Laparoscopic Splenectomy
Abhay N. Dalvi
Introduction
When Philippe Mouret presented the report of first laparoscopic cholecystectomy in April 1989
(Society of American Gastrointestinal and Endoscopic Surgeons, Louisville, Kentucky), shock
and disbelief were the initial reactions.1 Improvement in laparoscopic skills and boom in
technology since then has revolutionized the world of general surgeons into the world of
laparoscopic surgeons, applying this technique to almost all procedures including splenectomy.
Delaitre and Maignien first reported a successful laparoscopic splenectomy (LS).2 The procedure
over the last decade has been accepted as the gold standard for indications like Idiopathic
Thrombocytopenic Purpura (ITP) and has been extended to larger and complicated spleens faced
by surgeons in various hematological and non-hematological disorders.
Indications and Contraindications
ITP is the commonest indication for laparoscopic splenectomy. Hereditary spherocytosis,
thrombotic thrombocytopenic purpura and others hematological disorders follow. Hodgkin’s and
non-Hodgkin’s lymphomas,3 and chronic lymphocytic leukemia,4 are reported frequently in
literature, performed to manage the complications of hypersplenism, debulk disease, and
improve response to chemotherapy or for symptomatic splenomegaly.5 Patients with nonHodgkin’s lymphoma almost never require staging. Patients with Hodgkin’s disease who have
diffuse disease (stages III and IV) will all receive chemotherapy. Likewise, patients with limited
disease (stage I) are usually treated with radiotherapy. Some patients with stage II disease will
require surgical staging, which should be performed laparoscopically and will be an indication
for splenectomy.6
Literature review reveals that laparoscopic splenectomy is possible in patients when splenectomy
is indicated. Contraindications are proportional to surgeon’s experience and expertise. Absolute
contraindications to the laparoscopic approach include severe cardiopulmonary disease and other
co-morbid conditions making laparoscopic or even open splenectomy impossible to perform.
Relative contraindications may include large spleens, trauma, portal hypertension, aneurysms of
splenic pedicle, pregnancy, previous abdominal surgery and few others. Massive spleens greater
than 4000 gm have been tackled laparoscopically,7 though Terrosu et al8 report higher incidence
of conversion, bleeding and morbidity in spleens greater than 2000 gm. Experienced surgeons
have reported a successful laparoscopic splenectomy for trauma.9,10 Hashizume et al11 have
reported 42 successful splenectomies in cases of cirrhosis with portal hypertension. LS in
pregnancy and aneurysms have been reported. Upper abdominal surgery that had been a relative
contraindication has been circumvented by the use of the open technique. Significant obesity is
not a contraindication. On the contrary, the post-surgical consequences of open surgery in obese
patients often merit the extra laparoscopic effort in these patients. The bottom line that the
surgeon has to understand here is “one should know the limitations and convert as early as
possible.”
Though all indications given in standard textbooks of surgery have been conquered by
laparoscopy, the reported frequent indications are:
1.
2.
3.
4.
ITP
Hereditary Spherocytosis
Hodgkins and Non-Hodgkins lymphoma
Isolated indications
Advances in technology and its success in splenectomy
The Harmonic Shears
This instrument is possibly the best advance in the practice of laparoscopic and even open
surgery. The blades of the working instrument oscillate at 55,000 cycles per second generating
local heat in between blades. This induces coagulation of proteins (hemostasis) and
helps in cutting of tissues and vessels being dissected. Lateral thermal spread is limited to less
than 2 mm, allowing the use of the instrument in difficult spaces like the space between the
gastric fundus and the spleen. One should be careful however in using this instrument to seal
vessels over 4 mm. Another precaution to be kept in mind that the vessels sealed by this
instrument should not be handled as they tend to open and bleed. The harmonic shears has
certainly reduced operative time and has lessened blood loss during surgery.
The Vascular Endostaplers
The use of staplers in open surgery has been well known. The same has now been extended to
laparoscopy. Intestinal as well as vascular endoscopic staplers are available and can be used in
variety of indications. During laparoscopic splenectomy, the pedicle could be transected en bloc,
with a single application of a 3-cm vascular linear laparoscopic stapler. Complications such as
bleeding occur, but are mostly due to inappropriate technique.
Handport
Massively enlarged spleens are heavy and difficult to manipulate by thin and nimble
laparoscopic instruments. Handport (Lapdisc) is an adjustable device that fits the incision and
prevents gas leaks during manipulation, and at rest. Incision is often required for delivery as
these are difficult to place in bags. Morcellation may also be contraindicated. Alternatively,
when a counter-incision for intact removal of an enlarged spleen is anticipated, placement of the
incision can be planned to facilitate surgery with the “hand-assisted” technique.12 Having the
hand inside of the abdomen provides the all important touch perception, helps retraction and
dissection, control of bleed in necessity and retrieval of the specimen and is a suggested
procedure of choice in splenomegaly.13 Pfannenstiel incision is less painful than conventional
subcostal incision and is the preferred incision in hand assisted laparoscopic splenectomy.
