LAPAROSCOPIC SPLENECTOMY FORIDIOPATHIC
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
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.
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.
1 Dissection of spleen with harmonic shears in progress
2 Spleen placed in a plastic bag prior to removal
Four small incisions totalling about 5cm required for laparoscopic splenectomy.
Laparoscopic splenectomy was first reported by Carroll and colleagues in 1992,
 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
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.  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. 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.
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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
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6.Rudowski WJ. Accessory spleens: clinical significance with
particular reference to the recurrence of idiopathic thrombocytopenic purpura.
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