This document discusses laparoscopic splenectomy, including: 1) A brief history of splenectomy and the transition to the laparoscopic approach in the 1990s. 2) Indications for splenectomy including various hematologic disorders, malignancies, and traumatic injuries. 3) Techniques for laparoscopic splenectomy including trocar placement, mobilization of the spleen, and division of hilar vessels. 4) Outcomes data suggesting laparoscopic splenectomy offers benefits over open surgery such as less pain and earlier discharge while having similar operative times.

1. Laparoscopic Splenectomy George Ferzli, MD, FACS Department of Laparoscopic Surgery Staten Island University Hospital

2. 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)

3. 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)

4. Laparoscopic splenectomy In 1992, several reports of laparoscopic splenectomies started emerging in small series. Laparoscopic splenectomy has become a useful alternative to open splenectomy.

5. 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

6. Spleen Anatomy Major Ligaments Gastrosplenic Splenorenal (lienorenal) Minor Ligaments Splenocolic Splenophrenic Pancreaticosplenic

7. 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

8. 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

9. 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

10. 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

11. Personal experience (Indications) *6 patients with accessory spleen

12. Relative Contraindications to Laparoscopic Approach Active hemorrhage with hemodynamic instability Non-platelet coagulopathy Contraindications to pneumoperitoneum Splenomegaly Pregnancy Extensive previous upper abdominal surgery

13. 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

14. 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 ?

15. 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

16. 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

17. Massive Splenomegaly Laparoscopy vs Open

18. Laparoscopic Splenectomy for Ruptured Spleen Indications Incidental splenectomy Trauma splenorrhaphy splenectomy

19. 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

20. 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

21. 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

22. 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

23. Prevention of Residual Function Extreme care to avoid parenchymal rupture and cell spillage Systematic and careful exploration of the abdominal cavity for accessory spleens

24. 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

25. Technique Patient Positioning supine lithotomy right lateral decubitus Trocar placement 3 vs. 4 Angled scope

26. Technique 1) Splenic mobilization 2) Splenic hilum 3) Extraction after finger morcellation (depends on the anatomy)

27. Technique Division of the lowermost short gastric vessels

28. Technique Inferior and lateral mobilization of the spleen previously performed last now performed early to gain better access to the hilum

29. Technique Division of the hilar vessels with the vascular stapler

30. Technique Division of the uppermost short gastric vessels Can be approached from the medial or lateral aspect

31. Technique Placement in a retrieval bag Extraction in piecemeal fashion

32. 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

33. Personal experience Results * 50 days after surgery

34. Complications Wound infection Post splenectomy sepsis Atelectasis Post-op bleeding DVT Gastric perforation Pancreatic fistula

35. 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