esplen ecto mia

8/12/2019 Esplen Ecto Mia

1/6

The Ascendance of Laparoscopic SplenectomyR. MATTHEW WALSH, M.D.,* B. TODD HENIFORD, M.D., FREDRICK BRODY, M.D.,* JEFFREY PONSKY, M.D.*

From the *Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio and Departmentof Surgery, Medical Center of the Carolinas, Charlotte, North Carolina

The application of laparoscopic techniques for abdominal procedures has been achieved withvarying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by itsinfrequent performance and difficulty in manipulating the spleen. A retrospective review ofsplenectomies performed for primary splenic pathology was done to assess the role and outcomeof LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over thattime period the proportion of LS performed increased steadily from 17 to 75 per cent of allsplenectomies. The primary indications for splenectomy included immune thrombocytopenicpurpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86females and 64 males. Immediately before operation 36 patients (4%) had a platelet count


2/6

anemia in four each; splenic mass and thromboticthrombocytopenic purpura (TTP) in three each;splenic abscess in two, and splenic cyst, torsion, andcontained rupture in one each. There were 12 pediatricpatients ranging in age from 4 to 17 years. The mean

age of the remaining 138 adult patients was 54 years(range 1889), and there were 86 females and 64males. Thirty-seven adults (27%) had splenomegaly asdefined by a cranial-caudal length greater than 11 cmor a morcellated weight greater than 300 g. Addition-ally at the time of operation, 36 patients (24%) had aplatelet count less than 50,000/mL, and 24 patients(16%) had a hemoglobin less than 10 mg per cent.

The introduction of laparoscopic splenectomy didnot replace open splenectomy, but it has largely sup-planted its role. During the first 3 years after the in-troduction of laparoscopic splenectomy at the Cleve-land Clinic a total of 115 splenectomies (open and

laparoscopic) were performed, 23, 32, and 60 per year,respectively. During this period the proportion of lap-aroscopic splenectomies performed per year increasedfrom 17 to 38 to 75 per cent, respectively. Over a shortspan of time laparoscopic splenectomy has largely re-placed traditional splenectomy regardless of operativeindication and has also resulted in an overall increasein the number of splenectomies performed.

Operative Technique

The right lateral decubitus position is our preferredapproach for laparoscopic splenectomy and is particu-

larly well suited for patients with splenomegaly. En-largement of the spleen can result in unusual androunded configurations that in addition to sheer sizeand weight make the spleen difficult to manipulate.There also may be areas of autoinfarction that lead toinflammatory adhesions to the diaphragm and omen-tum. Lateral positioning facilitates manipulation of thespleen by taking advantage of gravity to expose the

retroperitoneal attachments and allow a safe dissectioneven in the presence of dense diaphragmatic adhe-sions. Fewer trocars are typically required and splenicretraction can be accomplished with less risk of cap-sular disruption.

At least one week before operation patients receivea polyvalent pneumococcal, meningococcal, and poly-saccharide Haemophilus-B conjugate vaccine. Pro-phylactic antibiotics are given immediately before sur-gery. Proper patient positioning and padding areimportant to achieve maximal operative exposure andavoid neurovascular traction and pressure injuries. Pa-tients undergo endotracheal intubation in the supineposition, a urinary catheter is placed, and any addi-tional invasive monitoring that may be required is per-formed before rolling to a right-lateral decubitus po-sition. The extended arms are secured by a double-armboard. Rolled blankets are placed at the umbilicus,

between the legs, and in the right axilla. The operat-ing-room table is flexed at the level of the umbilicus tolengthen the distance between the iliac crest and thecostal margin. Laparoscopic splenectomy is typically atwo-person operation with both persons facing the pa-tients abdomen. The surgeon and assistant direct theirattention to a single video monitor over the patientsleft shoulder for in-line operating. Reverse Trendelen-burg position allows for blood and irrigation fluid tocollect in the pelvis away from the operative field.

