INTRODUCTION

The birth of the laparoscopic era has revolutionized the surgical approach to the abdomen. Since Delaitre’s performance of the first laparoscopic splenectomy (LS) in 1991, LS has come to replace open splenectomy (OS), and it is now the standard procedure for patients with hematologic disorders.¹ LS is associated with a lower complication rate than that of OS, primarily owing to the greater visualization of anatomic structures and the less invasive nature of laparoscopy.² However, because of the fragile parenchyma, rich blood supply, and intimate relation to intra-abdominal organs such as the stomach, colon, and pancreas, LS, even when performed by experienced surgeons, is not without complications.³^–⁵

Multivariate analyses show that these parameters increase the risk of complications associated with LS: learning curve of the surgeon, patient age, degree of hematologic malignancy, and extent of splenomegaly defined as splenic weight greater than 1000 g or craniocaudal length greater than 20 cm.⁶^–⁸ Splenomegaly may compromise the surgeon’s ability to manipulate the spleen, achieve hemostasis, and retrieve the specimen.⁹ Malignant spleens also tend to weigh more than benign spleens.^10,¹¹ Large splenic size of greater than 2 kg has been shown to have a complication rate of 63% versus 25% for a normal-sized spleen.¹¹ Complications are also greater in elderly patients (53% vs. 13%).^7,¹² Because LS has a steep learning curve, performance of more than 10 cases has been recommended to achieve competency.¹²^–¹⁶

INDICATIONS ¹⁷

• Red blood cell disorders: sphereocytosis, elliptocytosis, autoimmune hemolytic anemia, thalassemias, sickle cell

• White blood cell disorders: lymphoma (staging), myelofibrosis, chronic lymphocytic leukemia, chronic myelogenous leukemia, hairy cell leukemia

• Platelet disorders: idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, Evans’ syndrome

• Secondary hypersplenism: cirrhosis, cystic fibrosis

• Miscellaneous: splenic trauma, abscess, cyst, tumor, angiomatosis, splenic artery aneurysms, Gaucher’s disease, sarcoidosis

CONTRAINDICATIONS ¹⁸

• Severe coagulopathy or thrombocytopenia (platelet <20 K)

• Severe splenomegaly defined as a craniocaudal access greater than 30 cm.

• Pregnancy

• Calcified splenic artery

• Relative contraindication exists in patients with portal hypertension secondary to the potential of lifethreatening hemorrhage and difficulty achieving hemostasis ¹⁹

INSTRUMENTATION

Preparation for the procedure with the appropriate equipment aids in performing a smooth operation and minimizes complications. The essential equipment for LS is as follows:

• Angled laparoscope (30°) 5 to 10 mm

• 5-mm graspers and dissector

• Curved laparoscopic scissors

• Linear laparoscopic stapling device—two should be readily available

• Ultrasonic dissector (harmonic)

• Nylon extraction sac (500–750 ml capacity)

• Clip appliers

• Suction cannula

PREOPERATIVE PREPARATION

All patients should be immunized against encapsulated bacteria, and coagulopathies should be corrected.

Polyvalent pneumococcal, Haemophilus influenzae, and Neisseria meningitidis vaccines should be administered 1 to 2 weeks prior to surgery to allow time for an adequate antibody response.^1,^10,²⁰ Patients who have received corticosteroids within the previous year should be treated with a stress dose to prevent acute adrenocortical insufficiency.²⁰ Splenic artery embolization is generally not indicated unless the spleen is larger than 30 cm.²¹

OPERATIVE STEPS

Step 1 Position patient

Step 2 Trocar placement

Step 3 Abdominal exploration and search for accessory spleens

Step 4 Mobilization of inferior pole of spleen

Step 5 Incision of lateral attachments to spleen

Step 6 Division of lower pole vessels

Step 7 Entrance to lesser sac and division of short gastrics

Step 8 Dissection and ligation of splenic artery and vein

Step 9 Place spleen into sac

Step 10 Division of remaining splenophrenic ligament and closure of sac

Step 11 Morcellate and extract spleen

Step 12 Irrigation and hemostasis

Step 13 Trocar removal

OPERATIVE PROCEDURE

Positioning (Fig. 56-1)

In the earliest reports of LS, the procedure was performed almost exclusively with the patient in the supine position. The gradual evolution of this procedure has led surgeons to perform the majority of LS using the hanging spleen technique, with the patient in the right lateral decubitus position with a kidney rest and about 30° of reverse Trendelenburg.²⁰ The peritoneal attachments of the spleen are used to suspend it in place. Gravity facilitates retraction of the stomach, omentum, and colon and allows slightly easier access and better visualization of the posterior aspect of the hilum, reducing the frequency of complications.²⁰

Figure 56-1 Ideal patient positioning for laparoscopic splenectomy.

Trocar Insertion ^1,²⁰ (Fig. 56-2)

Lifethreatening and less serious complications can occur with trocar insertion. Complications, repair, and prevention are discussed in Section I, Chapter 7, Laparoscopic Surgery.

Figure 56-2 Trocar positioning for laparoscopic splenectomy.

A standard three- or four-trocar technique is used, placing the working ports along the left subcostal border. The camera port site accommodating a 30° scope is placed at the rim of the umbilicus in pediatric and slender patients; for larger patients, this may need to be moved to the left upper quadrant. A 5- to 12-mm port placed either cranially or caudally in the medioclavicular line is used as a working port as well as for the endovascular stapler. A paramedial epigastric 5- to 12-mm port is used as a second working port for the grasper and suction. An optional fourth 5-mm trochar may be placed in the left anterior subcostal or subxiphoid space for retraction. If a hand-assisted technique is to be used, the hand is introduced through either a Pfannenstiel incision or a lower right or left 5- to 6-cm abdominal incision.^16,²¹^–²⁵ Consequences, repair, and prevention are discussed in Section I, Chapter 7, Laparoscopic Surgery.

Abdominal Exploration and Search for an Accessory Spleen (Fig. 56-3)

Accessory spleens are present in about 25% of patients and can cause recurrence of the hematologic disease after splenectomy.^10,^19,^26,²⁷

Figure 56-3 Locations of accessory spleens.

Recurrent Thrombocytopenia

• Consequence

Recurrent thrombocytopenia may occur, especially in patients with idiopathic thrombocytopenic purpura, secondary to failure to remove accessory spleens.^25,^28,²⁹ Although most recurrences happen within the first 2 years after splenectomy, they have been reported up to 18 years later.¹⁰

Grade 2/3 complication

• Repair

If disease recurrence is identified, a denatured red blood cell scintigraphy or sulfur colloid scan may be performed to identify the accessory spleen. Reoperation may be necessary for symptomatic disease.^25,²⁶

Laparoscopic magnification may improve detection of accessory splenic tissue.⁶ Careful and systematic dissection of splenic hilum, lateral lesser sac, pancreatic tail, splenocolic, and gastrosplenic ligaments allows accurate identification.¹⁷ This area is explored by gently retracting the spleen laterally and opening the gastrosplenic ligaments with endoshears. Once detected, an accessory spleen should be resected because it may later be mistaken for hematoma as the operation progresses, and it can cause disease recurrence or treatment failure.¹⁹ Accessory spleens can be found in a variety of locations with the following frequencies¹⁸:

• Hilar region 54%

• Pedicle 25%

• Greater omentum 12%

• Tail of pancreas 6%

• Splenocolic ligament 2%

• Mesentery 0.5%

• Left ovary 0.5%