five ports. The tumor was in fact separated from the pancreas and was dissected free from the body of the pancreas using scissors and laparoscopic coagulating shears. The left gastric vessels, which were compressed by the tumor, were preserved. As we realized that the tumor was connected to the retroperitoneal lymphatic tissue, we completed the procedure by performing a cystectomy without rupture. The specimen was extracted using a plastic bag. Our patient was discharged on postoperative day 7 without any complications. There is no evidence of recurrence during a >2-year observation period.
In addition to the therapeutic significance in differentiating between a cystic lymphangioma in close approximation to the body of the pancreas and a pancreatic cystic neoplasm, the laparoscopic approach is feasible and effective.
KeywordsCystic lymphangioma Retroperitoneum Laparoscopy
Lymphangiomas are rare and benign tumors, which are caused by a malformation or a blockage of lymphatic vessels . While in most cases the lesions are located superficially on the body, on rare occasions they can occur in the retroperitoneal space [2, 3]. There are two types of lymphangiomas, namely cystic and cavernous. If the tumor is located adjacent to the pancreas, it is very difficult to diagnose through preoperative imaging alone . Because recurrence after drainage of a cystic lymphangioma has been reported , complete surgical resection is preferred for a cure . However, some authors argue that an adequate resection for lymphangioma is a cystectomy and that extended resection should be avoided [1, 2]. Here we describe the case of a patient with cystic lymphangioma, which arose from retroperitoneal lymphatic vessels around the superior edge of the pancreas.
Laparoscopic resection of retroperitoneal lymphangioma around the pancreas. Movie file of our procedure. (M4V 20211 kb)
A cystic tumor in the retroperitoneal space has many potential diagnoses, particularly when located adjacent to the pancreas, in which case the decision to operate is more difficult . Lymphangiomas generally require only cystectomy; pancreatic tumors, on the other hand, usually require pancreatectomy, which is a far more involved operation.
Lymphangiomas are benign lesions characterized by proliferating lymphatic vessels, and are classified as either hamartomas or lymphangiectasis. Since lymphangiomas are tumors that develop before birth, in most cases they are discovered when patients are young . Adult cases are rare and retroperitoneal lesions are rarer still . In the present case, the tumor was located in the retroperitoneal space and abutting the pancreas; we were therefore unable to make a preoperative differential diagnosis between pancreatic tumors, such as a pancreatic pseudocyst or a mucinous cystic neoplasm, and a lymphangioma based on radiology alone.
Makni et al. espouse the concept that an extended resection should not be performed for benign lymphangiomas . In the last 10 years (since 2005), 31 cases of retroperitoneal lymphangioma were reported. Cystectomy was performed in 21 cases, pancreaticoduodenectomy in one case, distal pancreatectomy with splenectomy in four cases, adrenalectomy in two cases, and miscellaneous abdominal operation in one case (two reports did not describe details of the surgical procedure). If surgery is undertaken for a retroperitoneal mass of unknown cell origin, the surgeon must be able to modify the extent of surgery based on the nature of the tumor as observed intraoperatively in an attempt to preserve the integrity of any adjacent organs. To that end, a laparoscopic approach is useful for diagnosing and sometimes treating such lesions.
Previous reports on laparoscopic/retroperitoneoscopic resection for retroperitoneal cystic lymphangiomas
Tagarona et al. 
Abdominal pain and palpable mass
Tsukamoto et al. 
Hypochondralgia and back pain
Celia et al. 
Trindade et al. 
Kasza et al. 
Yagihashi et al. 
Makni et al. 
None (incidental finding)
Black et al. 
Liu et al. 
None (incidental finding)
Jung et al. 
Epigastric discomfort, poor oral intake
None (incidental finding)
A retroperitoneal lymphangioma in close approximation to the pancreas is easily and safely resected laparoscopically. In addition to the therapeutic significance in differentiating between a cystic lymphangioma in close approximation to the body of the pancreas and a pancreatic cystic neoplasm, the laparoscopic approach is feasible and effective.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Colovic RB, Grubor NM, Micev MT, Atkinson HD, Rankovic VI, Jagodic MM. Cystic lymphangioma of the pancreas. World J Gastroenterol. 2008;14:6873–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Makni A, Chebbi F, Fetirich F, Ksantini R, Bedioui H, Jouini M, et al. Surgical management of intra-abdominal cystic lymphangioma. Report of 20 cases. World J Surg. 2012;36:1037–43.View ArticlePubMedGoogle Scholar
- Singh S, Baboo ML, Pathak IC. Cystic lymphangioma in children: report of 32 cases including lesions atrrare sites. Surgery. 1971;69:947–51.PubMedGoogle Scholar
- Paal E, Thompson LD, Heffess CS. A clinicopathologic and immunohistochemical study of ten pancreatic lymphangiomas and a review of the literature. Cancer. 1998;82:2150–8.View ArticlePubMedGoogle Scholar
- Mansour NM, Salyers Jr WJ. Recurrence of a pancreatic cystic lymphangioma after diagnosis and complete drainage by endoscopic ultrasound with fine-needle aspiration. JOP. 2013;14:280–2.PubMedGoogle Scholar
- Bhavsar T, Saeed-Vafa D, Harbison S, Inniss S. Retroperitoneal cystic lymphangioma in an adult: a case report and review of the literature. World J Gastrointest Pathophysiol. 2010;1:171–6.View ArticlePubMedPubMed CentralGoogle Scholar
- Targarona EM, Moral A, Sabater L, Martinez J, Luque P, Trias M. Laparoscopic resection of a retroperitoneal cystic lymphangioma. Surg Endosc. 1994;8:1425–6.PubMedGoogle Scholar
- Jung HI, Ahn T, Son MW, Kim Z, Bae SH, Lee MS, et al. Adrenal lymphangioma masquerading as a pancreatic tail cyst. World J Gastroenterol. 2014;20:13195–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Black T, Guy CD, Burbridge RA. Retroperitoneal cystic lymphangioma diagnosed by endoscopic ultrasound-guided fine needle aspiration. Clin Endosc. 2013;46:595–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Yagihashi Y, Kato K, Nagahama K, Yamamoto M, Kanamaru H. A case of laparoscopic excision of a huge retroperitoneal cystic lymphangioma. Case Rep Urol. 2011;2011:712520.PubMedPubMed CentralGoogle Scholar
- Liu B, Li Y, Wang S. Adrenal lymphangioma removed by a retroperitoneoscopic procedure. Oncol Lett. 2013;5:539–40.PubMedGoogle Scholar
- Celia A, Breda G. Laparoscopic excision of a retroperitoneal cystic lymphangioma: an insidious case. J Laparoendosc Adv Surg Tech A. 2007;17:315–6.View ArticlePubMedGoogle Scholar
- Trindade EN, Trindade MR, Boza JC, Von Diemen V, Ilgenfritz RB. Laparoscopic excision of a retroperitoneal cystic lymphangioma in an elderly patient. Minerva Chir. 2007;62:145–7.PubMedGoogle Scholar
- Tsukamoto T, Tanaka S, Yamamoto T, Kakinoki E, Uemichi A, Kubo S, et al. Laparoscopic excision of a retroperitoneal cystic lymphangioma: report of a case. Surg Today. 2003;33:142–4.View ArticlePubMedGoogle Scholar
- Kasza J, Brody FJ, Khambaty F, Vaziri K, Wallace B. Laparoscopic resection of a retroperitoneal cystic lymphangioma in an adult. Surg Laparosc Endosc Percutan Tech. 2010;20:e114–116.View ArticlePubMedGoogle Scholar