TY - JOUR
AU - Teotia, Sumeet S.
AB - Laparoscopic splenectomy is emerging as the procedure of choice for splenic removal in patients with hematologic disorders and normal to moderately enlarged spleens. We herein describe our technique for laparoscopic splenectomy. Alternative techniques are also discussed, with detailed modifications of techniques for patients with splenomegaly.Laparoscopic splenectomy (LS) has been shown to decrease postoperative discomfort and shorten hospital stays, compared with open splenectomy.Laparoscopic splenectomy has been performed for immune thrombocytopenic purpura (ITP) in most cases. There have been few conversions, and results demonstrate more than 90% initial response of platelet counts, as well as long-term effects comparable with those of open splenectomy.The spleen in ITP is of normal size with normal vasculature, and there is generally not an associated coagulopathy. Therefore, these are the spleens with which surgeons should begin their LS experience. Spleens have been removed for a variety of other disease states, including massive enlargement (up to 26 cm, with weights >2500 g in our series).The following discussion describes our technique for LS. The major steps of the procedure are detailed, with particular attention to the techniques for the patient with ITP. Alternative techniques are discussed also in an effort to provide the surgeon with options, should the primary approach not work for a particular patient or surgeon. In addition, the modifications, which may be applied to patients with massive splenomegaly, are highlighted.PREOPERATIVE PREPARATIONAll patients undergoing splenectomy should be immunized against encapsulated bacteria, and coagulopathies should be corrected. Although the absolute value of platelet count required for safe splenectomy is not known, we have frequently performed LS for patients with platelet counts of 20×109/L or even lower without sequelae. As with laparoscopic cholecystectomy, we have noticed decreased oozing during LS, perhaps related to the increased intra-abdominal pressure related to the pneumoperitoneum. Platelets are, therefore, used selectively, and only if signs of bleeding are evident or if the counts are extremely low.Patients who have received corticosteroids within the previous year should be treated with perioperative steroids to prevent acute adrenocortical insufficiency.The use of preoperative angiographic ablation of the spleenhas been abandoned. Embolization led to severe pain in many patients and to splenic venous thrombosis in 1 of our patients. Blood loss without this is minimal and does not justify embolization, even for patients with splenomegaly. If, however, one chooses to perform embolization preoperatively, it should be done with anesthesia support and an operating room waiting so patients are spared the pain related to splenic infarction.POSITIONINGThe patient is placed in the right lateral semidecubitus position (rotated slightly back) from a full decubitus position, approximately 80° from supine (Figure 1). An axillary roll is placed, and the arms are secured on an arm board positioned as far superiorly as possible. The right knee is bent, and the left is straight. This increases working space at the surgical field. The patient is appropriately padded and secured. For splenomegaly, the patient is positioned in a 40° to 60° semidecubitus position. This facilitates retraction of the heavy spleen and exposure of the vasculature.Figure 1. Operating room setup.TROCAR PLACEMENTTrocar port sites are numbered in Figure 2. This numbering will be used to identify sites in the remaining discussion. An incision is made over the costal cartilage at port site 2. Pneumoperitoneum is instituted using an open or a closed technique. As the abdomen expands, this initial incision will be drawn down over the abdominal cavity. After a 12-mm trocar is inserted at port site 2, the camera port is placed at site 5 under direct vision. This port should be placed to allow the spleen to be visualized between ports 2 and 3. A 5-mm trocar is placed at port site 1. Adhesions, which are usually present near the splenic flexure of the colon, are then lysed to allow insertion of a 12-mm trocar at port site 3 and a 5-mm trocar at port site 4. In splenomegaly, ports 4 and 5 will need to be placed more inferiorly, and the operative ports (2 and 3) may need to be moved anteriorly to allow dissection without hindrance from the spleen.Figure 2. Trocar placement. Ports 1 and 4 are 5 mm, ports 2 and 3 are 12 mm, and port 5 is 11 mm in diameter. Port 5 should be placed to visualize the spleen between ports 2 and 3.EXPLORATIONIdentification of accessory splenic tissue is crucial to the