Typically three 10-mm ports are required. Port sitesare tentatively marked so that after insufflation theoptimal positions will be 4 cm below the inferior tip of

the spleen but within reach of the diaphragm. Substan-tial inferior and lateral placement of the trocars may benecessary with massive splenomegaly. Occasionallybetter access to the diaphragm is needed and can beaccomplished with a fourth or fifth trocar positionedfurther posterior to the usual three trocars. The typicalposition of the lateral port is at the level of the 11th ribtip, the medial port is close to the midline, and themiddle port is halfway between. An open insertion atthe middle port is performed followed by all additionalports placed under laparoscopic guidance. A 5/10-mm30 or 45 laparoscope is a requirement. Mobilizationof the splenic flexure of the colon is performed whennecessary.

Proceeding in an inferior-to-superior direction theperitoneal attachments are sharply divided approxi-mately one cm from the spleen. The dissection con-tinues lateral to medial with retraction toward the mid-line by a blunt grasper until the pancreas and hilarvessels are visualized. Mobilizations of the inferiorpole including branches from the epiploic vessels aredivided between clips or with a harmonic scalpel. Theoperation proceeds best when the laparoscope is ex-changed between the medial and lateral trocars and the

TABLE 1. Patient Characteristics: Indications forLaparoscopic Splenectomy

No. of Patients

ITP 75Lymphoma 26Splenomegaly 19Leukemia 10Hemolytic anemia 4Hereditary spherocytosis 4TTP 3Splenic mass 3Splenic abscess 2Splenic cyst 1Torsion 1Contained rupture 1Splenic artery aneurysm 1Total 150

No. 1 LAPAROSCOPIC SPLENECTOMY Walsh et al. 49


3/6

surgeon operates with both hands. Care should betaken when mobilizing the superior pole to identify thegreater curvature of the stomach and short gastric ves-sels. The remaining hilar pedicle is divided with avascular gastrointestinal anastomosis stapler. Several

firings of the stapler are usually required and may alsobe used to divide the short gastric vessels. If preferreda 10-mm right-angled clamp can individually dissectthe hilar and short gastric vessels before placing clips.The spleen is then placed into an appropriately sizedimpermeable retrieval bag. This bag should be strongyet flexible so that it is easy to manipulate but will notrupture during extraction.

Often the most challenging aspect of the operationis placing an enlarged spleen in the retrieval bag. Thisis facilitated by placing the closed end of the bag at thediaphragm and widely opening the bag toward thelateral trocar while holding the posterior lip of the bag

with a left-handed instrument. The hilum is graspedwith a right-handed instrument and the spleen is slidinto the bag while the patient is placed in the Tren-delenburg position. Occasionally placement of a mas-sively enlarged spleen into the bag is expeditiouslyaccomplished by using a hand-assisted technique.Typically the trocar site nearest the nondominant handis enlarged to just allow insertion of the hand. Theopening of the bag is delivered through the largest portsite and excised in chunks with a ringed forceps. Theabdomen is reinsufflated, the operative site is irrigated,and hemostasis is assured. A drain is placed if a pan-creatic injury is suspected.

The patients have the orogastric tube and typicallythe urinary catheter removed in the operating room. Aliquid diet is started the evening after surgery andregular diet the first postoperative day. Patients areencouraged to ambulate beginning the day of surgery.Serum amylase and hemoglobin levels are obtainedthe morning after surgery.

Results

Laparoscopic splenectomy was able to be com-pleted in all but two patients (98.6%). The reasons forconversion in these two patients with splenomegalywere a suspected gastrotomy in one and bleeding froma capsular tear in a previously irradiated spleen withextensive perisplenic adhesions in the other. Thuseven in the setting of splenomegaly 94.6 per cent ofprocedures were successfully completed laparoscopi-cally. The average cranial-caudal length in patientswith splenomegaly was 17.3 cm (range 1225) with amean weight of 735 g (range 2933300). In three pa-tients a laparoscopic hand-assist device was requiredfor manipulation or extraction of an enlarged spleen.The average morcellated splenic weight of the entire

group was 411 g. The mean operative time was 161minutes (range 69389). The average blood loss was138 cm3 (range


