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Acs0525 Splenectomy 2005


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Acs0525 Splenectomy 2005

  1. 1. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 1 25 SPLENECTOMY Eric C.Poulin, M.D., M.Sc., F.A.C.S., F.R.C.S.C.,Christopher M.Schlachta, M.D., F.A.C.S.,and Joseph Mamazza, M.D.,F.R.C.S.C. Medicine is not an exact science, and nowhere is this observation more Michels made clear, each spleen has its own peculiar pattern of appropriate than in the operating room when a spleen is being terminal artery branches.10 removed.1 SPLENIC ARTERY The first reported splenectomy in the Western world was per- formed by Zacarello in 1549, though the veracity of his operative The celiac axis is the largest but shortest branch of the abdom- description has been questioned. Between this initial report and inal aorta: it is only 15 to 20 mm long.The celiac axis arises above the 1800s, very few cases were recorded. The first reported the body of the pancreas and, in 82% of specimens, divides into splenectomy in North America was performed by O’Brien in three primary branches: the left gastric artery, which is the first 1816. The patient was in the act of committing a rape when his branch, and the hepatic and splenic arteries, which derive from a victim plunged a large knife into his left side. As in this case, most common stem. In rare instances, the splenic artery originates early splenectomies were done in patients who had undergone directly from the aorta; even less often, a second splenic artery penetrating trauma; often, the spleen was protruding from the arises from the celiac axis.There are numerous other possible vari- wound and the surgeon proceeded with en masse ligation. The ations, in which the splenic artery may originate from the aorta, first elective splenectomy was performed by Quittenbaum in 1826 the superior mesenteric artery, the middle colic artery, the left gas- for sequelae of portal hypertension, and soon afterward,Wells per- tric artery, the left hepatic artery, or the accessory right hepatic formed one of the first splenectomies using general anesthesia; artery. As a rule, however, the splenic artery arises from the celiac both patients died. In 1866, Bryant was the first to attempt axis to the right of the midline, which means that the aorta must splenectomy in a patient with leukemia. Over the following 15 be crossed to reach the spleen and that selective angiography is years, 14 splenectomies were attempted as therapy for leukemia; likely to be difficult at times.The splenic artery can take a very tor- none of the patients survived. In a 1908 review of 49 similar cases, tuous course, particularly in patients who are elderly or who have Johnston reported a mortality of 87.7%.2 These dismal results led a longer artery. to the abandonment of splenectomy for leukemia. In 1916, In his study of 100 cadaver spleens,10 Michels divided splenic Kaznelson, of Prague, was the first to report good results from arterial geography into two types, distributed and magistral (or splenectomy in patients with thrombocytopenic purpura. bundled) [see Figure 1]. In the distributed type, found in 70% of As the 20th century progressed, splenectomy became more dissections, the splenic trunk is short, and six to 12 long branch- common in direct proportion to the increase in the use of the es enter the spleen over approximately 75% of its medial surface. automobile. The eventual recognition of the syndrome known as The branches originate between 3 and 13 cm from the hilum [see overwhelming postsplenectomy infection (OPSI) made splenic Figure 1a]. In the bundled type, found in the remaining 30% of conservation an important consideration. Partial splenectomy had dissections, there is a long main splenic artery that divides near initially been described by the French surgeon Péan in the 19th the hilum into three or four large, short terminal branches that century. This procedure received little further study until almost enter the spleen over only 25% to 35% of its medial surface.These 100 years later, when the Brazilian surgeon Campos Cristo reeval- short splenic branches originate, on average, 3.5 cm from the uated Péan’s technique in his report of eight trauma patients treat- spleen, and they reach the center of the organ as a compact bun- ed with partial splenectomy.3 Simpson’s report on 16 children dle [see Figure 1b]. Early identification of the type of splenic blood admitted for splenic trauma to the Hospital for Sick Children in supply present can help the surgeon estimate how difficult a par- Toronto between 1948 and 1955 was instrumental in establishing ticular splenectomy is likely to be. Operation on a spleen with a the validity of nonoperative treatment of splenic trauma [see 7:7 distributed vascular anatomy usually involves dissection of more Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm].4 blood vessels; however, the vessels, being spread over a wider area In late 1991 and early 1992, four groups working indepen- of the splenic hilum, are relatively easy to deal with. Operation on dently—Delaître in Paris, Carroll in Los Angeles, Cushieri in the a spleen with a bundled-type blood supply typically involves dis- United Kingdom, and our group in Canada—published the first section of fewer vessels; however, because the hilum is narrower reports of laparoscopic splenectomy in patients with hematologic and more compact, dissection and separation of the vessels are disorders.5-7 Since then, the development of operative techniques more difficult. for partial laparoscopic splenectomy has tested the limits of mini- BRANCHES OF SPLENIC ARTERY mally invasive surgery and encouraged clinical research into meth- ods of simplifying the execution of the operation.8,9 The adoption The splenic branches vary so markedly in length, size, and ori- of laparoscopic splenectomy has led to a gradual decrease in the gin that no two spleens have the same anatomy. Outside the indications for open splenectomy; however, both procedures are spleen, the arteries also frequently form transverse anastomoses still essential components of spleen surgery. with each other that, like most collaterals, arise at a 90º angle to the vessels involved [see Figure 1].11 As a consequence, attempts to occlude a branch of the splenic artery by means of clips or Anatomic Considerations embolization, if carried out proximal to such an anastomosis, may Most anatomy texts suggest that the splenic artery is constant fail to devascularize the corresponding splenic segment. Before in its course and branches; however, as the classic essay by the splenic trunk divides, it usually gives off a few slender branch-
  2. 2. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 2 Transverse Anastomosis Penultimate Branch a Short Gastric Arteries Ultimate Branch Superior Polar Artery Aorta Inferior Superior Terminal Left Gastric Terminal Artery Artery Artery Transverse Anastomosis Hepatic Artery Penultimate Inferior Polar Branch Ultimate Branch Arteries Left Inferior Gastroepiploic Terminal Artery Artery Pancreatica Magna Short Gastric Arteries Superior Polar b Artery Superior Terminal Artery Figure 1 Shown are (a) the distrib- uted type and (b) the magistral (bun- dled) type of splenic vascularization. Inferior Polar Arteries es to the tail of the pancreas.The most important of these is called terminal artery, (2) the inferior terminal artery, (3) the medial the pancreatica magna (a vessel familiar to vascular radiologists); terminal artery, (4) the short gastric arteries, (5) the left gas- occlusion of this branch with embolic material has been reported troepiploic artery, (6) the inferior polar artery, and (7) the supe- to result in pancreatitis. Next, the splenic artery divides into two rior polar artery [see Figure 2]. Veins are usually located behind to six first and second terminal branches, and these branches the corresponding arteries, except at the ultimate level of divi- undergo two further levels of division into two to 12 penultimate sion, where they may be either anterior or posterior. and ultimate branches. Segmental and subsegmental division can First Terminal Division Branches occur either outside or inside the spleen. The number of arteries entering the spleen ranges from six to 36. The size of the spleen A classic study from 1917 found that 72% of specimens had does not determine the number of arteries entering it; however, three terminal branches (superior polar, superior terminal, and the presence of notches and tubercles usually correlates well with inferior terminal) and 28% had two12; the medial terminal artery a higher number of entering arteries. was observed in only 20% of cases. When the superior terminal A reasonable general scheme of splenic artery branches might artery is excessively large, the inferior terminal is rudimentary, include as many as seven principal branches at various division with an added blood supply often coming from the left gastroepi- levels and in various anatomic arrangements: (1) the superior ploic and polar vessels.