success of LS. Abdominal exploration is somewhat limited in the semidecubitus position. However, excellent visualization of the left upper quadrant is possible. The transverse colon is elevated to examine the left side of the transverse mesocolon. The omentum is examined also. During the course of the remaining steps, careful attention is paid to the tissues in an effort to identify accessory splenic tissue.MOBILIZATIONSkandalakis et alprovided an excellent review of splenic anatomy. This may prove useful to the surgeon embarking on LS. The division of the splenic ligaments proceeds in an orderly fashion. The object of this mobilization is the circumferential isolation of the splenic hilum before hilar vascular transection. The inferior tip of the spleen is initially elevated with a grasper, which holds the tissues adjacent to the spleen. Traction is always placed toward the spleen to prevent a capsular tear. The splenocolic ligament is then divided (Figure 3) with a commercially available shears (Harmonic Shears; Ethicon, Cincinnati, Ohio). Electrocautery may also be used. A vessel to the inferior pole of the spleen may be encountered and may require clips if it is large enough. As few clips as possible are used, however, as these may interfere with the use of vascular staplers on the splenic hilum.Figure 3. After exploration, the dissection of the splenic attachments is begun with the splenocolic ligament (arrow). Traction is always placed toward the spleen with countertraction, if necessary. C indicates colon; D, diaphragm.The gastrosplenic ligament is then divided beginning at the inferior border (Figure 4). The lesser sac is entered early during this maneuver, exposing the pancreas and splenic hilum at the posterior aspect of the sac. Dissection is performed between the stomach and the spleen, and all short gastric vessels are divided. The advantages of the shears used for this dissection have been published.Dissection continues as far as possible superior to the spleen, dividing the upper portions of the splenophrenic ligament.Figure 4. The gastrosplenic ligament is divided (arrow). Dissection is begun at the inferior aspect and continued until all short gastric vessels are divided. The superior medial aspect of the splenophrenic ligament is also divided. S indicates stomach; P, pancreas; D, diaphragm; and H, hilum.Attention is now turned to the splenorenal ligament. The spleen is reflected anteriorly, and the splenorenal ligament is grasped and pulled toward the spleen for exposure. The ligament is divided 1 to 2 cm away from the spleen (Figure 5.) Scissors with electrocautery have worked well here. This dissection is continued onto the splenophrenic ligament (Figure 6) and eventually should communicate with the previous dissection superior to the spleen. The areolar connective tissue located between the posterior aspect of the splenic hilum and the posterior splenic ligaments is taken down with a gentle sweeping motion and judicious use of electrocautery or harmonic oscillation. The splenic hilum should now be exposed circumferentially.Figure 5. The splenorenal ligament (arrow) is divided, retracting the spleen anteriorly. Areolar connective tissue between this ligament and the splenic hilum is gently divided. C indicates colon; D, diaphragm.Figure 6. The gastrophrenic ligament is divided (arrow), and areolar connective tissue again is dissected. At the completion of this step, the splenic hilum has been mobilized circumferentially. D indicates diaphragm; H, hilum.AlternativeSome authors have preferred the "hanging spleen" techniqueand have applied it with excellent results. With this variation, the splenophrenic ligament is not divided until the hilum is transected. We do not use this technique unless the patient has significant splenomegaly. We believe that we can expose the hilum better using traction to elevate the spleen rather than just allowing it to hang. In addition, should bleeding occur in the hilum, the splenophrenic ligament often has to be divided to control the hemorrhage. Instead, it would seem easier to us to divide this early in the dissection as described. Vessels in the gastrosplenic ligament may also be divided between clips or with endoscopic vascular staples at the discretion of the surgeon.SplenomegalyIn the case of splenomegaly, it is much harder to manipulate the spleen and to elevate it or to control its rotation. Therefore, for these spleens we prefer the hanging spleen technique. The splenocolic and gastrosplenic ligaments are divided as described above. The tissues posterior to the splenic hilum are dissected bluntly without division of the splenophrenic ligament.HILAR DISSECTIONThe use of vascular staplers to transect