Laparoscopic Splenectomy

George Ferzli, MD, FACS

Department of Laparoscopic SurgeryStaten Island University Hospital

Historical background

• “An organ of mystery” (Galen)

• “Unnecessary” (Aristotle)

• “An organ that hinders the speed of runners” (Pliny)

• “An organ that produce laughter and mirth” (Babylonian Talmud)

Open splenic surgery

• 1st splenectomy: 1549, Adrian Zacarelli

• 1st partial splenectomy: 1590, Franciscus Rosetti

• 1st splenectomy in the USA: 1816, O’Brien

• 1st repair of lacerated spleen: 1895, Zikoff (Russian)

Laparoscopic splenectomy• In 1992, several reports of laparoscopic

splenectomies started emerging in small series.

• Laparoscopic splenectomy has become a useful alternative to open splenectomy.

Spleen Anatomy

• Most common relationship of artery and vein is artery anterior

• Other positions occur• Main artery divides

into hilar branches over the pancreatic tail

Spleen Anatomy

• Major Ligaments– Gastrosplenic

– Splenorenal (lienorenal)

• Minor Ligaments– Splenocolic

– Splenophrenic

– Pancreaticosplenic

Spleen Anatomy

Locations of Accessory SpleensA Splenic hilum

B Along splenic vessels

C Splenocolic ligament

D Perirenal omentum

E Small bowel mesentery

F Presacral area

GUterine adnexa

HPeritesticular region

Splenic Function

• Immune function– Filtering function

– Opsonin production

– Clearance of encapsulated organisms

– Clearance of metastatic cells

• Erythrocyte maintenance

• Platelet reservoir• Storage organ for

factor VIII

Indications for splenectomy

• Hematologic disorder– Hereditary spherocytosis

– Autoimmune anemia

– Thalassemia

– Hereditary Hemolytic anemia

– Sickle cell disease

– ITP

– TTP

– Sickle cell

• Malignancy– Lymphoma (Hodgkin’s and non

Hodgkin’s disease)– Lymphoproliferative disorders– Hairy cell leukemia

• Splenic Mass– Cysts and tumors– Abscesses

• Ruptured spleen– Trauma– Incidental

• Other– Felty’s syndrome– Gaucher’s disease– Splenic vein thrombosis– AIDS

Change of Indications

Decrease Increase

• Decline of staging laparotomy for Hodgkin’s disease

• Increase of splenectomies for hereditary spherocytosis and myeloproliferative disorders

• Significant Increase indication for ITP

• New indication: Hairy cell leukemia, Felty’s syndrome, AIDS

Personal experience (Indications)

Diagnosis Patients ITP* 32 Hodgkin’s 8

Hamartoma 1 Gaucher’s disease 1

HIV 8 Lymphoma 14 Splenic cyst 2 Hereditary spherocytosis 2 Hypersplenism 7 Sideroblastic anemia 1 Trauma 4 Total 86

*6 patients *6 patients with with accessory accessory spleenspleen

Relative Contraindications to Laparoscopic Approach

• Active hemorrhage with hemodynamic instability

• Non-platelet coagulopathy• Contraindications to pneumoperitoneum• Splenomegaly• Pregnancy• Extensive previous upper abdominal surgery

Laparoscopic versus open splenectomy*

• Earlier discharge

• Less pain

• Earlier resumption of oral intake

• Fewer blood transfusions

• Similar operative time with increased experience

*Donini et al. Surg Endosc (1999) 13:1220-1225*Donini et al. Surg Endosc (1999) 13:1220-1225

Three Areas of Controversy

• Is massive splenomegaly a contraindication for laparoscopic splenectomy?

• What is the role of laparoscopy in the management of splenic rupture?

• Does laparoscopic splenectomy for hematologic disease result in higher recurrence?