  3. 3. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 3 Second Terminal Division Branches Collaterals Superior polar artery The superior polar artery is present Short gastric arteries As many as six short gastric arteries in 65% of patients. It usually arises from the main splenic trunk may arise from the fundus of the stomach, but as a rule, only the (75% of cases) or the superior terminal artery (20% of cases), but one to three that open into the superior polar artery must be li- on occasion, it may originate from the inferior terminal artery or gated during laparoscopic splenectomy [see Figure 1]. separately from the celiac axis (thus providing the spleen with a SUSPENSORY LIGAMENTS OF SPLEEN AND TAIL OF PANCREAS double splenic artery). In most instances, the superior polar artery gives rise to one or two short gastric branches; rarely, it gives rise Duplications of the peritoneum form the many suspensory lig- to the left inferior phrenic and pancreatic rami. The presence and aments of the spleen [see Figure 3]. Medially and posteriorly, the size of this artery appear to be correlated with tubercle formation, splenorenal ligament contains the tail of the pancreas and the in that it is more prominent in spleens with large tubercles. The splenic vessels. Anteriorly, the gastrosplenic ligament contains the superior polar artery is frequently very long and slender and thus short gastric and gastroepiploic arteries. In the lateral approach to easily torn during splenectomy; accordingly, it was suggested in laparoscopic splenectomy [see Operative Technique, below], the 1928 that ligation of splenic branches be started from the inferior splenorenal and gastrosplenic ligaments are easily distinguished, and dissection of the anatomic structures they contain is relative- pole of the spleen.13 ly simple. In the anterior approach, these two ligaments lie on top of each other, and to separate them correctly and safely requires Inferior polar artery The inferior polar artery is present in considerable experience with splenic anatomy. 82% of cases. As many as five collateral branches may arise from The phrenicocolic ligament courses laterally from the the splenic trunk, the inferior terminal artery, or, as noted, the left diaphragm to the splenic flexure of the colon; its upper portion is gastroepiploic artery. Inferior polar branches may have multiple called the phrenicosplenic ligament. The attachment of the lower origins, and they tend to be of smaller caliber than the superior pole on the internal side is called the splenocolic ligament. polar artery. Between these two structures, a horizontal shelf of areolar tissue, known as the sustentaculum lienis, is formed on which the inferi- Left gastroepiploic artery The left gastroepiploic artery, the or pole of the spleen rests.The sustentaculum lienis is often mold- most varied of the splenic branches, courses along the left side of ed into a sac that opens cephalad and acts as a support for the the greater curvature in the anterior layer of the greater omentum. lower pole. This structure, often overlooked during open proce- In 72% of cases, it arises from the splenic trunk several centimeters dures, is readily visible through a laparoscope. The phrenicocolic from its primary terminal division, and in 22% of cases, it origi- ligament, the splenocolic ligament, and the sustentaculum lienis nates from the inferior terminal artery or its branches; however, it are usually avascular, except in patients who have portal hyper- may also originate from the middle of the splenic trunk or from the tension or myeloid metaplasia. superior terminal artery. Characteristically, the left gastroepiploic A 1937 study found that the tail of the pancreas was in direct artery gives off inferior polar arteries, which vary in number (rang- contact with the spleen in 30% of cadavers.14 A subsequent report ing from one to five), size, and length.Typically, these branches are confirmed this finding and added that in 73% of patients, the dis- addressed first during laparoscopic splenectomy. When they are tance between the two structures was no more than 1 cm.15 Care small, they can usually be controlled with the electrocautery. must be exercised to avoid damage with the electrocautery during Splenic Artery FIRST TERMINAL DIVISION Superior Terminal Inferior Terminal Medial Terminal Artery Artery Artery SECOND TERMINAL Superior Polar Inferior Polar Left Gastroepiploic DIVISION Artery Artery Artery Short Gastric COLLATERALS Vessels (1– 3) THIRD TERMINAL DIVISION Penultimate Branches (2–12) FOURTH TERMINAL Ultimate Branches DIVISION (within Spleen) (2–12) Figure 2 Outlined is a general scheme of the levels of division of the splenic artery branches.
  4. 4. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 4 Gastrosplenic Short Gastric Ligament Vessels Splenorenal Cardia Ligament Splenic Vessels Gastroepiploic Artery Lesser Sac Phrenicocolic Ligament Sustentaculum Gastrocolic Lienis Ligament Splenocolic Ligament Greater Figure 3 Depicted are the suspensory Omentum ligaments of the spleen. dissection as well as damage with the linear stapler in the course size of the spleen. Spleen size is expressed in terms of the maxi- of en masse ligation of the splenic hilum (a maneuver more easily mum interpole length (i.e., the length of the line joining the two performed via the lateral approach to laparoscopic splenectomy). organ poles) and is generally classified into three categories: (1) normal spleen size (< 11 cm), (2) moderate splenomegaly (11 to 20 cm), and (3) severe splenomegaly (> 20 cm).16 Because Laparoscopic Splenectomy extremely large spleens present special technical problems that test the current limits of laparoscopic surgery, we make use of a fourth PREOPERATIVE EVALUATION category for spleens longer than 30 cm or heavier than 3 kg, which Currently, we consider all patients evaluated for elective we call megaspleens [see Table 1]. The ultrasonographer is also splenectomy to be potential candidates for laparoscopic splenec- asked to try to identify any accessory spleens that may be present. tomy. Contraindications to a laparoscopic approach include severe Computed tomography is done when there is doubt about the portal hypertension, uncorrectable coagulopathy, severe ascites, exactness of the ultrasonographic measurement; such measure- and most traumatic injuries to the spleen. Extreme splenomegaly ment is sometimes inaccurate at the upper pole and with spleens remains a relative contraindication as well. Because most patients longer than 16 cm. scheduled for laparoscopic splenectomy have hematologic disor- Patients receive thorough counseling about the consequences of ders, they undergo the same hematologic preparation that patients the asplenic state. Polyvalent pneumococcal vaccine is adminis- scheduled for open surgery do—namely, steroids and γ-globulins tered at least 2 weeks before operation in all cases; preoperative vac- (when required). Ultrasonography is performed to determine the cination against Haemophilus influenzae and meningococci is also
