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LAPAROSCOPIC SPLENECTOMY FORIDIOPATHIC THROMBOCYTOPENIC PURPURA

DEEPRAJ S BHANDARKAR*, RASIK SHAH***, MARKAND BHATT**
*Consultant GI and Laparoscopic Surgeon; **Consultant Surgeon, Sir Hurkisondas Nurrotumdas Hospital and Research Centre, Raja Ram Mohan Roy Marg, Mumbai 400 004.** *Consultant Pediatric Surgeon, Jaslok Hospital and Research Centre, Pedder Road, Mumbai 400 026.

We describe a young girl with idiopathic thrombocytopenic purpura who underwent a successful laparoscopic splenectomy. Issues pertaining to laparoscopic splenectomy in patients with haematological disorders are discussed and advantages of this approach over traditional open splenectomy highlighted.

INTRODUCTION

Laparoscopic surgery was added to the armamentarium of the general surgeons in the early 1990s, and laparoscopic cholecystectomy was the earliest procedure to gain popularity owing to benefits it offered to patients. With refinement in surgical technique and availability of better instrumentation laparoscopic surgery is today being increasingly used for performance of a variety of complex operations, including splenectomy. Patients with haematological disorders requiring splenectomy form ideal candidates for the laparoscopic approach. We describe the successful performance of laparoscopic splenectomy in a patient with idiopathic thrombocytopenic purpura (ITP) with a good outcome.

CASE REPORT

An 8-year-old girl was diagnosed to have chronic ITP during the course of investigations undertaken, at the age of three years, for a tendency to easy bruisability. She had been treated with steroids and Azathioprine and, being only partially responsive, was advised splenectomy by her haematologist. The preoperative platelet count was 45,000 / cu mm. A radionuclide scan was undertaken preoperatively to exclude the presence of accessory spleens, and she received pneumococcal, meninogococcal and haemophilus vaccines prior to surgery.

The surgery was performed under general endotracheal anaesthesia using two 10 mm and two 5 mm ports. The dissection was commenced at the lower pole of the spleen and the splenocolic ligament was taken down. Later, the gastrosplenic ligament was taken down in a similar fashion. A thorough search was made for accessory spleens, but none were identified. The entire dissection was performed using Ultrasonic shears (Ethicon Endosurgery, Mumbai) (Fig. 1). The splenic artery and vein were dissected out, clipped individually and divided. Finally, the splenophrenic and the splenorenal attachments were taken down to free up the spleen. The spleen was placed in a plastic bag (Fig. 2). The mouth of the bag was drawn into the supraumbilical incision that was extended to about 2.5 cm, and the spleen was extracted in a piecemeal fashion taking care to avoid peritoneal spillage. The fascia at the site of 10 mm and the 2.5 cm incisions was closed with No 1 Vicryl (Johnson and Johnson, Mumbai) and skin approximated with subcuticular suture (Fig. 3). The total duration of surgery was 90 minutes and intraoperative blood loss was estimated to be 50 ml. No perioperative blood or platelet transfusions were administered. She tolerated fluids and diet the day after surgery and was discharged on the second postoperative day. Her platelet count on the day following surgery had risen to 150,000 / cu mm. Six months after surgery she remains well, is off her steroids, and her platelet count has stabilised around 370,000 / cu mm.

Fig.1 Fig.2
Fig. 1 Dissection of spleen with harmonic shears in progress Fig. 2 Spleen placed in a plastic bag prior to removal
Fig.3
Fig.3 Four small incisions totalling about 5cm required for laparoscopic splenectomy.


DISCUSSION

Laparoscopic splenectomy was first reported by Carroll and colleagues in 1992, [1] and since then several series documenting its utility for a variety of conditions have appeared in the surgical literature. [2-4] Laparoscopic splenectomy seems to be best suited for patients with normal-sized or moderately enlarged spleens, e.g. for ITP, hereditary spherocyotosis, haemolytic anaemias and Hodgkin’s lymphoma. However, experienced laparoscopic surgeons have undertaken the procedure for massive spleens.5 Portal hypertension, coagulopathy and trauma are considered contraindications for laparoscopic splenectomy and the operation needs to be performed with extreme caution in patients likely to have perisplenitis and in the presence of large lymph nodes at the splenic hilum.