Massive splenomegaly

• Technical challenge– Difficulty to manipulate the spleen– Difficulty in the extraction of the spleen

• Options– Totally laparoscopic splenectomy– Hand port assisted *

*Meijer et al J Laparoendosc & Adv Techn (1999) 9:507-10*Meijer et al J Laparoendosc & Adv Techn (1999) 9:507-10

Massive SplenomegalyLaparoscopy vs Open

Targarona et al. Surg Endosc 1999

105 laparoscopic vs 81 open– Group A<400

– Group B 400-1000

– Group C>1000

Massive SplenomegalyLaparoscopy vs Open

Group Conversion

OR time

Transfusion

Morb. Analg. Hospital stay

A(<400) 4% 143 vs 102

Lower Lower Lower Shorter

B(400-1000)

0% 179 vs 103

Similar Similar Similar Shorter

C(>1000) 23% 176 vs 111

Lower Lower Similar Shorter

Laparoscopic Splenectomy for Ruptured Spleen

• Indications– Incidental splenectomy– Trauma

• splenorrhaphy

• splenectomy

Laparoscopic Splenectomy for Ruptured Spleen

• The patient has to be hemodynamically stable (on going bleeding requiring large blood transfusion)

• Use of 10mm suction/irrigation device

• Early control of splenic hilum

• Hand port could be helpful

Accessory spleens (AS)

• The reported incidence in OS (15 30%) is higher then LS (4-12%)

• Long term follow up is essential because a small accessory spleen can hypertrophy after splenectomy and be detected via CT scan or scintigraphy

Residual Splenic Function

Targarano et al. Arch Surg 1998

– 48 LS for hematologic disease

– 9 patients no clinical improvement

– Of the 9 patients, 3 had residual function on scintigraphy scan

– Of the 3 patients, 2 had accessory spleen and 1 had implants of splenic tissue

Residual Splenic Function

• Shimomatsuya et al. Surg Endos 1999

– 20 OS and 14 LS for ITP

– Similar failure rate between OS and LS

– Similar number of accessory spleens detected intraoperatively between OS and LS

Prevention of Residual Function

• Extreme care to avoid parenchymal rupture and cell spillage

• Systematic and careful exploration of the abdominal cavity for accessory spleens

Preoperative Considerations

• Pneumovax, haemophilus, meningococcus vaccinations 2 weeks pre-op

• Corticosteroids• Availability of blood and platelet products• Preoperative IgG administration to patients

with ITP and critically low platelet counts• Perioperative antibiotics• Pre-operative embolization- controversial

Technique

• Patient Positioning– supine

– lithotomy

– right lateral decubitus

• Trocar placement– 3 vs. 4

• Angled scope

1) Splenic mobilization

2) Splenic hilum

3) Extraction after finger morcellation

Technique

(depends on the anatomy)

Technique

• Division of the lowermost short gastric vessels

Technique

• Inferior and lateral mobilization of the spleen– previously performed

last

– now performed early to gain better access to the hilum

Technique

• Division of the hilar vessels with the vascular stapler

Technique

• Division of the uppermost short gastric vessels

• Can be approached from the medial or lateral aspect

Technique

• Placement in a retrieval bag

• Extraction in piecemeal fashion

Post-op Considerations

• Removal of NGT and foley prior to extubation

• Up in chair for a few hours the night of surgery

• Liquid diet begun on the first post-op day

• Ambulate in the hall on the first post-op day

• Discharge on the first or second post-op day

Personal experience Results

Mean Number of patients 86

Age 9-82 Y/O 42

OR time 47-250 min. 96 min.

Weight 96-4800 gm 405 gm

Blood transfusion 1

Conversion 1

Mortality* 1 Hospital stay 1.8day

* 50 days after surgery* 50 days after surgery

Complications

• Wound infection

• Post splenectomy sepsis

• Atelectasis

• Post-op bleeding

• DVT

• Gastric perforation

• Pancreatic fistula

Conclusion

• Our data indicates that the indications for laparoscopic splenectomy are the same as for open splenectomy

• Massive splenomegaly, ruptured spleen are not a contraindication

• Residual function and accessory spleen are not a concern