  5. 5. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 5 advisable. Heparin prophylaxis for thrombophlebitis is administered Table 1 Classification of Spleens according to standard guidelines, provided that there is no hema- According to Spleen Length* tologic contraindication [see 6:6 Venous Thromboembolism]. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often given orally before Spleen Class Spleen Length operation to minimize postoperative pain; however, on empirical grounds, NSAIDs are not used when heparin prophylaxis is em- Normal-size spleen 7–11 cm ployed. Platelets are rarely, if ever, required when laparoscopic Moderate splenomegaly 12–20 cm splenectomy is performed for idiopathic (immune) thrombocy- Massive splenomegaly 21–30 cm topenic purpura (ITP). Megaspleen > 30 cm OPERATIVE PLANNING *Spleen length is defined as interpole length, measured along a straight line connecting the two poles. Laparoscopic splenectomy presents special problems, such as the necessity of dealing with a fragile and richly vascularized organ a left-side posterolateral thoracotomy. The operating table is that is situated close to the stomach, the colon, and the pancreas flexed and the kidney bolster raised to increase the distance and the difficulty of devising an extraction strategy that is compat- between the lower rib and the iliac crest. Usually, four 12 mm ible with proper histologic confirmation of the pathologic process trocars are used around the costal margin so that the camera, the while maintaining the advantages of minimal access surgery. For clip applier, and the linear stapler can be interchanged with max- successful performance of laparoscopic splenectomy, a detailed imum flexibility [see Figure 4]. The trocars must be far enough knowledge of both splenic anatomy and potential complications is apart to permit good working angles. Some advantage may be essential. The operative strategy is largely determined by the gained from tilting the patient slightly backward; this step gives anatomic features, which, as noted [see Anatomic Considerations, the operating team more freedom in moving the instruments above], may vary considerably from patient to patient.17 placed along the left costal margins, especially during lifting movements, when it is easy for instrument handles to touch the OPERATIVE TECHNIQUE operating table. For the same reason, it is also advisable to place the anterior or abdominal side of the patient closer to the edge Lateral Approach of the operating table. This approach was first described in connection with laparoscop- A local anesthetic is infiltrated into the skin at the midpoint of ic adrenalectomy and is currently used for most laparoscopic splen- the anterior costal margin, and a 12 mm incision is made.The first ectomies.18 At present, the only indication for the anterior approach trocar is inserted under direct vision, and a symmetrical 15 mm to laparoscopic splenectomy is the presence of massive splenomegaly Hg pneumoperitoneum is created.The locations of the remaining or a megaspleen.Typically, this alternative approach is taken when trocars are determined by considering the anatomic configuration a spleen reaches or exceeds 23 cm in length or 3 kg in weight. in relation to the size of the spleen to be excised. In most cases, the fourth posterior trocar cannot be inserted until the splenic flexure Step 1: placement of trocars The patient is placed in the of the colon has been mobilized. Accordingly, the procedure is right lateral decubitus position, much as he or she would be for usually started with three trocars in place. Figure 4 Laparoscopic splenectomy: lateral approach. Shown is standard trocar placement. Four trocars are used. In most cases, the procedure is begun without the posterior trocar in place. 12 mm Usual 12 mm Extraction Site 4 3 2 1
  6. 6. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 6 Troubleshooting. After years of using the Veress needle, we now fully explored [see Figure 6]. Any accessory spleens found should prefer the open method of inserting the first trocar. It is true that be removed immediately; they are considerably harder to locate use of the Veress needle is for the most part safe; however, the small once the spleen is removed and the field is stained with blood. number of catastrophic complications that occur with blind meth- ods of first trocar insertion are more and more difficult to justify. Troubleshooting. It is especially important to retrieve accessory Admittedly, these complications are infrequent, and thus, it is spleens from patients with ITP, in whom the presence of overlooked unlikely that even a large randomized trial would be able to show accessory spleens has been associated with recurrence of the disease. any significant differences between various methods of first trocar Remedial operation for excision of missed accessory spleens has insertion. Nevertheless, even though complications occur with the been reported to bring remission of recurrent disease; such operation open method of first trocar insertion as well, they are very uncom- can be performed laparoscopically.The overall retrieval rate for ac- mon and tend to be limited to trauma to the intestine or the omen- cessory spleens should fall between 15% and 30%. tal blood vessels; they do not have the same serious consequences Splenic activity has been demonstrated after open and laparo- as the major vessel injury that may arise from blind trocar insertion. scopic splenectomy for trauma and hematologic disorders19,20; Trocar placements differing from the ones we describe may be accordingly, it is advisable to wash out and recover all splenic frag- considered. More experienced surgeons (or those simply wishing ments resulting from intraoperative trauma at the end of the pro- to make the procedure easier) may choose to replace one or two cedure.This step is particularly important for patients with ITP, in 12 mm trocars with 5 mm trocars [see Figure 5a]. The procedure whom intraoperative trauma to the spleen is thought to contribute can also be performed with only three trocars. In leaner patients, to postoperative scan-detectable splenic activity. As of this writing, one of the trocars can be inserted into the umbilicus to gain a cos- we have recovered accessory spleens in 33% of ITP cases treated metic advantage.The advent of needlescopic techniques has made laparoscopically. it possible to replace some of the 5 and 12 mm trocars with 3 mm trocars. The ultimate (i.e., least invasive) technique, usually Step 3: control of vessels at lower pole, demonstration of reserved for lean patients with ITP and normal-size spleens, “splenic tent,” and incision of phrenicocolic ligament The involves one 12 mm trocar placed in the umbilicus and two 3 mm splenic flexure is partially mobilized by incising the splenocolic lig- trocars placed subcostally [see Figure 5b]. This approach requires ament, the lower part of the phrenicocolic ligament, and the sus- two different camera-laparoscope setups, so that a 3 mm laparo- tentaculum lienis. The incision is carried slightly into the left side scope can be interchanged with a 10 mm laparoscope as necessary of the gastrocolic ligament. This step affords access to the gastro- to permit application of clips or staplers through the umbilical splenic ligament, which can then be readily separated from the incision once the dissection is completed. The specimen is then splenorenal ligament to create what looks like a tent.This maneu- retrieved through the umbilicus. Because the use of 3 mm laparo- ver cannot be accomplished in all cases, but when it can be done, scopes is accompanied by a decrease in available intra-abdominal it simplifies the procedure considerably.The walls of this so-called light and focal width, a meticulously bloodless field and sophisti- splenic tent are made of the gastrosplenic ligament on the left and cated surgical judgment are critical for successful performance of the splenorenal ligament on the right, and the floor is made up of needlescopic splenectomy. the stomach. In fact, this maneuver opens the lesser sac in its lat- eral portion (a point that is better demonstrated with gentle Step 2: search for and retrieval of accessory spleens The upward retraction of the splenic tip) [see Figure 7]. camera is inserted, and the stomach is retracted medially to expose The branches of the left gastroepiploic artery are controlled the spleen. Then a fairly standard sequence is followed. A thor- with the electrocautery or with clips, depending on the size of the ough search is then made for accessory spleens. To maximize branches.The avascular portion of the gastrosplenic ligament, sit- retrieval, all known locations of accessory spleens should be care- uated between the gastroepiploic artery and the short gastric ves- a b Figure 5 Laparoscopic splenectomy: lateral approach. Shown are alternative trocar placements. (a) In some patients (e.g., thin patients with normal-size spleens), a 12 mm trocar may be placed in the umbilicus to gain a cosmetic advantage, and most of the other trocars may be downsized to 5 mm. (b) In the needlescopic approach, only three trocars are placed: a 12 mm trocar in the umbilicus and two 3 mm subcostal trocars.Two camera-laparoscope setups (3 and 10 mm) are required.
