laparoscopy for splenic conditions george w. holcomb, iii, m.d., mba surgeon-in-chief children’s...
TRANSCRIPT
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Laparoscopy for Splenic Laparoscopy for Splenic ConditionsConditions
George W. Holcomb, III, M.D., MBA
Surgeon-in-ChiefChildren’s Mercy Hospital
Kansas City, Missouri
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Splenic Conditions
• ITP
• Spherocytosis
• Splenic cysts
• Wandering spleen
J Pediatr Surg 28:689-692, 1993J Pediatr Surg 28:689-692, 1993
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Pre-Operative Preparation• Ultrasound
• Often done by pediatrician, hematologist• Rarely needed for splenectomy, except may be useful for
extremely large spleen
• CT Scan – Useful in planning splenic cystectomy
• WinRho• Bone marrow stimulant• Usually used to platelet count• Useful pre-operatively to platelet count in ITP pt.
• Immunizations –Pneumococcus (Prevnar, Pneumovax)
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Patient Positioning
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Patient Positioning
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Personnel Positions
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Laparoscopic Splenectomy
• ITP, spherocytosis
• Port placement• (2) cannulas (5, 12)• (2) stab (3 mm) incisions
• Instruments• Harmonic scalpel (5 mm)• Articulating stapler (12 mm)
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Laparoscopic Splenectomy
Operative Steps• Divide spleno-colic
ligament, then short gastrics
• Clip artery• Autotransfuse pt• Protects stapler malfxn
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Laparoscopic Splenectomy
Operative Steps
• Divide spleno-renal lig.
• Articulating stapler across hilum
• Bag specimen, morcellate extracorporally
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Laparoscopic Splenectomy
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Single Site Umbilical Laparoscopic Surgery
Umbilical Portals (U.S.)
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SSULS Splenectomy
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SSULS Splenectomy
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Prospective Randomized Trial
SSULS vs 4-Port Laparoscopic Splenectomy
• Alpha – 0.05• Power – 0.80• 60 patients total• 10 patients to date
www.cmhclinicaltrials.com
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Issues
• How large is too large?
• 28 cm. – Splenic artery ligation helpful
• Can divide spleen (spherocytosis) with harmonic, if necessary
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Issues
• Postoperative platelet ct. > 500,000
• Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic)
• Baby aspirin ( 81 mg) QD for 6 mos
• Re-check at 3 months & 6 months
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Splenic Cysts
• Primary
• epithelial lining
• Pseudocysts (secondary)
• no epithelial lining
• often develop after trauma
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Laparoscopic Splenic Cystectomy
• First step is decompression of cyst
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Laparoscopic Splenic Cystectomy
• Excise cyst as close as possible to splenic parenchyma with harmonic scalpel
• Coagulate lining with Argon beam coagulator
• ? Place omentum adjacent to exposed cyst lining
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European Experience
• 3 European centers (Mainz, Mannheim, Hannover)
• 1995 - 2005
• 14 pts (median 8.5 yr)
• 10 recurrences (71%)
APSA 2006APSA 2006
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Wandering Spleen
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Wandering Spleen
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Laparoscopic Splenopexy
J Pediatr Surg 42:E23-27, 2007J Pediatr Surg 42:E23-27, 2007Please use this link if you experience problems viewing the video above.
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I.U. Experience1995 - 2006
231 patients
• Mean age 7.7 yrs
• Lap splenectomy – 223• 211 - total• 12 - partial
• Lap splenic cystectomy – 6
• Lap splenopexy - 2Ann Surg, in PressAnn Surg, in Press
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I.U. Experience1995 – 2006
Complications
• Ileus - 5
• Bleeding - 4
• Acute chest syndrome- 5
• Pneumonia - 2
• Portal vein thrombosis - 1
• HUS - 1
• Diaphragm perforation 2
• Colon injury - 1
• Port site hernia - 1
• Total splenectomy after partial - 1
• Recurrent cyst - 1
11% overall, 22% in SCD
Ann Surg, in PressAnn Surg, in Press