Laparoscopic Splenectomy

Abhay N. Dalvi

Introduction

When Philippe Mouret presented the report of firstlaparoscopic cholecystectomy in April 1989 (Society ofAmerican Gastrointestinal and Endoscopic Surgeons,Louisville, Kentucky), shock and disbelief were theinitial reactions.1 Improvement in laparoscopic skillsand boom in technology since then has revolutionizedthe world of general surgeons into the world oflaparoscopic surgeons, applying this technique to almostall procedures including splenectomy.Delaitre and Maignien first reported a successfullaparoscopic splenectomy (LS).2 The procedure over thelast decade has been accepted as the gold standard forindications like Idiopathic Thrombocytopenic Purpura(ITP) and has been extended to larger and complicatedspleens faced by surgeons in various hematological andnon-hematological disorders.

Indications and Contraindications

ITP is the commonest indication for laparoscopicsplenectomy. Hereditary spherocytosis, thromboticthrombocytopenic purpura and others hematologicaldisorders follow. Hodgkin’s and non-Hodgkin’slymphomas,3 and chronic lymphocytic leukemia,4 arereported frequently in literature, performed to managethe complications of hypersplenism, debulk disease, andimprove response to chemotherapy or for symptomaticsplenomegaly.5 Patients with non-Hodgkin’s lymphomaalmost never require staging. Patients with Hodgkin’sdisease who have diffuse disease (stages III and IV) willall receive chemotherapy. Likewise, patients with limiteddisease (stage I) are usually treated with radiotherapy.Some patients with stage II disease will require surgicalstaging, which should be performed laparoscopically andwill be an indication for splenectomy.6

Literature review reveals that laparoscopicsplenectomy is possible in patients when splenectomyis indicated. Contraindications are proportionalto surgeon’s experience and expertise. Absolutecontraindications to the laparoscopic approachinclude severe cardiopulmonary disease and otherco-morbid conditions making laparoscopic or evenopen splenectomy impossible to perform. Relativecontraindications 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 beentackled laparoscopically,7 though Terrosu et al8 reporthigher incidence of conversion, bleeding and morbidityin spleens greater than 2000 gm. Experienced surgeonshave reported a successful laparoscopic splenectomyfor trauma.9,10 Hashizume et al11 have reported 42successful splenectomies in cases of cirrhosis with portalhypertension. LS in pregnancy and aneurysms havebeen reported. Upper abdominal surgery that had beena relative contraindication has been circumvented bythe use of the open technique. Significant obesity is nota contraindication. On the contrary, the post-surgicalconsequences of open surgery in obese patients oftenmerit the extra laparoscopic effort in these patients. Thebottom line that the surgeon has to understand here is“one should know the limitations and convert as earlyas possible.”

Though all indications given in standard textbooks ofsurgery have been conquered by laparoscopy, the reportedfrequent indications are:

  1. ITP
  2. Hereditary Spherocytosis
  3. Hodgkins and Non-Hodgkins lymphoma
  4. Isolated indications

Advances in technology and its success in splenectomy

The Harmonic Shears

This instrument is possibly thebest advance in the practiceof laparoscopic and even opensurgery. The blades of theworking instrument oscillateat 55,000 cycles per secondgenerating local heat in betweenblades. This induces coagulationof proteins (hemostasis) and

helps in cutting of tissues andvessels being dissected. Lateralthermal spread is limited to less

than 2 mm, allowing the useof the instrument in difficultspaces like the space between thegastric fundus and the spleen.One should be careful however in using this instrumentto seal vessels over 4 mm. Another precaution to bekept in mind that the vessels sealed by this instrumentshould not be handled as they tend to open and bleed.The harmonic shears has certainly reduced operativetime 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 areavailable and can be used in variety of indications.During laparoscopic splenectomy, the pedicle couldbe transected en bloc, with a single application of a3-cm vascular linear laparoscopic stapler. Complicationssuch as bleeding occur, but are mostly due toinappropriate technique.

Handport

Massively enlarged spleens are heavy and difficultto manipulate by thin and nimble laparoscopicinstruments. Handport (Lapdisc) is an adjustabledevice that fits the incision and prevents gas leaksduring manipulation, and at rest. Incision is oftenrequired for delivery as these are difficult to placein bags. Morcellation may also be contraindicated.Alternatively, when a counter-incision for intactremoval of an enlarged spleen is anticipated, placementof the incision can be planned to facilitate surgerywith the “hand-assisted” technique.12 Having the handinside of the abdomen provides the all important touchperception, helps retraction and dissection, control ofbleed in necessity and retrieval of the specimen andis a suggested procedure of choice in splenomegaly.13Pfannenstiel incision is less painful than conventional

subcostal incision and is the preferred incision in handassisted laparoscopic splenectomy.

