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Laparoscopic Splenectomy
 

Laparoscopic Splenectomy

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    Laparoscopic Splenectomy Laparoscopic Splenectomy Presentation Transcript

    • Laparoscopic Splenectomy George Ferzli, MD, FACS Department of Laparoscopic Surgery Staten Island University Hospital
    • Historical background
      • “An organ of mystery” (Galen)
      • “Unnecessary” (Aristotle)
      • “An organ that hinders the speed of runners” (Pliny)
      • “An organ that produce laughter and mirth” (Babylonian Talmud)
    • Open splenic surgery
      • 1 st splenectomy: 1549, Adrian Zacarelli
      • 1 st partial splenectomy: 1590, Franciscus Rosetti
      • 1 st splenectomy in the USA: 1816, O’Brien
      • 1 st repair of lacerated spleen: 1895, Zikoff (Russian)
    • Laparoscopic splenectomy
      • In 1992, several reports of laparoscopic splenectomies started emerging in small series.
      • Laparoscopic splenectomy has become a useful alternative to open splenectomy.
    • Spleen Anatomy
      • Most common relationship of artery and vein is artery anterior
      • Other positions occur
      • Main artery divides into hilar branches over the pancreatic tail
    • Spleen Anatomy
      • Major Ligaments
        • Gastrosplenic
        • Splenorenal (lienorenal)
      • Minor Ligaments
        • Splenocolic
        • Splenophrenic
        • Pancreaticosplenic
    • Spleen Anatomy
      • Locations of Accessory Spleens
        • A Splenic hilum
        • B Along splenic vessels
        • C Splenocolic ligament
        • D Perirenal omentum
        • E Small bowel mesentery
        • F Presacral area
        • G Uterine adnexa
        • H Peritesticular region
    • Splenic Function
      • Immune function
        • Filtering function
        • Opsonin production
        • Clearance of encapsulated organisms
        • Clearance of metastatic cells
      • Erythrocyte maintenance
      • Platelet reservoir
      • Storage organ for factor VIII
    • Indications for splenectomy
      • Hematologic disorder
        • Hereditary spherocytosis
        • Autoimmune anemia
        • Thalassemia
        • Hereditary Hemolytic anemia
        • Sickle cell disease
        • ITP
        • TTP
        • Sickle cell
      • Malignancy
        • Lymphoma (Hodgkin’s and non Hodgkin’s disease)
        • Lymphoproliferative disorders
        • Hairy cell leukemia
      • Splenic Mass
        • Cysts and tumors
        • Abscesses
      • Ruptured spleen
        • Trauma
        • Incidental
      • Other
        • Felty’s syndrome
        • Gaucher’s disease
        • Splenic vein thrombosis
        • AIDS
    • Change of Indications Decrease Increase
      • Decline of staging laparotomy for Hodgkin’s disease
      • Increase of splenectomies for hereditary spherocytosis and myeloproliferative disorders
      • Significant Increase indication for ITP
      • New indication: Hairy cell leukemia, Felty’s syndrome, AIDS
    • Personal experience (Indications) *6 patients with accessory spleen
    • Relative Contraindications to Laparoscopic Approach
      • Active hemorrhage with hemodynamic instability
      • Non-platelet coagulopathy
      • Contraindications to pneumoperitoneum
      • Splenomegaly
      • Pregnancy
      • Extensive previous upper abdominal surgery
    • Laparoscopic versus open splenectomy*
      • Earlier discharge
      • Less pain
      • Earlier resumption of oral intake
      • Fewer blood transfusions
      • Similar operative time with increased experience
      *Donini et al. Surg Endosc (1999) 13:1220-1225
    • Three Areas of Controversy
      • Is massive splenomegaly a contraindication for laparoscopic splenectomy?
      • What is the role of laparoscopy in the management of splenic rupture ?
      • Does laparoscopic splenectomy for hematologic disease result in higher recurrence ?
    • Massive splenomegaly
      • Technical challenge
        • Difficulty to manipulate the spleen
        • Difficulty in the extraction of the spleen
      • Options
        • Totally laparoscopic splenectomy
        • Hand port assisted *
      *Meijer et al J Laparoendosc & Adv Techn (1999) 9:507-10
    • Massive Splenomegaly Laparoscopy vs Open
      • Targarona et al. Surg Endosc 1999
      • 105 laparoscopic vs 81 open
        • Group A<400
        • Group B 400-1000
        • Group C>1000
    • Massive Splenomegaly Laparoscopy vs Open
    • Laparoscopic Splenectomy for Ruptured Spleen
      • Indications
        • Incidental splenectomy
        • Trauma
          • splenorrhaphy
          • splenectomy
    • Laparoscopic Splenectomy for Ruptured Spleen
      • The patient has to be hemodynamically stable (on going bleeding requiring large blood transfusion)
      • Use of 10mm suction/irrigation device
      • Early control of splenic hilum
      • Hand port could be helpful
    • Accessory spleens (AS)
      • The reported incidence in OS (15 30%) is higher then LS (4-12%)
      • Long term follow up is essential because a small accessory spleen can hypertrophy after splenectomy and be detected via CT scan or scintigraphy
    • Residual Splenic Function
      • Targarano et al. Arch Surg 1998
        • 48 LS for hematologic disease
        • 9 patients no clinical improvement
        • Of the 9 patients, 3 had residual function on scintigraphy scan
        • Of the 3 patients, 2 had accessory spleen and 1 had implants of splenic tissue
    • Residual Splenic Function
      • Shimomatsuya et al. Surg Endos 1999
        • 20 OS and 14 LS for ITP
        • Similar failure rate between OS and LS
        • Similar number of accessory spleens detected intraoperatively between OS and LS
    • Prevention of Residual Function
      • Extreme care to avoid parenchymal rupture and cell spillage
      • Systematic and careful exploration of the abdominal cavity for accessory spleens
    • Preoperative Considerations
      • Pneumovax, haemophilus, meningococcus vaccinations 2 weeks pre-op
      • Corticosteroids
      • Availability of blood and platelet products
      • Preoperative IgG administration to patients with ITP and critically low platelet counts
      • Perioperative antibiotics
      • Pre-operative embolization- controversial
    • Technique
      • Patient Positioning
        • supine
        • lithotomy
        • right lateral decubitus
      • Trocar placement
        • 3 vs. 4
      • Angled scope
    • Technique 1) Splenic mobilization 2) Splenic hilum 3) Extraction after finger morcellation (depends on the anatomy)
    • Technique
      • Division of the lowermost short gastric vessels
    • Technique
      • Inferior and lateral mobilization of the spleen
        • previously performed last
        • now performed early to gain better access to the hilum
    • Technique
      • Division of the hilar vessels with the vascular stapler
    • Technique
      • Division of the uppermost short gastric vessels
      • Can be approached from the medial or lateral aspect
    • Technique
      • Placement in a retrieval bag
      • Extraction in piecemeal fashion
    • Post-op Considerations
      • Removal of NGT and foley prior to extubation
      • Up in chair for a few hours the night of surgery
      • Liquid diet begun on the first post-op day
      • Ambulate in the hall on the first post-op day
      • Discharge on the first or second post-op day
    • Personal experience Results * 50 days after surgery
    • Complications
      • Wound infection
      • Post splenectomy sepsis
      • Atelectasis
      • Post-op bleeding
      • DVT
      • Gastric perforation
      • Pancreatic fistula
    • Conclusion
      • Our data indicates that the indications for laparoscopic splenectomy are the same as for open splenectomy
      • Massive splenomegaly, ruptured spleen are not a contraindication
      • Residual function and accessory spleen are not a concern