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Laparoscopic Splenectomy

Ravindra Ramadwar
 

Historical Background
Splenectomy was first described for hereditary spherocytosis in 1910 by Sutherland and Burghard1 and for idiopathic thrombocytopenic purpura (ITP) in 1916 by Kaznelson. It was the main stay of treatment for haematological conditions. However with the advent of medical therapy for ITP in the form of steroids and immunoglobulins, surgery is offered less frequently for chronic ITP. Splenectomy is offered to patients who do not respond to medical therapy or due to adverse effects of steroids in chronic ITP. Remission after splenectomy is seen in 66% in chronic ITP as compared to 25% with medical therapy.

Review of Literature
Laparoscopic splenectomy was first described in 1991 by Delaitre and Maignien.2 In 1993 it was first reported in children by Lobe, et al. Since then significant improvements in instrumentation and technology such as harmonic scalpel, endovascular staplers have increased the ease of performance and scope of this type of surgery.

A combined review of 5 published series of open splenectomy in 611 patients revealed morbidity in 26% and mortality in 3.1%. A combined review of 461 cases from 15 published series revealed morbidity in 8%, mortality in 0.65% and conversion to open surgery in 8%. Katkhouda reported the largest series of 103 laparoscopic splenectomies in 1998.3 They did not have any mortality, requiring conversion to open surgery in 4 patients and complications in 6 patients. Harold et al in 1999 reported a mean hospital stay of 1.5 days after laparoscopic splenectomy.4 Friedman et al reported their experience of 63 laparoscopic splenectomies in 1997. Only 3 patients required blood transfusion during surgery.5 With the current published data and increased experience, laparoscopic splenectomy is emerging as a gold standard for the management of haematological disorders.

Indications
Indications for laparoscopic splenectomy are similar to open splenectomy excluding trauma.

The indications are
Autoimmune disorders – ITP, HIV related thrombocytopenic purpura, systemic lupus erythematosus related thrombocytopenic purpura, thrombotic thrombocytopenic purpura, autoimmune haemolytic anaemias

Hereditary haemolytic anaemias – Hereditary spherocytosis, ellipsocytosis

Haematological malignancies – Hodgkin’s disease, non-Hodgkin’s disease, chronic lymphocytic leukaemia

Miscellaneous disorders – Myeloproliferative disorders, Gaucher’s disease, Felty’s syndrome, Haemoglobinopathies like sickle cell anaemia and Thalassaemia, cysts, tumours of spleen, in conjunction with distal pancreatectomy

ITP is the most common disorder requiring splenectomy. In children ITP is of acute onset and 80% have spontaneous remission in 6 months. In adults the disease is chronic and remissions are few. Splenectomy is offered to patients who have significant symptomatic thrombocytopenia despite medical therapy or who have developed complications of medical therapy.

Hereditary spherocytosis is another common indication for splenectomy. Anaemia is curable in almost 90% of patients after splenectomy. If patients

have gall stone, laparoscopic splenectomy and cholecystectomy can be performed in the same sitting.

Massive splenomegaly per se is not a contraindication. The author has done splenectomy for grade III splenomegaly in thalassaemia major in a 7 year old girl. The availability of technological advances like harmonic scalpel, endovascular stapler, hand-assisted devices have contributed to the successful outcome in laparoscopic splenectomy.

The absolute contraindications for laparoscopic splenectomy are cirrhosis with portal hypertension, blunt trauma with instability and severe cardiopulmonary disease. The relative contraindications are previous abdominal surgery, significant obesity and are based on the expertise and experience of the operating surgeon. Open insertion of primary trocar and requirement of a large incision for open surgery in obese patients does merit attempt at laparoscopy.

Preoperative evaluation includes ultra sonography for gall stones and size of spleen. Preoperative splenic artery embolization for massive splenomegaly carries a significant risk of complications. Medical preparation include steroids, immunoglobulin, and if platelet count is below 10,000 then platelet transfusion. Preoperative low platelet count (< 10,000) is not a contraindication for laparoscopic splenectomy. All patients should receive polyvalent pneumococcal and H. influenza type B vaccinations 2 weeks prior to the surgery.