4/6

tion of the operation in 80 to 100 per cent of pa-tients.3, 57

The addition of laparoscopic techniques has not al-tered the indications for any operation, including sple-nectomy (Table 2). Our early experience has shown a

rapid rise in the total number of splenectomies per-formed and likely reflects broad patient and physicianacceptance of laparoscopy and an increase in appro-priate referrals. ITP is well suited for laparoscopicsplenectomy and is the most frequent indication foroperation. In our experience it accounted for half of alloperations. The earliest attempts at laparoscopic sple-nectomy were performed for ITP owing to its overallfrequency and normal splenic size.8, 9 Medical therapyis initially indicated for the treatment of ITP with sple-nectomy reserved for an inability to achieve or sustainremission or for complications developing duringmedical therapy. Durable responses to splenectomy

are expected in 70 to 90 per cent of patients regardlessof the operative approach.6, 1012 Concern has beenraised as to the ability to identify accessory spleensthat may be present in 10 to 30 per cent of patients andcan result in recurrence of disease.1317 This problemmay be of particular concern for patients operated inthe lateral position, and one series has reported a 50per cent persistence of splenic tissue by nuclear imag-ing, although few had clinically recurrent disease.18

Our results of a 12 per cent recurrence of ITP corre-spond favorably with other series as does the lack ofmissed accessory spleens by nuclear imaging.19 A dili-

gent search should routinely be made to identify ac-cessory spleens during elective splenectomy in thesplenic hilum, vascular pedicle, pancreatic tail, omen-tum, and splenic ligaments.15 Should a missed acces-sory spleen be ultimately discovered to account for

recurrent disease then repeat laparoscopic excisionmay be accomplished.20

Splenectomy may be required for benign or malig-nant hematologic disease associated with splenomeg-aly. An enlarged spleen makes the performance morechallenging because of the reduced functional operat-ing space, limited retraction of the spleen, enlargedhilar vessels, and difficulty in placing the spleen in theretrieval bag. This is not an infrequent problem as 27per cent of our laparoscopic patients had associatedsplenomegaly. Nearly all of these were completedlaparoscopically and are typically associated withlonger operative times, less blood loss, and shorter

hospital stay as compared with traditional surgery.21

Our experience has shown that laparoscopic splenec-tomy is particularly difficult for spleens greater than20 cm in length or after radiation to the spleen andsplenomegaly. We recommend a hand-assist techniquefor spleens >23 cm in length or >19 cm in diameter.Two of the most common causes of splenomegaly inour experience were chronic lymphocytic leukemiaand non-Hodgkins lymphoma. Splenectomy is war-ranted for these types of hematologic malignancies fordiagnosis, treatment of intractable pain, respiratorycompromise, and amelioration of hypersplenism andimmune-mediated cytopenias.5, 22 The suspicion of

malignant disease is not a contraindication for laparo-scopic splenectomy, but additional care should betaken to avoid splenic disruption. Laparoscopic sple-nectomy may also be successfully applied to staging inHodgkins disease when the status of abdominal dis-ease will alter management.23, 24 There is reason to beoptimistic that the acceptance of laparoscopic splenec-tomy will result in earlier diagnosis and effective pal-liation of hematologic malignancies.

Perioperative complications are well known aftersplenectomy and are not eliminated by the adaptationto laparoscopy. The dreaded and often lethal compli-cation is that of overwhelming post-splenectomy in-fection. Fortunately rare, fulminant sepsis accounts foran operative mortality in 2 to 4 per cent of patientsafter splenectomy and is usually related to the under-lying malignant hematologic disease.2527 The inci-dence of post-splenectomy sepsis has not been higherin those having laparoscopic splenectomy, nor havethe other postoperative complications. The overallmorbidity of laparoscopic splenectomy should not ex-ceed 10 per cent and is usually attributable to hemor-rhage or pancreatitis. In our experience pancreatic in-

jury is the most frequent complication and typically

TABLE 2. Indications for Splenectomy

Hematologic disordersHemolytic anemias

Hereditary spherocytosisThalassemia majorSickle cell diseaseAutoimmune hemolytic anemiaPyruvate kinase deficiency