the splenic hilum has resulted in a substantial reduction in operating times and yielded excellent hemostasis in our experience (unpublished data, 1996). Staplers may be placed across individual vessels or used to transect the hilum en masse. Concern has been raised about the potential for the development of arteriovenous fistulas with the en masse technique. To date, such a fistula has not been documented in a human, although arteriograms have not been performed routinely. As a precaution, we try to place a ligature about the main splenic artery before mass hilar transection.The spleen is reflected posteriorly, and the splenic artery can be seen pulsating just superior to the tail of the pancreas. The artery often has a prominent knuckle and is mobilized at this point (Figure 7). The vessel is exposed, and an instrument is placed around the artery. A tie is brought in through a separate port and placed around the dissected vessel. The tie is then brought out through the initial port. (The use of a grasper as a fulcrum protects the artery from the sawing motion of the tie during this maneuver.) The tie is secured with an extracorporeal tie. (We have found this to be more secure than an intracorporeal tie on this major vessel.) A large clip may be used also; however, this may necessitate use of a clip applier, which would not otherwise have been opened. At times the camera may need to be moved to a different site to visualize the artery. If the artery cannot be identified (uncommonly), then we will omit this step.Figure 7. If the splenic artery can be identified superior to the tail of the pancreas, it is ligated (arrow). S indicates stomach; D, diaphragm; P, pancreas; and H, hilum.With adequate mobilization, as described above, the spleen now may be elevated into the left upper quadrant. A flexible 5-mm retractor may be placed through port 3 and used to encircle the hilum and elevate the spleen in patients with a normal-sized hilum. Graspers and retractors to balance the spleen also may be used to provide exposure of the hilum (Figure 8).Figure 8. The splenic hilum is now divided with the spleen retracted far into the left upper quadrant. After transection, the spleen is placed in a bag, morcellated, and removed. P indicates pancreas; D, diaphragm; and S, stomach.Ideally, the tail of the pancreas should be identified. However, if the pancreas is not well seen, one must at least be certain there is nothing along the line of hilar transection except blood vessels and connective tissue.A vascular stapler is now inserted through port 3 and placed across the hilum. It usually will require 2 applications of the stapler for a normal-sized hilum. There is a potential for bleeding if the stapler only partially crosses a vessel. This has not happened in our experience; however, we have a second stapler cartridge available during any application of the stapler that does not completely cross the hilum. Should bleeding occur, the site would be temporarily occluded with a grasper while the cartridge is rapidly changed and the stapler is reapplied. Any tissue left superior to the hilum is divided with cautery or harmonic oscillation.AlternativeVessels within the splenic hilum also may be controlled and divided individually. We used this technique early in our experience and found it to be quite tedious without depth perception. In addition, should bleeding ensue within the hilum, we frequently had to revert to the use of staplers to control it. Application of the staplers was hindered by the presence of previously placed clips. Therefore, we now prefer to use staplers initially. Excellent results, however, may be obtained with individual vessel ligation.SplenomegalyHilar dissection is similar for splenomegaly in that we prefer to ligate the splenic artery initially. Tissues posterior to the hilum are then bluntly dissected. This allows placement of the staplers without division of the splenophrenic and splenorenal ligaments.SPECIMEN REMOVALA number of plastic bags are available now to facilitate specimen removal, each with advantages and disadvantages. No incisions need to be enlarged for specimen removal unless an intact specimen is required for pathologic review (the specimen need not be intact for ITP).Once the specimen is in the bag, the open end of the bag is brought out through trocar port 3. The spleen is then morcellated using blunt dissection with clamps, a sucker tip, or a finger, and the pieces are removed. Great care is exercised to prevent tearing the bag. Traction should be applied to the contents rather than the bag.Following specimen removal, the abdomen is insufflated again, and hemostasis is checked. The abdomen is irrigated before