Technique
The patient is placed in a right lateral decubitus position at 60° after placement of a Ryle’s tube and urethral catheter. The primary port is inserted by open method. After creating pneumoperitoneum additional ports are inserted. The table is tilted to 15-20° head high position to allow gravity to retract bowel, stomach and liver away from the spleen while the spleen remains anchored by the diaphragmatic attachments. A 30°telescope is used and left lobe of liver is retracted with a grasper. A careful search for accessory spleen is performed. The dissection is performed by harmonic scalpel (Ethicon) and colon is separated by dividing splenocolic ligament. The omentum is cut and lesser sac opened. The short gastric vessels are cut with the harmonic scalpel and splenic hilum exposed. The peritoneum over the splenic vessels and the tail of pancreas is incised. The splenic artery is ligated by ligaclips or ties. The splenic attachments to the lateral abdominal wall are released and splenic hilum exposed. The tail of pancreas is separated from the spleen and splenic vessels are occluded by ligaclips or endovascular stapler. The diaphragmatic attachments are released last and spleen is placed in endobag for retrieval. The spleen can be delivered via a port site in piecemeal keeping the endobag in view all the time to minimise chances of splenosis. The spleen can be also retrieved by a pfannenstiel incision. A drain may be kept in splenic fossa in difficult splenectomies.

Postoperative course
Adequate analgesia (Paracetamol/ Jonac / Tramadol) is prescribed. The Foley catheter and nasogastric tube are removed 10-12 hours post-operatively. Fluids are started next day and feeding is established rapidly. Patient is usually discharged home on third postoperative day.

Postoperatively patient is followed up in the clinic after 6 weeks.

Laparoscopic versus open splenectomy
The advantages of laparoscopic splenectomy are
1) Great visualisation of the splenic pedicle
2) Pancreatic tail injury is avoided
3) Accessory spleens can be identified easily
4) Can be combined with other procedures as Cholecystectomy
5) Avoids muscle cutting incision
6) Reduced postoperative pain
7) Faster postoperative recovery
8) Cosmetically superior even if pfannenstiel incision is used for splenic extraction

The open splenectomy is quicker than laparoscopic splenectomy and hence preferred in trauma.

Current Status
Laparoscopic splenectomy is a gold standard in management of haematological conditions.

Laparoscopic splenectomy can also be done safely for massive splenomegaly. The author has performed laparoscopic splenectomy in 16 patients (14 ITP, 1 thalassaemia, and 1 spherocytosis) at Bombay Hospital in last 3 years with no mortality. With the availability of harmonic scalpel and endovascular stapler mean operative time for laparoscopic splenectomy has reduced considerably. Laparoscopic splenectomy is as safe as open splenectomy in experienced hands. Laparoscopic splenectomy for selected haematological conditions should replace open splenectomy as the technique of choice and should be offered to all patients.

References

  1. Sutherland GA, Burghard FF. The treatment of splenic anaemia by splenectomy. Lancet 1910; 2 : 1819.
  2. Katkhouda N, Mavor E. Laparoscopic Splenectomy. Surg Clin North Am 2000; 80 (4) : 1285-97.
  3. Katkhouda N, Hurwitz MB, Rivera RT, et al. Laparoscopic splenectomy: Outcome and efficacy in 103 consecutive patients. Ann Surg 1998; 228 : 568.
  4. Harold KL, Schlinkert RT, Mann DK, et al. Long-term results of laparoscopic splenectomy for immune thrombocytopenic purpura. Mayo Clin Proc 1999; 74: 37.
  5. Friedman RL, Hiatt JR, Korman JL, et al. Laparoscopic or open splenectomy for hematologic disease: Which approach is superior? J Am Coll Surg 1997; 185 : 49.

 

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BMJ, 2005; 330 : 1357


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Honorary Consultant Paediatric Surgeon, Bombay Hospital, Mumbai 400 020.
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