ThrombocytopeniasITPTTP

Myeloproliferative disordersMyelofibrosis

Neoplasia

Hairy cell leukemiaHodgkins diseaseNon-Hodgkins lymphomaChronic lymphocyte leukemia

Miscellaneous diseaseFelty syndromeGauchers diseaseSarcoidosisSplenic cystsSplenic vein thrombosisAcquired immunodeficiency syndromeSplenic artery aneurysmSplenic abscessTrauma



5/6

resolves without intervention. The injury occurs at thepancreatic tail as the splenic hilum is divided and maywell occur as often with open splenectomy. Interven-tion when necessary is directed toward symptomaticfluid collections that can be accessed by percutaneous

drainage. Hemorrhage during routine laparoscopicsplenectomy is minimal in our experience with a largenumber of patients having an operative blood loss lessthan 50 mL. In general laparoscopic splenectomycompares favorably with open splenectomy (Table 3).The two approaches are similar in amount of bloodloss, complication rate, and efficacy in treatment ofhematologic disease. Laparoscopic splenectomy ap-pears superior to open splenectomy in amount of post-operative pain, parenteral analgesic use, length of hos-pital stay, and return to normal activity. Theexperience to date indicates that laparoscopic splenec-tomy is indicated for all elective splenectomies.

REFERENCES

1. Glasgow RE, Yee LF, Mulvihill SJ. Laparoscopic splenec-

tomy: The emerging standard. Surg Endosc 1997;11:10812.

2. Delaitre B, Maignien B, Icard P. Laparoscopic splenectomy.

Br J Surg 1992;79:1334.

3. Park A, Gagner M, Pomp A. The lateral approach to lapa-

roscopic splenectomy. Am J Surg 1997;173:12630.

4. Smith CD, Meyer TA, Goretsky MJ, et al. Laparoscopic

splenectomy by the lateral approach: A safe and effective alterna-

tive to open splenectomy for hematologic diseases. Surgery 1996;

120:78994.

5. Walsh RM, Heniford BT. Laparoscopic splenectomy for

non-Hodgkins lymphoma. J Surg Oncol 1999;70:11621.6. Tsiotos G, Schlinkert RT. Laparoscopic splenectomy for im-

mune thrombocytopenic purpura. Arch Surg 1997;132:6426.

7. Rhodes M, Rudd M, ORourke N, et al. Laparoscopic sple-

nectomy and lymph node biopsy for hematologic disorders. Ann

Surg 1995;222:436.

8. Carroll BJ, Phillips EH, Semel CJ, et al. Laparoscopic sple-

nectomy. Surg Endosc 1992;6:1835.

9. Lefor AT, Melvin WS, Bailey RW, Flowers JL. Laparoscop-

ic splenectomy in the management of immune thrombocytopenia

purpura. Surgery 1993;114:6138.

10. Akwari OE, Itani KM, Coleman RE, Rosse WF. Splenec-

tomy for primary and recurrent immune thrombocytopenic purpura

(ITP). Ann Surg 1987;206:52941.

11. Gigot JF, Lengele B, Gianello P, et al. Present status oflaparoscopic splenectomy for hematologic diseases: Certitudes and

unresolved issues. Semin Laparosc Surg 1998;5:14767.

12. Schlinkert FT, Mann D. Laparoscopic splenectomy offers

advantages in selected patients with immune thrombocytopenic

purpura. Am J Surg 1995;170:6246.

13. Olsen WR, Beaudoin DE. Increased incidence of accessory

spleens in hematologic disease. Arch Surg 1969;98:7623.

14. Davis PW, Williams DA, Shamberger RC. Immune throm-

bocytopenia: Surgical therapy and predictors of response. J Pediatr

Surg 1991;26:40712.