The Ligasure

Ligasure (Ligasure vessel sealing system) is a newdevice that imparts precise amount of bipolar energyand pressure to tissue achieving permanent seal.The device can and has been used not only to sealsmaller vessels but also the main splenic pedicle withsuccess.14

The Use of Needlescope

Tagaya N et al15 have reported three successfullaparoscopic splenectomies using a 2 mm telescope. Theyused three 2 mm ports for telescope and instruments andone 12 mm port for retrieval.

The Robotics

Use of robotics, though in its infancy in surgicalapplications have also been successfully applied inlaparoscopic splenectomy by Chapman et al.16

Preoperative evaluation and preparation

Imaging

Ultrasonography should be performed on patients withHereditary Spherocytosis to identify cholelithiasis.Imaging techniques can only mark a pathway to the sizeof the spleen and possibly accessory spleens. They do notpredict the risk of conversion to open surgery.CECT scans were performed to evaluate size ofspleen, prediction of conversion and to detect accessoryspleens. This has however been given up.17, 18

Splenic Artery Embolization

Preoperative embolization of the splenic artery wasadvocated in large spleens to decrease blood loss duringsurgery and operative time.19 This method has its owncomplications (severe presurgical pain, migration ofcoils, and splenic abscesses) and has been abandoned bymost authors.19

Preoperative Preparation

In elective situations, all patients should receivepolyvalent pneumococcal and Haemophilus influenza type B vaccinations 2 -3 weeks before surgery. Blood andblood products are essential in taking care of unexpectedcomplications.

Technique

Position and approach:

All the positions - supine, lateral and angled havebeen described. The initial literature describes supineposition for laparoscopic splenectomy.20 Lateral andangled positions are preferred today. Surgeons who useendostaplers for pedicle transection seem to prefer lateralposition. The angled or the partial right lateral positionis 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 “hangingspleen technique”), effect of position and gravity after thedissection of the gastrocolic ligament retracts the visceraand 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. Earlyligation is supposed to reduce the size and decrease bloodloss during surgery. The splenophrenic ligament is thelast to be tackled. Despite the 6% incidence of benignpancreatic reaction21,22 and a slightly higher risk ofpancreatic injury (9.5%),23 we feel that the procedure doesnot handle the spleen as much as in posterior approachand in event of conversion, it is easier to tackle the spleenin the same position. Accessory spleens are also easy tolook for in this technique. Hence, this is the preferredapproach in literature.

The posterior (“posterolateral detached spleen”)technique was described by Gagner et al.24 In thisapproach, the spleen is retracted medially after dividingthe splenophrenic and splenorenal ligaments. Thepancreatic tail is visualized and so is the splenic pedicle.The approach is reported to have a lesser incidence ofpancreatic complications and bleeding.25 This approachrequires experience with retroperitoneal laparoscopicdissection technique unfamiliar to an average laparoscopicsurgeon as most are trained in open splenectomy bytransabdominal technique.

The Procedure - Anterolateral approach

Carbon dioxide insufflation is created using a Veressneedle at umbilicus or open technique at preplanned portsite and maintained at 12 mm Hg to 14 mm Hg.

The port placement

The success story to any laparoscopic procedure lies inaccurate port placement. Though books mention portsrelated to fixed anatomical landmarks, we feel that theport placement be planned after examining the inflatedabdomen and the splenic size. The Indian abdomen variesfrom that of patient from West. The main objective ofport placements should be to tackle the splenic pedicleeasily. 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 infollowing stages:

  1. Division of the gastrocolic ligament including theshort gastric vessels,
  2. Retraction of splenic flexure of the colon by dividingthe splenocolic ligament
  3. Control of the splenic pedicle
  4. Hilar dissection
  5. Division of the splenorenal ligament and attachmentto the diaphragm
  1. Division of gastrocolic ligament including theshort gastric vessels

The stomach is retracted to the right and the gastrocolicligament opened. The ligament is divided usingmonopolar or bipolar electrocautery, clips or harmonicshears. We find that careful use of monopolar coagulation(small intermittent bursts of current) is usually sufficienteven for short gastric vessels in an average Indian patient.When lateral thermal spread is a worry specially in theregion of the fundus of the stomach and upper pole of thespleen (the two can be awesomely close), or short gastricvessels are of larger caliber than expected, bipolar or clips

come in handy. Harmonic shears scores over all thesemodalities. On opening the gastrocolic and gastrosplenicligament, the splenic pedicle behind the pancreatic tailis inspected. The spleen is also evaluated for notching ofthe anterior border, which correlates with a distributedhilar vasculature and is predictive of the level of difficulty.Inspection is also performed for accessory spleens at thisstage.

