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Laparoscopic Splenectomy George Ferzli, MD, FACS Department of Laparoscopic Surgery Staten Island University Hospital
Historical background <ul><li>“An organ of mystery” (Galen) </li></ul><ul><li>“Unnecessary” (Aristotle) </li></ul><ul><li>...
Open splenic surgery <ul><li>1 st  splenectomy: 1549, Adrian Zacarelli </li></ul><ul><li>1 st  partial splenectomy: 1590, ...
Laparoscopic splenectomy <ul><li>In 1992, several reports of laparoscopic splenectomies started emerging in small series. ...
Spleen Anatomy <ul><li>Most common relationship of artery and vein is artery anterior </li></ul><ul><li>Other positions oc...
Spleen Anatomy <ul><li>Major Ligaments </li></ul><ul><ul><li>Gastrosplenic </li></ul></ul><ul><ul><li>Splenorenal (lienore...
Spleen Anatomy <ul><li>Locations of Accessory Spleens </li></ul><ul><ul><li>A Splenic hilum </li></ul></ul><ul><ul><li>B A...
Splenic Function <ul><li>Immune function </li></ul><ul><ul><li>Filtering function </li></ul></ul><ul><ul><li>Opsonin produ...
Indications for splenectomy <ul><li>Hematologic disorder </li></ul><ul><ul><li>Hereditary spherocytosis </li></ul></ul><ul...
Change of Indications Decrease  Increase <ul><li>Decline of staging laparotomy for Hodgkin’s disease </li></ul><ul><li>Inc...
Personal experience  (Indications) *6 patients with accessory spleen
Relative Contraindications to Laparoscopic Approach <ul><li>Active hemorrhage with hemodynamic instability </li></ul><ul><...
Laparoscopic versus open splenectomy* <ul><li>Earlier discharge </li></ul><ul><li>Less pain </li></ul><ul><li>Earlier resu...
Three Areas of Controversy <ul><li>Is  massive splenomegaly  a contraindication for laparoscopic splenectomy? </li></ul><u...
Massive splenomegaly <ul><li>Technical challenge </li></ul><ul><ul><li>Difficulty to manipulate the spleen </li></ul></ul>...
Massive Splenomegaly Laparoscopy vs Open <ul><li>Targarona et al. Surg Endosc 1999 </li></ul><ul><li>105 laparoscopic vs 8...
Massive Splenomegaly Laparoscopy vs Open
Laparoscopic Splenectomy for Ruptured Spleen <ul><li>Indications </li></ul><ul><ul><li>Incidental splenectomy </li></ul></...
Laparoscopic Splenectomy for Ruptured Spleen <ul><li>The patient has to be hemodynamically stable (on going bleeding requi...
Accessory spleens (AS) <ul><li>The reported incidence in OS (15 30%) is higher then LS (4-12%)  </li></ul><ul><li>Long ter...
Residual Splenic Function <ul><li>Targarano et al. Arch Surg 1998 </li></ul><ul><ul><li>48 LS for hematologic disease </li...
Residual Splenic Function <ul><li>Shimomatsuya et al. Surg Endos 1999 </li></ul><ul><ul><li>20 OS and 14 LS for ITP </li><...
Prevention of Residual Function <ul><li>Extreme care to avoid parenchymal rupture and cell spillage </li></ul><ul><li>Syst...
Preoperative Considerations <ul><li>Pneumovax, haemophilus, meningococcus vaccinations 2 weeks pre-op </li></ul><ul><li>Co...
Technique <ul><li>Patient Positioning </li></ul><ul><ul><li>supine </li></ul></ul><ul><ul><li>lithotomy </li></ul></ul><ul...
Technique 1) Splenic mobilization 2) Splenic hilum 3) Extraction after finger morcellation (depends on the anatomy)
Technique <ul><li>Division of the lowermost short gastric vessels </li></ul>
Technique <ul><li>Inferior and lateral mobilization of the spleen </li></ul><ul><ul><li>previously performed last </li></u...
Technique <ul><li>Division of the hilar vessels with the vascular stapler </li></ul>
Technique <ul><li>Division of the uppermost short gastric vessels </li></ul><ul><li>Can be approached from the medial or l...
Technique <ul><li>Placement in a retrieval bag </li></ul><ul><li>Extraction in piecemeal fashion  </li></ul>
Post-op Considerations <ul><li>Removal of NGT and foley prior to extubation </li></ul><ul><li>Up in chair for a few hours ...
Personal experience  Results * 50 days after surgery
Complications <ul><li>Wound infection </li></ul><ul><li>Post splenectomy sepsis </li></ul><ul><li>Atelectasis </li></ul><u...
Conclusion <ul><li>Our data indicates that the indications for laparoscopic splenectomy are the same as for open splenecto...
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Laparoscopic Splenectomy

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Laparoscopic Splenectomy

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

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