The Ligasure
Ligasure (Ligasure vessel sealing system) is a new device that imparts precise amount of bipolar
energy and pressure to tissue achieving permanent seal. The device can and has been used not
only to seal smaller vessels but also the main splenic pedicle with success.14
The Use of Needlescope
Tagaya N et al15 have reported three successful laparoscopic splenectomies using a 2 mm
telescope. They used three 2 mm ports for telescope and instruments and one 12 mm port for
retrieval.
The Robotics
Use of robotics, though in its infancy in surgical applications have also been successfully applied
in laparoscopic splenectomy by Chapman et al.16
Preoperative evaluation and preparation
Imaging
Ultrasonography should be performed on patients with Hereditary Spherocytosis to identify
cholelithiasis. Imaging techniques can only mark a pathway to the size of the spleen and possibly
accessory spleens. They do not predict the risk of conversion to open surgery. CECT scans were
performed to evaluate size of spleen, prediction of conversion and to detect accessory spleens.
This has however been given up.17, 18
Splenic Artery Embolization
Preoperative embolization of the splenic artery was advocated in large spleens to decrease blood
loss during surgery and operative time.19 This method has its own complications (severe
presurgical pain, migration of coils, and splenic abscesses) and has been abandoned by most
authors.19
Preoperative Preparation
In elective situations, all patients should receive polyvalent pneumococcal and Haemophilus
influenza type B vaccinations 2 -3 weeks before surgery. Blood and blood products are essential
in taking care of unexpected complications.
Technique
Position and approach:
All the positions - supine, lateral and angled have been described. The initial literature describes
supine position for laparoscopic splenectomy.20 Lateral and angled positions are preferred today.
Surgeons who use endostaplers for pedicle transection seem to prefer lateral position. The angled
or the partial right lateral position is amenable to urgent conversion to laparotomy if severe
hemorrhage occurs and is our preferred position.
Two approaches are described:
1. Anterolateral approach
2. Posterior or Posterolateral approach
In the anterolateral approach (also known as the “hanging spleen technique”), effect of position
and gravity after the dissection of the gastrocolic ligament retracts the viscera and exposes the
pancreatic tail and the splenic pedicle. There is direct access to the splenic artery and vein. The
splenic artery can be ligated early in the procedure. Early ligation is supposed to reduce the size
and decrease blood loss during surgery. The splenophrenic ligament is the last to be tackled.
Despite the 6% incidence of benign pancreatic reaction21,22 and a slightly higher risk of
pancreatic injury (9.5%),23 we feel that the procedure does not handle the spleen as much as in
posterior approach and in event of conversion, it is easier to tackle the spleen in the same
position. Accessory spleens are also easy to look for in this technique. Hence, this is the
preferred approach in literature.
The posterior (“posterolateral detached spleen”) technique was described by Gagner et al.24 In
this approach, the spleen is retracted medially after dividing the splenophrenic and splenorenal
ligaments. The pancreatic tail is visualized and so is the splenic pedicle. The approach is reported
to have a lesser incidence of pancreatic complications and bleeding.25 This approach requires
experience with retroperitoneal laparoscopic dissection technique unfamiliar to an average
laparoscopic surgeon as most are trained in open splenectomy by transabdominal technique.
The Procedure - Anterolateral approach
Carbon dioxide insufflation is created using a Veress needle at umbilicus or open technique at
preplanned port site and maintained at 12 mm Hg to 14 mm Hg.
The port placement
The success story to any laparoscopic procedure lies in accurate port placement. Though books
mention ports related to fixed anatomical landmarks, we feel that the port placement be planned
after examining the inflated abdomen and the splenic size. The Indian abdomen varies from that
of patient from West. The main objective of port placements should be to tackle the splenic
pedicle easily. The author normally advocates 4 ports.
1. For the telescope (30 degree) - This port is probably the most important. It usually lies
along the line joining the umbilicus and the costal margin in the midclavicular line.
2. Two working ports would lie on either side of the telescope.
3. The fourth port lies in the left anterior or midaxillary line to retract the spleen and use
suction when necessary. Care should be taken to place this port so that the port is away
from the spleen as well as the working port.
4. A fifth port may be required in cases of enlarged spleen or hanging left lobe of liver at the
xiphisternum.
Laparoscopic splenectomy is performed in following stages:
1.
2.
3.
4.
5.