15. Rudowski WJ. Accessory spleens: Clinical significanceTABLE3.

ComparisonofOpena

ndLaparoscopicSplenectomy

Study

No.ofPatients

OperativeTime(min)

Complications(%)

BloodLoss(mL)

H

ospitalDays

OS

LS

OS

LS

OS

L

S

OS

LS

O

S

LS

ClevelandClinic(presentstudy)

150

161

8

138

2.3

Glasgowetal.1

(1997)

28

52

156

196

14

10

274

320

6

.7

4.8

Friedmanetal.1

9

(1997)

74

63

121

153

34

14

437

259

6

.7

3.5

Diazetal.2

8

(1997)

15

15

116

196

13

7

359

385

8

.8

2.3

Watsonetal.2

9

(1997)

47

13

84

89

19

0

NA

NA

10

2

Smithetal.4

(1996)

10

10

131

261

20

0

NA

NA

5

.8

3.0

Bruntetal.3

0

(1996)

20

26

134

202

30

23

376

222

5

.8

2.5

OS

opensplenectomy;LS

laparoscopicsplenectomy;NA

no

tapplicable.

52 THE AMERICAN SURGEON January 2001 Vol. 67


6/6

with particular reference to the recurrence of idiopathic thrombo-

cytopenic purpura. World J Surg 1985;9:42230.

16. Wallace D, Fromm D, Thomas D. Accessory splenectomy

for idiopathic thrombocytopenic purpura. Surgery 1982;91:1346.

17. Glasgow RE, Mulvihill SJ. Laparoscopic splenectomy.

World J Surg 1999;23:3848.

18. Gigot JF, Jamar F, Ferrant A, et al. Inadequate detection ofaccessory spleens and splenosis with laparoscopic splenectomy.

Surg Endosc 1998;12:1016.

19. Friedman RL, Hiatt JR, Korman JL, et al. Laparoscopic or

open splenectomy for hematologic disease: Which approach is

superior? J Am Coll Surg 1997;185:4954.

20. Morris KT, Horvath KD, Jobe BA, Swanstrom LL. Lapa-

roscopic management of accessory spleens in immune thrombo-

cytopenic purpura. Surg Endosc 1999;13:5202.

21. Terrosu G, Conini A, Baccarani U, et al. Laparoscopicver-

sus open splenectomy in the management of splenomegaly: Our

preliminary experience. Surgery 1998;124:83943.

22. Cusack JC, Seymour JF, Lerner S, et al. Role of splenec-

tomy in chronic lymphocytic leukemia. J Am Coll Surg 1997;185:

23743.

23. Walsh RW, Heniford BT. Role of laparoscopy for Hodg-

kins and non-Hodgkins lymphoma. Semin Surg Oncol 1999;16:

28492.

24. Lefor AT, Flowers JL, Heyman MR. Laparoscopic staging

of Hodgkins disease. Surg Oncol 1993;2:21720.

25. Flowers JL, Lefor AT, Steers J, et al. Laparoscopic sple-

nectomy in patients with hematologic diseases. Ann Surg 1996;224:1928.

26. Ellison EC, Fabri PJ. Complications of splenectomy: Etiol-

ogy, prevention, and management. Surg Clin North Am 1983;63:

131330.

27. Shaw JH, Print CG. Postsplenectomy sepsis. Br J Surg

1989;76:107481.

28. Diaz J, Eisenstat M, Chung R. A case-controlled study of

laparoscopic splenectomy. Am J Surg 1997;173:34850.

29. Watson DI, Coventry BJ, Chin T, et al. Laparoscopicversus

open splenectomy for immune thrombocytopenic purpura. Surgery

1997;121:1822.

30. Brunt LM, Langer JC, Quasebarth MA, Whitman ED. Com-

parative analysis of laparoscopic versus open splenectomy. Am J

Surg 1996;172:5969.


esplen ecto mia

Documents