  7. 7. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 7 Hilar Region (54%) Pedicle (25%) a Tail of Pancreas (6%) Greater Omentum (12%) Splenocolic Ligament (2%) b Left Ovary (0.5%) Mesentery Figure 6 Laparoscopic splenectomy: lateral approach. (0.5%) (a) Accessory spleens are known to occur at specific sites. (b) Shown is an accessory spleen. sels, is then incised sufficiently to expose the hilar structures in the When a powered instrument is called for, we use a monopolar splenorenal ligament. To accomplish this, the lower pole is gently electrocautery with an L hook or a gently curved scissors. elevated; in this position, the spleen almost retracts itself as it nat- Alternatively, an ultrasonic dissector or a tissue-welding device urally falls toward the left lobe of the liver. At this point, the sur- may be used, albeit at a much higher cost. geon can usually assess the geography of the hilum and determine the degree of difficulty of the operation.The fourth trocar, if need- Step 4: dealing with splenic hilum and tailoring operative ed, is then placed posteriorly under direct vision, with care taken strategy to anatomy It is advisable to base one’s operative to avoid the left kidney. Caution must also be exercised in placing strategy on the specific splenic anatomy. If a distributed anatomy the trocars situated immediately anterior and posterior to the iliac crest. The iliac crest can impede movement and hinder upward mobilization of structures if the trocars are placed over it rather than in front of or behind it [see Figure 8]. Finally, the phrenicocolic ligament is incised all the way to the left crus of the diaphragm, either with a monopolar electrocautery with an L hook or with scissors. A small portion of the ligament is left to keep the spleen suspended and facilitate subsequent bag- ging.The phrenicocolic ligament is avascular except in patients with portal hypertension or myeloproliferative disorders (e.g., myeloid metaplasia). Leaving 1 to 2 cm of ligament all along the spleen side facilitates retraction and handling of the spleen with instruments. Troubleshooting. Remarkably few instruments are needed for laparoscopic splenectomy: most of the operation is done with three reusable instruments. A dolphin-nose 5 mm atraumatic grasper is used to elevate and hold the spleen. It is also used to sep- arate tissue planes and vessels with blunt dissection because its atraumatic tip is easily insinuated between tissue planes. A gently curved 5 mm fine-tip dissector (Crile or Maryland) and a 10 mm Figure 7 Laparoscopic splenectomy: lateral approach. The so- 90º right-angle dissector are the only other tools required for cost- called splenic tent is formed by the gastrosplenic and splenorenal efficient dissection. ligaments laterally and the stomach below.
  8. 8. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 8 Troubleshooting. It is at this point in the procedure that experi- ence in designing the operative strategy pays off in reduced oper- ating time. Because of the many variations in size, shape, vascular patterns, and relations to adjacent organs, spleens are almost as individual as fingerprints. Accordingly, an experienced spleen sur- Rib Margin geon learns to keep an open mind with regard to operative strate- gy and must be able to call on a wide range of skills to facilitate the procedure. The surgeon should start by looking at the internal surface of the spleen. If the splenic vessels cover more than 75% of the inter- nal surface (as is the case in 70% of patients), a distributed anato- my is present. With a distributed vascular anatomy, the vessels tend to be easier to dissect and isolate and thus can be readily (and cost-effectively) controlled with clips. On the other hand, if the Iliac Crest splenic vessels entering the spleen cover only 25% to 35% of the inner surface of the hilum (30% of patients), the pattern is bun- dled. With a bundled vascular anatomy, the vessels, being fewer and closer together, can usually be controlled with a single appli- cation of the vascular stapler across the hilum, provided that the tail of the pancreas can be protected. Figure 8 Laparoscopic splenectomy: lateral approach. Shown is the recommended trocar placement around the iliac crest. Step 5: extraction of spleen A medium-size or large heavy- duty plastic freezer bag, of the sort commercially available in gro- is present, the splenic branches are usually dissected and clipped. cery stores, is used to bag the spleen. This bag is sterilized and This is not only the least costly approach but also the simplest, in folded, then introduced into the abdominal cavity through one of that the vessels are spread over a wider area of the splenic hilum the 12 mm trocars [see Figure 11]. The bag is unfolded and the and are easier to dissect and separate [see Figure 9]. spleen slipped inside to prevent splenosis during the subsequent A bundled anatomy lends itself more to a single use of the lin- manipulations. Grasping forceps are used to hold the two rigid ear stapler, provided that the tail of the pancreas is identified and edges of the bag and to effect partial closure. Bagging is facilitat- dissected away when required. When possible, a window is creat- ed by preserving the upper portion of the phrenicocolic ligament. ed above the hilar pedicle in the splenorenal ligament so that all After final section of the phrenicocolic ligament and any diaphrag- structures can be included within the markings of the linear sta- matic adhesions present, extraction is performed through one of pler under direct vision [see Figure 10].The angles provided by the the anterior port sites. Extraction through a posterior site is more various trocars make this maneuver much easier via the lateral difficult because of the thickness of the muscle mass; usually, the approach than via the anterior approach. Dissection continues incision must be opened, and more muscle must be fulgurated with individual dissection and clipping of the short gastric vessels; than is desirable. occasionally, these vessels can also be taken en masse with the lin- The subcostal or umbilical incision through which extraction is ear stapler. So far, we have not used sutures in this setting, except to take place is extended slightly. A grasping forceps is inserted once to control a short gastric vessel that was too short to be through the extraction incision to hold the edges of the bag inside clipped safely.This portion of the operation is performed while the the abdomen. Gentle traction on the bag from outside brings the spleen is hanging from the upper portion of the phrenicocolic lig- spleen close to the peritoneal surface of the umbilical incision and ament, which has not yet been entirely cut. then out of the wound [see Figure 12]. Specimen retrieval bags a b Figure 9 Laparoscopic splenectomy: lateral approach. (a, b) Clipping is well suited to controlling short gastric or gastroepiploic vessels. It is also appropriate for distributed-type splenic vasculatures, in which more splenic vessels are spread over a wider area of the hilum.
  9. 9. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 9 a b Figure 11 Laparoscopic splenectomy: lateral approach. Illustrated is the introduction of a sterile freezer bag for specimen extraction via the pull method. A toothed grasper is passed across the abdomen between two trocars and brought out through the 12 mm umbilical trocar site. This grasper is used to pull the extrac- tion bag back into the abdomen. Troubleshooting. The freezer bags can be more easily intro- duced into the abdomen if they are pulled in rather than pushed in [see Figure 11]. This may be accomplished by bringing out a 5 mm toothed grasper through the introduction trocar from anoth- er properly angled trocar, grasping the specimen bag, and pulling the bag back down through the trocar. A laparoscopic hernia mesh c introducer may also be used. Slipping the spleen into a freezer bag is also an acquired skill that takes some time to master. It is an important skill that is use- ful in many other instances where specimen retrieval is needed (e.g., in procedures involving the gallbladder, the appendix, the adrenal glands, or the colon). In addition, it is highly cost-effective, in that these commercially available bags cost only a few cents each. Admittedly, laparoscopic retrieval bags are easier to use, but their substantially higher cost can become a factor in a busy min- Figure 10 Laparoscopic splenectomy: lateral approach. (a through c) Stapling is particularly well suited to the compact hilum found in the magistral-type distribution of splenic vessels. As shown, all of the vas- cular structures are within the stapler markers, and the tail of the pancreas is well protected. have been developed that can accommodate a normal-size spleen and thus make bagging much easier, but they are costly. A biopsy specimen of a size suitable for pathologic identification is obtained by incising the splenic tip. The spleen is then frag- mented with finger fracture, and the resulting blood is suctioned. The remaining stromal tissue of the spleen is then extracted through the small incision, hemostasis is again verified, and all tro- Figure 12 Laparoscopic splenectomy: lateral approach. Shown is cars are removed. No drains are used. The incisions are closed the position of the specimen bag before finger fragmentation or with absorbable sutures and paper strips. pulp suction.