Division of the gastrocolic ligament including the short gastric vessels,
Retraction of splenic flexure of the colon by dividing the splenocolic ligament
Control of the splenic pedicle
Hilar dissection
Division of the splenorenal ligament and attachment to the diaphragm
1. Division of gastrocolic ligament including the short gastric vessels
The stomach is retracted to the right and the gastrocolic ligament opened. The ligament is
divided using monopolar or bipolar electrocautery, clips or harmonic shears. We find that careful
use of monopolar coagulation (small intermittent bursts of current) is usually sufficient even for
short gastric vessels in an average Indian patient. When lateral thermal spread is a worry
specially in the region of the fundus of the stomach and upper pole of the spleen (the two can be
awesomely close), or short gastric vessels are of larger caliber than expected, bipolar or clips
come in handy. Harmonic shears scores over all these modalities. On opening the gastrocolic and
gastrosplenic ligament, the splenic pedicle behind the pancreatic tail is inspected. The spleen is
also evaluated for notching of the anterior border, which correlates with a distributed hilar
vasculature and is predictive of the level of difficulty. Inspection is also performed for accessory
spleens at this stage.
It is advantageous to keep some amount of gastrosplenic ligament on the side of splenic hilum so
that the same may be handled to retract the spleen laterally when necessary.
2. Retraction of splenic flexure of the colon by dividing the splenocolic ligament
The splenocolic ligament is next dissected bringing down the splenic flexure of the colon. The
position of the patient and effect of gravity now keeps away the colon from the operative field.
3. The Splenic pedicle
Michels (1942) described the importance of distributed and magesterial pattern of arterial supply
to the spleen.26 In the distributed pattern, multiple branches arise from the main trunks before
entering the spleen, while in the magesterial pattern the artery enters the hilum as a bundle with
the vein.
The artery is easily located along the superior border of the pancreas (even in obese patients) due
to its pulsations. Incision on the visceral peritoneum over this artery makes the dissection easy.
The arterial interruption can be achieved using suture knotting, clips, and endostaplers or even
using the newer modalities like Ligasure. The author uses intracorporeal knotting as primary
modality with clips to ensure secure ligation.
There are two described ways of tackling the splenic artery. One is to ligate the splenic artery
early in the procedure while others take the branches of the artery while the dissection proceeds
along the hilum of the spleen. Early ligation of the vessel is supposed to decrease the size of
spleen and cause lesser hemorrhage. Interruption of artery soon changes the colour of the spleen
from brown to blue and is a useful indicator of progress of the procedure. If colour of any part of
the spleen remains unchanged, it should indicate a separate arterial supply to that part and
meticulously looked for during further dissection. We have found this approach satisfying in our
experience.
The splenic vein is tackled as a part of hilar dissection.
In patients where magistral pattern is encountered, endoscopic vascular staplers are used to
tackle the completely dissected pedicle en-block in Western countries.
4. Hilar dissection and the splenic vein
The hilar dissection starts at the lower pole of the spleen and proceeds superiorly staying close to
the medial surface. This decreases the chances of injury to the pancreas. In enlarged spleens, the
tail of the pancreas can come dangerously close to the hilum and make matters worse. Lower
polar vessels are often constant and require clips or harmonic shear. The splenic vein is usually a
conglomerate of two tributaries. There is a very thin fascia covering the anterior aspect of the
vein that needs careful dissection. Entering the correct plane between this fascia and the vein is
the key to successful dissection. This is particularly true as the vein is a thin walled structure that
can be easily injured. The splenic vein is interrupted in a similar manner as described for the
artery. As the dissection proceeds superiorly, one may find a separate pedicle supplying the
upper pole or even supply from the pancreatic bed. These also require clipping or shearing using
harmonic scalpel.
5. Division of the splenorenal ligament and attachment to the diaphragm
Once the hilar dissection is complete, the spleen is detached from the diaphragmatic and renal
ligamentous attachments using electrocautery or harmonic shears.
6. Delivery of the spleen
The spleen is delivered by use of commercially available puncture resistant bags. The bags are
delivered out through one of the ports and the spleen morcellated before removal. Care should be
taken that there are no punctures in the bag and spillage into the peritoneal cavity.
Enlargedspleens are difficult to place in the bags and may require incision for removal.
Pathologists sometimes require the entire specimen for reporting. We have been as a routine,
employing Pfannenstiel incision of extraction of the spleen due to larger spleens encountered.
Drain is placed after confirming hemostasis in the splenic fossa and ports are closed.
Complications
The complications of laparoscopic splenectomy as a procedure are the same as that of open
splenectomy ranging from intraoperative bleeding, postsplenectomy sepsis, wound/port site
infection and pancreatic injury. Most of the complications are technique related.27 Higher
pancreatic complications23 like pancreatic injury has been a matter of debate, with a higher
incidence as compared to open procedure.
Summary
Laparoscopic splenectomy is not difficult if one has experience in open splenectomy. Knowledge
of anatomy and experience in laparoscopy are key to success. With practice, patience,
determination and low threshold for conversion, the procedure is easy to learn. Pace DE et al28
report no difference in the outcome in this procedure when trained staff were compared to
fellows in training. The procedure of laparoscopic splenectomy has the same benefits of minimal
invasive surgical techniques as against open surgery and should become the surgeon’s procedure
of choice soon in our country.
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