closure.AlternativePort sites may be enlarged to aid removal; however, this generally results in increased postoperative pain, and there is little to be gained.SplenomegalyTechniques are not altered for mild to moderate degrees of splenomegaly. Patients with massive splenomegaly, however, pose unique challenges. A counterincision may be made low on the abdomen for specimen removal. However, this will often need to be substantial in its length, thus negating many of the benefits gained from the laparoscopic dissection. Placing the truly massive spleen into a bag for removal is frequently futile, even if one is using a hand-assisted technique. This has led some to divide the spleen within the abdomen and to place the pieces in separate bags. Although this may seem objectionable initially, it may be justified in select cases. First, spread of disease is unlikely. There is a great deal of experience with incisional biopsies of intra-abdominal lymphomas, and these are performed without fear of spread (lymphoma being a systemic disease). Second, although splenosis is a concern, this should be preventable. The abdomen is irrigated copiously after splenic removal and aspirated with a 10-mm suction tip. At the conclusion of this, there should be no visible splenic tissue within the abdomen. Finally, most of these patients undergo operation for symptoms of splenomegaly and not hyperfunction. Therefore, it is unlikely that splenic implants would cause significant morbidity, even if they were to occur. Long-term review of patients will be required to substantiate the use of this maneuver; however, it may be reasonable to use it now. Patients are informed of these options preoperatively. This maneuver should never be used for conditions such as ITP or hemolytic anemia, as splenic implants might cause recurrence of the disease.CLOSURETrocars are removed under direct vision, and we close the fascia of all trocar ports 10 mm in diameter or larger. In the obese patient, we use a fascial closure device, and a number of these are available. Subcutaneous tissues are irrigated before skin closure. Sites may also be injected with a long-acting local anesthetic.POSTOPERATIVE CAREPatients are allowed to take liquids later the same day and progress to a regular diet the following day. Approximately 75% of our patients are discharged on the day after surgery. Most patients require little or no parenteral narcotics, and oral pain medications frequently suffice. The risk for bleeding from open procedures on the night of surgery is well known. Postoperative bleeding likely will occur, on rare occasions, following LS. Therefore, we have elected not to perform LS as an outpatient procedure at this time.CONCLUSIONSCurrent techniques for LS have been discussed. These techniques allow for a systematic and controlled dissection and have led to high success rates for the procedure. However, minimally invasive surgery is still a new discipline, and these techniques will likely be improved in the future.RTSchlinkertDMannLaparoscopic splenectomy offers advantages in selected patients with immune thrombocytopenic purpura.Am J Surg.1995;170:624-627.ECPoulinCThibaultJMamazzaLaparoscopic splenectomy.Surg Endosc.1995;9:172-177.DIWatsonBJCoventryTChinPGGillPMalychaLaparoscopic versus open splenectomy for immune thrombocytopenic purpura.Surgery.1997;121:18-22.EHPhillipsBJCarrollMJFallasLaparoscopic splenectomy.Surg Endosc.1994;8:931-933.NKathoudaDJWaldrepDFeinsteinUnresolved issues in laparoscopic splenectomy.Am J Surg.1996;72:1-5.GTsiotosRTSchlinkertLaparoscopic splenectomy for immune thrombocytopenic purpura.Arch Surg.1997;132:642-646.KLHaroldRTSchlinkertDMannLong-term results of laparoscopic splenectomy for immune thrombocytopenic purpura.Mayo Clin Proc.In press.EPoulinCThibaultJMamazzaMGirottiGCoteARenaudLaparoscopic splenectomy: clinical experience and the role of preoperative splenic artery embolization.Surg Laparosc Endosc.1993;3:445-450.PNSkandalakisGLColbornLJSkandalakisDDRichardsonWEMitchellJESkandalakisThe surgical anatomy of the spleen.Surg Clin North Am.1993;73:747-768.WSLaycockTLTrusJHHunterNew technology for the division of short gastric vessels during laparoscopic Nissen fundoplication.Surg Endosc.1996;10:671-673.BDelaitreLaparoscopic splenectomy: the "hanged spleen" technique.Surg Endosc.1995;9:528-529.Reprints: Richard T. Schlinkert, MD, Department of Surgery, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (e-mail: schlinkert.richard@mayo.edu).
TI - Laparoscopic Splenectomy
JF - JAMA Surgery
DO - 10.1001/archsurg.134.1.99
DA - 1999-01-01
UR - https://www.deepdyve.com/lp/american-medical-association/laparoscopic-splenectomy-6Mny5JVubB
SP - 99
EP - 103
VL - 134
IS - 1
DP - DeepDyve
ER -