  10. 10. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 10 Figure 13 Laparoscopic splenectomy: anterior approach. Shown is standard trocar placement. The umbilical site is used for the camera. The remaining trocars are placed in the left and right upper quadrants, the epigastrium, and the right subcostal region. Depending on the size of 5 mm the spleen, the trocars can also be disposed in a semicircle away from the left upper quadrant. 5 mm 12 mm 12 mm 12 mm Usual Extraction Site Alternate Surgical Extraction imally invasive surgery unit. We use a powerful suction machine the lateral approach because it is so much easier, even with spleens (–70 mm Hg) and a custom-made sharp beveled 10 mm cannula that are longer than 20 cm and are readily palpable. The decision to suction splenic tissue from the plastic retrieval bag. is arbitrarily made on the basis of estimated available working space. If the spleen comes too close to the iliac crest or the mid- Anterior Approach line, the anterior approach should be taken instead. The anterior approach is seldom used nowadays; however, it remains the preferable approach in some patients with massive Step 2: isolation of lower pole and control of blood splenomegaly (21 to 30 cm long) and all patients with mega- supply The left hepatic lobe is retracted, and the stomach is spleens (> 30 cm or > 3 kg) with the aid of hand-assisted devices retracted medially to expose the spleen. Accessory spleens are [see Special Considerations, Hand-Assisted Laparoscopic searched for, and the phrenicocolic ligament, the splenocolic lig- Splenectomy, below]. Very large spleens are extremely heavy and ament, and the sustentaculum lienis are incised near the lower difficult to manipulate with laparoscopic instruments, and it is pole with an electrocautery and a hook probe or with scissors. complicated to lift them so as to gain access to the phrenicocolic Vascular adhesions—frequently found on the medial side of the ligament posteriorly.The anterior approach can also be considered spleen—are cauterized. The gastrocolic ligament is carefully dis- if another procedure (e.g., cholecystectomy) is being contemplat- sected close to the spleen, and the left gastroepiploic vessels are ed; alternatively, in this situation, the lateral approach can be used, ligated one by one with metallic clips or, if small, simply cauter- and the patient can be repositioned for the secondary procedure. ized. The upper and lower poles of the spleen are gently lifted with one or both palpators (placed through the 5 mm ports) to Step 1: placement of trocars Under general anesthesia, the expose the splenic hilum and the tail of the pancreas within the patient is placed in a modified lithotomy position to allow the sur- splenorenal ligament, thereby facilitating individual dissection geon to operate between the patient’s legs and to allow the assis- and clipping of all the branches of the splenic artery and vein tants to stand on each side of the patient. The procedure is per- close to the spleen. The short gastric vessels are then identified formed through five trocars in the upper abdomen [see Figure 13], and ligated with clips or, occasionally, with staples. No sutures with the patient in a steep Fowler position with left-side elevation. are used. Alternatively, the splenic artery itself can be isolated A 12 mm trocar is introduced through an umbilical incision, and and clipped within the lesser sac before extensive dissection of a 10 mm laparoscope (0° or 30°) is connected to a video system. the lower pole and suspensory ligaments. A 12 mm trocar is placed in each upper quadrant, and two 5 mm Because of the segmental and terminal distribution of splenic trocars are inserted close to the rib margin on the left and right arteries, it is easy to determine the devascularized portions of the sides of the abdomen. Alternatively, trocars can be deployed in a spleen: these segments exhibit a characteristic grayish color, semicircle away from the left upper quadrant.Trocar sites are care- whereas the vascularized segments retain a pinkish hue.When the fully selected to optimize working angles. The 12 mm ports are organ is completely isolated, it is left in its natural cavity, and hemo- used to allow introduction of clip appliers, staplers, or the laparo- stasis is verified. scope from a variety of angles as needed. Troubleshooting. If one elects first to clip the splenic artery within Troubleshooting. With increasing experience, we find that we the lesser sac, there are a few precautions that must be taken. First, prefer to do as many laparoscopic splenectomies as possible via the clipping must be done distal to the pancreatica magna to prevent
  11. 11. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 11 pancreatic injury. Second, one must make sure that the splenic splenic capsule circumferentially, with care taken to ensure that a artery proper is clipped, not one of its branches (e.g., the superior 5 mm rim of devascularized splenic tissue remains in situ; this is terminal branch).This is an easy mistake to commit with the distrib- the most important technical point for this procedure [see Figure uted type of splenic vasculature [see Figure 1] because the splenic 14]. The incision is then carried into the splenic pulp. Atraumatic artery itself is short and the branches can take off very early.Third, intestinal graspers are also used to fracture the splenic pulp in a one must always keep in mind the possibility of an anastomotic bloodless fashion. The laparoscopic L hook and scissors provide branch between the major splenic branches, as described by Tes- excellent hemostatic control. tut.11 Should a major terminal branch be clipped rather than the Once the spleen has been allowed to demarcate, resection is splenic artery proper, there will be no spleen ischemia if such an remarkably bloodless, provided that the 5 mm rim of ischemic tis- anastomosis is present [see Figure 1]. sue is left in place. Complete control of the splenic artery is not Yet another challenge posed by the anterior approach is that if required before splenic separation, because division occurs in an bleeding occurs, the blood tends to pool in the area of the hilum ischemic segment of spleen.9 The feasibility of leaving portions of and obscure vision even more, whereas in the lateral approach, the ischemic spleen in situ has been demonstrated in a large prospec- blood tends to flow away from the operative field. One quickly tive, randomized trial involving partial splenic embolization as pri- learns that there is a steep price to pay for cutting corners during mary treatment of hematologic disorders.26 the dissection. The dissection must be meticulous, especially If the superior pole is to be removed, the phrenicocolic ligament behind branches of the splenic vein. must be incised almost entirely so that the spleen can be easily mobilized and the proper exposure achieved. The short gastric Step 3: extraction of spleen Given that the anterior branches are taken first, along with the desired number of superi- approach is now used only in cases of massive splenomegaly or or polar artery branches. megaspleen, bagging can be problematic.The largest commercial- Laparoscopic partial splenectomy can be performed either with ly available freezer bag we have seen measures 27 by 28 cm, and or without the aid of selective preoperative arterial embolization the largest spleen we have been able to bag in one of them was 24 (see below). Radiologists are capable of cannulating the desired cm long. Furthermore, an accessory extraction incision is often segmental splenic arterial branch and embolizing the segment that required; a Pfannenstiel incision gives better cosmetic results, but is to be resected. We have removed the superior pole in a patient a left lower quadrant incision can also be used. Hand-assisted with a class IV isolated splenic injury sustained while skiing8; devices are used with increasing frequency in laparoscopic laparoscopic partial splenectomy was made possible largely by the removal of large spleens [see Special Considerations, Hand-Assist- accuracy of selective arterial embolization, which permitted con- ed Laparoscopic Splenectomy, below]. trol of the bleeding and allowed laparoscopy to be performed in If the spleen cannot be bagged, it may be fragmented in the unhurried conditions.27 pelvis before extraction, provided that the abdomen is copiously washed and cleaned of any residual spleen fragments before clo- Preoperative Splenic Artery Embolization sure to prevent splenosis. Most patients with large spleens have Preoperative splenic artery embolization is used as an adjuvant hematologic malignancies; thus, residual splenic activity is not as