It is advantageous to keep some amount of gastrosplenicligament on the side of splenic hilum so that the samemay be handled to retract the spleen laterally whennecessary.

  1. Retraction of splenic flexure of the colon bydividing the splenocolic ligament

The splenocolic ligament is next dissected bringingdown the splenic flexure of the colon. The position of thepatient and effect of gravity now keeps away the colonfrom the operative field.

  1. The Splenic pedicle

Michels (1942) described the importance of distributedand magesterial pattern of arterial supply to the spleen.26In the distributed pattern, multiple branches arise fromthe main trunks before entering the spleen, while inthe magesterial pattern the artery enters the hilum as abundle with the vein.

The artery is easily located along the superior border ofthe pancreas (even in obese patients) due to its pulsations.Incision on the visceral peritoneum over this arterymakes the dissection easy. The arterial interruption canbe achieved using suture knotting, clips, and endostaplersor even using the newer modalities like Ligasure. Theauthor uses intracorporeal knotting as primary modalitywith clips to ensure secure ligation.

There are two described ways of tackling thesplenic artery. One is to ligate the splenic artery earlyin the procedure while others take the branches of theartery while the dissection proceeds along the hilumof the spleen. Early ligation of the vessel is supposed todecrease the size of spleen and cause lesser hemorrhage.Interruption of artery soon changes the colour of thespleen from brown to blue and is a useful indicator ofprogress of the procedure. If colour of any part of thespleen remains unchanged, it should indicate a separatearterial supply to that part and meticulously looked forduring further dissection. We have found this approachsatisfying in our experience.

The splenic vein is tackled as a part of hilardissection.

In patients where magistral pattern is encountered,endoscopic vascular staplers are used to tackle thecompletely dissected pedicle en-block in Westerncountries.

  1. Hilar dissection and the splenic vein

The hilar dissection starts at the lower pole of the spleen andproceeds superiorly staying close to the medial surface. Thisdecreases the chances of injury to the pancreas. In enlargedspleens, the tail of the pancreas can come dangerously closeto the hilum and make matters worse. Lower polar vesselsare often constant and require clips or harmonic shear. Thesplenic vein is usually a conglomerate of two tributaries.There is a very thin fascia covering the anterior aspect ofthe vein that needs careful dissection. Entering the correctplane between this fascia and the vein is the key to successfuldissection. This is particularly true as the vein is a thinwalledstructure that can be easily injured. The splenic vein isinterrupted in a similar manner as described for the artery.As the dissection proceeds superiorly, one may find aseparate pedicle supplying the upper pole or even supplyfrom the pancreatic bed. These also require clipping orshearing using harmonic scalpel.

  1. Division of the splenorenal ligament and attachmentto the diaphragm

Once the hilar dissection is complete, the spleen isdetached from the diaphragmatic and renal ligamentousattachments using electrocautery or harmonic shears.

  1. Delivery of the spleen

The spleen is delivered by use of commercially availablepuncture resistant bags. The bags are delivered outthrough one of the ports and the spleen morcellated beforeremoval. Care should be taken that there are no puncturesin the bag and spillage into the peritoneal cavity. Enlargedspleens are difficult to place in the bags and may requireincision for removal. Pathologists sometimes require theentire specimen for reporting. We have been as a routine,employing Pfannenstiel incision of extraction of the spleendue to larger spleens encountered.

Drain is placed after confirming hemostasis in thesplenic fossa and ports are closed.

Complications

The complications of laparoscopic splenectomy as aprocedure are the same as that of open splenectomyranging from intraoperative bleeding, postsplenectomysepsis, wound/port site infection and pancreatic injury.Most of the complications are technique related.27 Higherpancreatic complications23 like pancreatic injury has beena matter of debate, with a higher incidence as comparedto open procedure.

Summary

Laparoscopic splenectomy is not difficult if one hasexperience in open splenectomy. Knowledge of anatomyand experience in laparoscopy are key to success. Withpractice, patience, determination and low threshold forconversion, the procedure is easy to learn. Pace DE etal28 report no difference in the outcome in this procedurewhen trained staff were compared to fellows in training.The procedure of laparoscopic splenectomy has the samebenefits of minimal invasive surgical techniques as againstopen surgery and should become the surgeon’s procedure

of choice soon in our country.

References

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