laparoscopic splenectomy
TRANSCRIPT
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