in a few patients to make laparoscopic splenectomy possible and crucial an issue in these patients as it would be in others. to reduce blood loss. Although it is now infrequently used, it remains a useful tool in the armamentarium of spleen surgeons. Laparoscopic Partial Splenectomy Generally speaking, the technique involves embolization of the Concern regarding the risk of OPSI has encouraged the prac- spleen with coils placed proximally in the splenic artery and tice of preserving splenic tissue and function whenever possible. absorbable gelatin sponges and small coils placed distally in each For this reason, partial splenectomy has occasionally been indi- splenic arterial branch (the double embolization technique), with cated for treatment of benign tumors of the spleen and for exci- care taken to spare vessels supplying the tail of the pancreas [see sion of cystic lesions.21 Its use has been described in connection Figure 15]. with the management of type I Gaucher disease, cholesteryl The procedure is ended when it is estimated radiologically that ester storage disease, chronic myelogenous leukemia, and tha- 80% or more of the splenic tissue has been successfully embolized. lassemia major, as well as with the staging of Hodgkin dis- In most cases, successful embolization is achieved with both prox- ease.22,23 Partial splenectomy has also been an option in the imal and distal emboli; in a minority of cases, it is achieved with management of splenic trauma when the patient’s condition is proximal emboli alone or with distal emboli alone.28 stable enough to permit the meticulous dissection required for the operation.24,25 Troubleshooting Preoperative splenic artery embolization is Like standard laparoscopic splenectomy, laparoscopic partial safe, provided that two main principles are adhered to. First, splenectomy is performed with the patient in the right lateral decu- embolization must be done distal to the pancreatica magna to bitus position. Trocar placement is similar as well. The splenocolic avoid damaging the pancreas. Second, neither microspheres nor ligament and the lower part of the phrenicocolic ligament are absorbable gelatin powder should be used, because particles of incised to permit mobilization of the lower pole of the spleen. If the this small size may migrate to unintended target organ capillaries lower portion of the spleen is to be excised, branches of the gas- and cause tissue necrosis; only coils and absorbable gelatin sponge troepiploic vessels supplying the lower pole are dissected and fragments should be used. clipped close to the parenchyma. An appropriate number of penul- POSTOPERATIVE CARE timate branches of the inferior polar artery are then taken in such a way as to create a clear line of demarcation between normal Postoperative care for patients who have undergone laparo- spleen and devascularized spleen. This process is continued until scopic splenectomy is usually simple.The nasogastric tube insert- the desired number of splenic segments are devascularized. ed after induction of general anesthesia is removed either in the Next, a standard monopolar electrocautery is used to score the recovery room, once stomach emptying has been verified, or the
  12. 12. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 12 a b c d Figure 14 Laparoscopic splenectomy: partial splenectomy. (a, b) The splenic capsule is scored with the monopolar cautery, and a 5 mm margin of devitalized tissue is left. (c) The splenic pulp is frac- tured with an atraumatic grasper. The electrocautery with the L hook is also used to control parenchymal bleeding. (d) Shown is the cut surface of the spleen after transection. The operative field remains remarkably dry. next morning, depending on the duration and the degree of tech- COMPLICATIONS nical difficulty of the procedure. The urinary catheter is usually Postoperative complications directly related to splenectomy removed before the patient leaves the recovery room. The patient include intraoperative and postoperative hemorrhage; left lower is allowed to drink clear fluids on the morning after the operation; lobe atelectasis and pneumonia; left pleural effusion; subphrenic when clear fluids are well tolerated, the patient is allowed to pro- ceed to a diet of his or her choice. If the patient has no history of ulcer or dyspepsia, one naprox- en sodium tablet (500 mg) is given with sips of water on the morn- ing before operation. Meperidine injections (1 mg/kg) are admin- istered during the first night, followed by oral acetaminophen (1 g every 6 hours). If pain is not well controlled, coanalgesia with an NSAID is added; this combination produces the best results. Because of its side effects (i.e., nausea, vomiting, abdominal full- ness, and constipation), codeine is currently avoided if at all possi- ble. When naproxen sodium is used, prophylactic doses of subcu- taneous heparin are avoided on empirical grounds, especially if the platelet count is low or platelet function is abnormal. Patients receiving I.V. cortisone are given oral steroids on postoperative day 1 after an overlap I.V. injection; thereafter, steroids are gradually tapered. Patients are allowed to shower 12 hours after surgery and are advised to keep the paper strips cov- Figure 15 Laparoscopic splenectomy: splenic artery emboliza- ering the trocar incisions in place for 7 to 10 days. No drains are tion. Shown are splenic angiograms of a patient with thrombotic used. No limitations are imposed on physical activity, and thrombocytopenic purpura before (left) and after (right) splenic patients are allowed to tailor their activities to their degree of artery embolization with 3, 5, and 7 cm coils and absorbable asthenia or discomfort. gelatin sponge fragments.
  13. 13. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 13 collection; iatrogenic pancreatic, gastric, and colonic injury; and venous thrombosis.24-31 Successful laparoscopic splenectomy depends to a large extent on proper preparation. Recognition of anatomic elements and their arrangement is paramount. As with other laparoscopic pro- cedures, the keys are avoiding complications and minimizing tech- nical misadventures.Vascular structures should be cleanly isolated and dissected from surrounding fat; they then can usually be con- trolled with two clips proximally and distally. Staplers should be used with care and should not be applied blindly. The stapler tip should be clearly seen to be free of tissue before it is closed; oth- erwise, hemorrhage from partial section of a major splenic branch might occur after the instrument is released. Blind application of the stapler may also result in damage to the tail of the pancreas, which often lies in close proximity to the inner surface of the spleen. If both clips and a linear stapler are used, it is vital to pre- vent interposition of clips in the staple line, which will cause the stapler to misfire and possibly to jam. Improper use of the electrocautery during the procedure can Figure 16 Laparoscopic splenectomy: hand-assisted. Shown is cause iatrogenic injury to the stomach, the colon, or the pancreas. the use of a hand port in the left lower quadrant to facilitate laparoscopic splenectomy in a patient with a large spleen. In a smoke-filled environment, where controlling vessels is difficult and time consuming, blind fulguration of fat in the hilum can lead to bleeding. Structures close to the lower pole in the gastrocolic tissue (in the case of preoperative splenic artery embolization) or ligament can be approached more aggressively, but not those in altered tissue architecture (in the case of finger fragmentation), the hilum. To prevent arcing and spot necrosis, which may result especially if malignancy is suspected but not proved. In practice, in delayed perforation and sepsis, the instrument should be acti- however, we have found that the diagnosis is made preoperatively vated only in proximity to the target organ. in more than 90% of patients with benign and malignant hemato- The assistants also play an important role in preventing com- logic disease; hence, the issue rarely arises. plications. All instruments, including those handled by assistants, should be moved under direct vision. Especially in the anterior Hand-Assisted Laparoscopic Splenectomy approach, retraction of the liver and stomach and elevation of the The term hand-assisted laparoscopic surgery refers to laparo- spleen require constant concentration if lacerations and subse- scopic procedures performed with the aid of a plastic device quent hemorrhage or perforation are to be avoided. inserted in a 7.5 to 10 cm wound. This plastic hand port consists SPECIAL CONSIDERATIONS of a sealed cuff that enables a hand to be