When performing laparoscopic splenectomy for haematological disorders, the main goal of therapy is removal of all splenic tissue including accessory spleens. Accessory spleens commonly occur around the splenic hilum, along the pancreas and in the lesser sac; rarely they may be encountered in locations such as the retroperitoneum, paracolic gutter or pelvis. Radionuclide studies such as 99mTechnetium-labelled RBC scan or 111Indium-labelled platelet scan may be performed for preoperative localisation of accessory spleens but false positive as well as false negative results have been reported. [6] Laparoscopy affords excellent magnification and provides adequate visualization to help in the search for accessory spleens present in commoner locations. A meticulous search is made for the accessory spleens at preliminary laparoscopy as well after opening the lesser sac and exposing structures around the splenic hilum. If found, they can be easily removed laparoscopically. Lack of tactile sensation and difficulty with retraction and adequate exploration of the retroperitoneum are considered to be factors that make detection of small accessory spleens tedious. Also, at times, accessory spleens occurring at locations other than the common ones, those buried in omental fat or covered by bowel loops or mesentery may be difficult to locate, particularly in obesepatients. Nevertheless, in many series the short to medium-term haematological outcomes in terms of recurrence of thrombocytopenia following laparoscopic splenectomy have been reported to be no different from those after open splenectomy. [5,7,8]

Extraction of the spleen can pose a significant challenge to the surgeon during laparoscopic splenectomy. Keeping in mind the potential for splenosis due to intraperitoneal seedling of splenic tissue as a result of capsular injury, it is best to avoid direct handling of the spleen and to place the freed spleen in a strong plastic bag prior to extraction. This allows most normal or moderate-sized spleens to be extracted through a 2-3 cm midline incision after enlargement of one of the port sites. The spleen is cut inside the plastic bag into long slivers prior to extraction. An incision 6 to 10 cm in length may have to be made for extraction when a large spleen cannot be placed inside a bag. An alternative is to use commercially available retrieval endobags, but these are quite expensive.

Laparoscopic splenectomy today forms a superior alternative to open splenectomy in patients with haematological disorders as its efficacy and complication rate are comparable to the latter. Also, laparoscopic splenectomy offers definite benefits to patients in terms of reduced postoperative pain, shorter hospital stay, earlier return to normal activity and often lower total procedural costs. Moreover, in experienced hands the blood loss during a laparoscopic splenectomy can be lower than that during open splenectomy.[9] However, being challenging and complex in nature, laparoscopic splenectomy remains an operation to be undertaken only by laparoscopic surgeons with considerable expertise.

In conclusion, laparoscopic splenectomy is a safe and effective technique for elective removal of a spleen, particularly in patients with haematological disorders. It should be preferred over a traditional open splenectomy as it offers several advantages to the patient.

REFERENCES

1. Carroll B, Philips E, Semel C, et al. Laparoscopic splenectomy. Surg Endosc 1992;6:183-185.

2. Trias M, Targarona EM, Espert JJ, et al. Impact of hematological diagnosis on early and late outcome after laparoscopic splenectomy: an analysis of 111 cases. Surg Endosc 2000;14:556-60.

3.Szold A, Schwartz J, Abu-Abeid S, et al. Laparoscopic splenectomies for idiopathic thrombocytopenic purpura: experience of sixty cases. Am J Hematol 2000;63:7-10.

4. Park AE, Birgisson G, Mastrangelo MJ, et al. Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases. Surgery 2000;128:660-7.

5.Targarona EM, Espert JJ, Cerdan G, et al. Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery. Surg Endosc 1999;13:559-62.

6.Rudowski WJ. Accessory spleens: clinical significance with particular reference to the recurrence of idiopathic thrombocytopenic purpura. World J Surg 1985;9:422-430.

7. Monteferrante E, Giunta A, Bigi L, et al. Splenectomy for hematologic disease. Comparison of laparoscopic versus open technique. Minerva Chir 2001;56:229-35.

8.Franciosi C, Caprotti R, Romano F, et al. Laparoscopic versus open splenectomy: a comparative study. Surg Laparosc Endosc Percutan Tech 2000;10:291-5.

9.Park A, Marcaccio M, Sternbach M, et al. Laparoscopic vs open splenectomy. Arch Surg 1999;134:1263-9.


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