inserted into and with- drawn from the abdomen without loss of pneumoperitoneum dur- Extraction of Specimens ing the operation; in this way, the surgeon regains some of the tac- tile feedback lost in conventional laparoscopic surgery [see Figure Spleens removed via the anterior approach are extracted 16]. A number of different models have been developed, some of through the umbilical trocar site after finger fragmentation in a them quite expensive. Most use either an inflatable sleeve clipped plastic bag. It is rarely necessary to enlarge the umbilical incision to an O-ring, a spiral inflatable valve, or a flap valve to maintain to more than 2 or 3 cm.When the lateral approach is used, extrac- pneumoperitoneum. tion is more easily performed through one of the ports situated The optimal placement of the incision for a hand-assisted anteriorly. This extraction site also requires little or no enlarge- laparoscopic splenectomy remains a subject of debate: recom- ment. On occasion, for a spleen longer than 20 cm, a 7.5 to 10 cm mended locations have included the upper midline, the right Pfannenstiel incision is made, and the operator’s forearm is intro- upper quadrant, the left iliac fossa, and, for very large spleens, the duced into the abdomen to deliver the spleen into the pelvis for Pfannenstiel position.Whether the surgeon is left-handed or right- extraction in large fragments under direct vision.32 The abdomen handed plays a role; most surgeons agree that the nondominant is copiously irrigated before closure. hand should be used in the device. Special mention should be made of extraction of the splenic There are obvious advantages and drawbacks to hand-assisted specimen from patients with malignant disease. If lymphoma or laparoscopic splenectomy. The most apparent disadvantage is the Hodgkin disease is suspected, neither preoperative splenic artery cosmetic cost of a longer abdominal incision (except when a embolization nor finger fragmentation in a plastic bag should be Pfannenstiel incision is employed). More generally, the use of a performed, for fear of making the histologic diagnosis difficult. longer incision would seem to be at odds with the current trend Extraction of intact spleens through a small left subcostal or medi- toward developing surgical techniques that reduce surgical trauma an incision has also been employed when preservation of tissue as much as possible. Nevertheless, comparative studies of splenec- architecture is required. Alternatively, a port site may be slightly tomy in patients with large spleens (> 700 g) seem to indicate that enlarged, and a knife or a Mayo scissors may be used to furnish for the most part, the hand-assisted approach yields outcomes the pathologist with intact specimen pieces of various sizes. The similar to those of conventional laparoscopic splenectomy.33 various techniques of fragmentation and extraction of splenic tis- Although the precise role of hand-assisted laparoscopic splenec- sue during laparoscopic splenectomy should be discussed and tomy remains to be defined, it is likely that this technique will find agreed on with the pathologist ahead of time to ensure that prop- a place in the surgical management of patients with large spleens. er pathologic diagnoses are not compromised by either necrotic In addition, the hand-assisted approach may be a valuable aid for
  14. 14. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 14 Table 2 Clinical Results of Laparoscopic Splenectomy Conversion OR Time Morbidity Mortality Length of Stay Accessory Spleen Authors N ITP/Non-ITP Rate (%) (min) (%) (%) (days) Present (%) All diagnoses Katkhouda et al (1998)38 103 67/36 3.9 161 6 0 2.5 16.5 Targarona et al (2000)36 122 54/68 7.4 153 18 0 4.0 12 Park et al (2000)37 203 129/74 3.0 145 9 0.5 2.7 12.3 Poulin et al (2001)39 100 50/50 8.0 180 15 4 3.0 25 ITP Trias et al (2000)40 48 — 4.2 142 12 N/A 4.0 11 Poulin et al (2001)39 51 — 3.9 160 5.9 0 2.0 32 Malignancy Schlachta et al (1999)41 14 — 21 239 18 9 3.0 — Trias et al (2000)40 28 — 14* 171 28 N/A 5.5 — * 71% required accessory incision because of spleen size. surgeons who have not yet completed the learning curve for con- laparoscopic splenectomies with simplified trays of reusable in- ventional laparoscopic splenectomy. Finally, this technique may struments. Our basic laparoscopic tray contains a few instru- render preoperative splenic embolization unnecessary for most ments and two sizes of reusable clip appliers with inexpensive very large spleens. clips. As noted [see Operative Technique, above], clips are used for distributed-type spleens, and single-use linear staplers are OUTCOME EVALUATION mostly used for magistral-type spleens. To reduce costs, ultra- No randomized, prospective trials comparing open splenectomy sonic dissectors are rarely used. In addition, the use of commer- with laparoscopic splenectomy have yet been conducted. At pres- cially available freezer bags instead of laparoscopic retrieval bags ent, such trials are unlikely to be held, for a variety of reasons. For further reduces the cost of specimen extraction. Finally, even if one thing, randomization is difficult with procedures that are still in intraoperative costs are higher with laparoscopic splenectomy, evolution. At one end of the spectrum, laparoscopic splenectomy is our experience is that the increase is offset by reductions in post- done for patients with ITP, who usually are relatively healthy and operative stay. have normal-size spleens. In many of these patients, needlescopic We, like most authorities, believe that as a surgeon gains expe- instruments (< 3 mm) can be used in conjunction with a single 12 rience with laparoscopic splenectomy, operating time tends to fall mm port site in the umbilicus.This approach permits hospital dis- until it approaches that of open splenectomy.We also concur with charge within 24 hours of operation in a significant number of the numerous authors who have suggested that once laparoscopic cases. At the other end of the spectrum, laparoscopic splenectomy splenectomy is mastered, use of blood products tends to decrease is done for patients with myeloid metaplasia and spleens longer substantially. than 30 cm. In this setting, a laparoscopic approach poses formi- dable challenges, and the optimal technique and its justification remain to be determined.The window of opportunity for random- Open Splenectomy ized comparative trials may have been lost. PREOPERATIVE EVALUATION Large case series and nonrandomized comparative trials, how- ever, have consistently reported better outcomes from laparoscop- With the growing acceptance of laparoscopic splenectomy, the ic splenectomy than from open splenectomy.34-41 For example, in indications for open splenectomy have essentially been reduced one set of 528 patients [see Table 2],36-39 the rate of postoperative to (1) elective removal of megaspleens and (2) treatment of pneumonia was 1.1% (6/528), and no subphrenic abscesses oc- splenic trauma when conservative treatment either is not indi- curred as postoperative complications. Many surgeons who have cated or has failed. In rare cases, open splenectomy may be done completed the learning curve associated with the procedure feel for iatrogenic injuries incurred during left upper quadrant surgi- that there is still room for improvement regarding complication cal procedures. rates and length of stay for patients with ITP and other relatively Preoperative evaluation for elective open splenectomy is similar benign conditions necessitating laparoscopic splenectomy. The to that for laparoscopic splenectomy [see Laparoscopic more serious conditions and the mortality seen in conjunction Splenectomy, Preoperative Evaluation, above]. Preoperative evalu- with the procedure tend to occur in patients with advanced hema- ation of trauma patients is covered in more detail elsewhere [see tologic malignancies or megaspleens. In such cases, most of the 7:1 Initial Management of Life-Threatening Trauma]. Essentially, a adverse results are related to the disease state rather than to the coagulogram and blood typing and crossmatching are required. A operation, and it remains to be seen whether laparoscopic splenec- preoperative CT scan will have established the size of the spleen, tomy will have a positive effect on outcome. the grade of the splenic injury, the presence of other injuries (if One of the great attractions of minimally invasive surgery has any), and, in elective cases, the location and configuration of any been the prospect of significant cost reductions. At this point in masses or cysts. the development of laparoscopic splenectomy, however, we are OPERATIVE PLANNING reluctant to place too much trust in premature cost analyses that do not take into account the “work in progress” nature of mini- Most surgeons would agree that the lessons learned from success- mally invasive surgery. Most surgeons can now perform most ful performance of minimally invasive procedures have had a positive
  15. 15. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 15 impact on the refinement of the corresponding open procedures. formed splenectomy via a thoracoabdominal approach, but most The principles of careful appreciation of fine anatomic details (as de- have abandoned this approach. Appropriate retraction of the left scribed for laparoscopic splenectomy) and maximal reduction of tis- lobe of the liver and the abdominal wall is achieved with the help of sue trauma from retractors or excessive tissue handling should be in- surgical assistants placed on each side of the table or the use of self- corporated into the planning of open splenectomy. retaining retractors. Total versus Partial Splenectomy Troubleshooting In trauma cases, the anesthetist should As a consequence of the recognition that splenectomy renders always be informed when the peritoneum is opened; release of a patients susceptible to a lifelong risk of OPSI, it is now routine tense hemoperitoneum can precipitate hypotension with the loss practice to attempt splenic conservation. Accordingly, saving nor- of tamponade. mally functioning splenic parenchyma has become the most Step 2: Evacuation of Blood and Packing of the Abdomen important goal in the management of splenic injuries. In some 50% of adults (and over 80% of children), this goal can be In trauma cases, gross blood and clots are evacuated manually achieved by means of nonoperative treatment. In approximately with large laparotomy sponges. All quadrants of the abdomen are 20% of adults, splenorrhaphy and partial splenectomy are possi- then packed with laparotomy pads. Standard suction equipment is ble; splenectomy is indicated in the remainder. Partial splenecto- not very useful for evacuating large quantities of blood from the my is also favored on occasion when excision of splenic tissue is abdomen. required for the treatment of other elective conditions. Step 3: Control of Splenic Artery For the sake of brevity, we describe the surgical technique for total splenectomy and partial splenectomy concurrently, noting Once other major injuries are excluded, the first decision to be differences only where significant. made is whether to control the splenic artery first or to mobilize the spleen to the midline.This decision is dictated by the urgency OPERATIVE TECHNIQUE of the clinical situation, the spleen size, and the presence of under- lying disease. Step 1: Incision If the decision is made to control the splenic artery first, the main The patient is supine, in a reverse Tredelenburg position with a splenic trunk is identified above the pancreas via an approach that 15° tilt to the right. For maximal exposure, a midline incision is leads to the lesser sac either through the gastrocolic ligament or made, starting on the left side of the xiphoid process [see Figure 17]. through the avascular plane of the greater omentum above the distal The incision is extended below the umbilicus for a variable distance, transverse colon. Once dissected, the artery is controlled with a vas- depending on circumstances such as the size of the patient, the surgi- cular loop.The main artery can also be accessed and dissected poste- cal situation (traumatic versus nontraumatic), the possibility of asso- riorly after the spleen is mobilized [see Figure 18]. ciated injury, and the size of the spleen. Occasionally, a left subcostal incision may be used for nontraumatic indications in patients with Troubleshooting One advantage of dissecting the splenic normal-size spleens. This incision may be extended onto the right artery in the lesser sac (as opposed to the hilum) is that the splenic side to form a chevron incision if necessary; however, this may im- vein is rarely damaged, being located under the pancreas and away pede the search for accessory spleens. Some surgeons have per- from the artery. Good proximal control of the splenic blood sup- ply facilitates the performance of the more complex variations of partial splenectomy or total splenectomy for megaspleens. Step 4: Mobilization of Spleen If the decision is made to mobilize the spleen first, as in most trauma cases, mobilization should be carried out in a carefully planned manner; it is all too easy to compound splenic injury with ill-advised maneuvers that obligate the surgeon to perform a total splenectomy. Gastric decompression is ensured with a properly placed naso- gastric tube. The spleen is then retracted anteromedially with the left hand, with care taken to confirm proper retraction of the left abdominal wall. The phrenicocolic ligament is thereby placed on stretch, and the ligament insertion on the lateral abdominal wall serves as countertraction. The phrenicocolic ligament is then incised from the bottom up with either long scissors or the 45°- angle tip of a monopolar cautery [see Figure 19]. Efforts should be made to leave 2 cm of ligament on the spleen side and to avoid capsular injury. If the surgeon cannot put a finger behind the liga- ment, an assistant should elevate the ligament between the jaws of a right-angle clamp. The incision of the phrenicocolic ligament is then extended to the left crus of the diaphragm. Except in patients with portal hypertension or myeloproliferative disorders, this liga- ment is avascular. The left lateral portion of the gastrocolic liga- Figure 17 Open splenectomy. Shown are midline and left sub- ment (the greater omentum) is also dissected away from the costal incisions. splenic flexure of the colon to facilitate mobilization of the spleen.
  16. 16. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 25 Splenectomy — 16 Splenic Artery Pancreas Stomach Figure 18 Open splenectomy. The splenic artery is controlled above the pancreas in the lesser sac. The artery must be ligated distal to the pancreat- ica magna artery. Spleen Left Gastroepiploic Artery At this point, the splenocolic ligament and the sustentaculum vessels between curved clamps, starting from the lower pole. lienis are left alone. Alternatively, the vessels may be controlled with clips. After complete division of the phrenicocolic ligament, a plane is developed between the pancreas and the retroperitoneal structures Troubleshooting We frequently use laparoscopic clip appli- with gentle blunt finger dissection. The spleen can then be deliv- ers to achieve vascular control in open splenectomy. The long, ered to the midline, where the splenectomy can be planned in an slender design of these devices is particularly useful in obese unhurried manner [see Figure 20]. Continuing splenic bleeding patients, in whom it is often difficult to achieve complete mobi- during this maneuver can be controlled with manual compression lization of the spleen without causing additional splenic trauma. of the organ. The splenic pedicle may also be gently compressed With laparoscopic clip appliers, vessels can be safely controlled between the thumb and the index finger at this stage. Laparotomy inside the abdomen. Locking plastic clips may also be used. sponges are placed in the left subphrenic space. Troubleshooting When performing elective resections of very large spleens, experienced spleen surgeons use a few tricks to simplify the procedure. In most patients with megaspleens, the suspensory ligaments have been stretched over time, allowing the surgeon much more leeway in mobilizing or turning the spleen. This greater leeway allows the surgeon to rotate the spleen from the lower pole so as to deliver it transversely into the incision. Thus, the presence of a large spleen does not always necessitate the creation of a long xiphopubic incision, because a transversely placed spleen can be extracted into the abdominal wall through a shorter incision. Step 5a (Total Splenectomy): Planning of Resection To devise the appropriate operative strategy, the surgeon per- forming open total splenectomy must address the same anatomic issues that he or she would if performing laparoscopic total splenectomy—for example, the nature of the splenic blood supply (distributed or bundled) and the distance between the tip of the pancreas and the splenic hilum. The anatomy must be appreciat- ed before the operative strategy can be defined. Once the spleen has been delivered into the abdominal wall, various techniques may be employed to control the blood supply. Figure 19 Open splenectomy. With the spleen retracted The classic approach is to serially clamp, ligate, or suture-ligate the medially, the phrenicocolic ligament is incised.