LAPAROSCOPIC SPLENECTOMY

INDICATIONS Thrombocytopenia 1.Idiopathic Thrombocytopenic Purpura a. Adults: if a trial of glucocorticoid therapy fails to produce a persistent improvement in platlet count. b. Children : if there are important consequences of abnormal bleeding (ie. Intracranial hemorrhage) 2.Thrombotic Thrombocytopenic Purpura The role for splenectomy in TTP is currently unclear. It may have a role in those resistant to plasmapheresis 

Anemias 1.Erythrocyte Structural abnormalities a. Hereditary Spherocytosis- splenectomy at 6 to 8 yrs of age. b. Hereditary Eliptocytosis- if have symptoms of severe anemia. c. Hereditary Pyropoikilocytosis- if severe, usually required as a child.

C. Hypersplenism (Most of these patients will have splenomegaly, and will not be candidates for laparoscopic splenectomy. Although no size guidelines exist, we have had limited success with spleens over 18 to 20 cm in the long axis, and recommend open splenectomy in these patients.) 1. Primary Hypersplenism 2. Secondary Hypersplenism a. Splenic Vein Thrombosis b. Gaucher Disease c. Felty Syndrome d. SLE In general, indications remain same as for Conventional surgery

D. Malignancy Malignancy often confers splenomegaly, which increases the need for an open procedure. Although no real guidelines exist, laparoscopic splenectomy is not recommended for moderate and large sized spleens, as discussed for hypersplenism. 1. Hairy Cell Leukemia 2. Chronic Myelogenous Leukemia Justified for compressive symptoms, or sequestration of cellular elements. 3. Chronic Lymphocytic Leukemia For splenomegaly 4. Primary Splenic Tumors

CONTRAINDICATIONS Spleen Size - No real consensus on exactly what is too large. Large spleens decrease the likelihood of successful laparoscopic removal. Borderline sized spleens can be attempted, if the dissection is successful, often placement in the removal bag can be difficult. If this occurs a small incision is made to avoid intra-abdominal fracture. B. Physiologic Limitations - Those who cannot tolerate operation, or have uncorrectable severe bleeding dyscrasias.

Pre operative Vaccination Optimise Blood parameters Arrange for blood components like for ITP

Position Modified Lithotomy ( Semi frog leg ) Right Lateral Position : Surgeon preference We use the second position

Mod. Lithotomy Liver retraction necessary ( Extra port ) Can combine with cholecystectomy in patients with congenital hemolytic anaemia

Setup Right Lateral Position Monitor – Left side near Head End Surgeon – Right side 1st and 2nd Assistant – Right side Scrub nurse – Right side

Modified Lithotomy Disadvantage : Liver retraction necessitates an extra port Advantage : Can combine with cholecystectomy without change in position especially in patients with Congenital Hemolytic Anaemia

Patient Position Reverse Trendelenburgh with Left side up ( Right tilt )

Ports Camera ( 10 mm ) – Midline Supraumbilical Right Hand Working ( 10 mm ) – Left Midclavicular Left Hand Working ( 5 mm ) – Midline Epigastric Retractor ( 10 mm ) – Midline Subxyphoid

Determination of Port Position Preoperatively confirm Spleen size Exact port position depends on patient habitus and Spleen size In general, Smaller the Speen – Ports tend to be closer to the costal margin like ITP

Instruments ( 10 mm ) 30 degree Telescope Fan Blade Retractor Babcock Forceps Clip Applicator

Instruments ( 5 mm ) Dissecting Forceps - Curved Atraumatic Forceps Neddle holder Scissor – Regular, Hook Suction / Irrigation

Additional 10 mm Harmonic Scalpel 10 mm Ligasure 12 mm Endoscopic Stapling device Retrieval Bag

Technique Pneumoperitoneum – Veress Adequate distension First, Camera port Note findings Rest of the ports

Technique Mobilise Splenic flexure of Colon inferiorly Divide Splenocolic ligament to mobilise lower pole Divide Splenorenal attachment

Technique Divide Gastrosplenic ligament Retract Stomach superiorly and to the right with Babcock forceps Make a small opening in Gastrosplenic ligament to enter the lesser sac

Technique Continue division of the ligament superiorly along the greater curvature to divide the short gastric vessels by clipping and cautery. We use Harmonic Scalpel Reposit the Babcock forceps frequently to maintain visibility during the above step

Technique Highest short gastric vessels will be best visualised by gentle retraction of the spleen Some prefer Gastrosplenic ligament division first followed by posterior mobilisation of the Splenic attachments

Technique – Vasculature Carefully dissect adipose tissue to visualise Splenic vessels and Distal Pancreas Create a window around the Splenic artery Doubly ligate the artery with Silk before division Similarly divide the vein

Technique – Vasculature Look for branches especially to the upper pole Also note the change in colour to confirm the absence of branches Usually the upper pole has a separate branch

Technique – Vasculature Another method of division is Endoscopic Linear Stapling device passed through a left lateral port. Stapler is passed cephalad along the left colic gutter so as to lie perpendicular to the vein NEVER Open the device repositioning without firing as this may tear the vein Another option is Ligasure

Technique Divide the posterior attachments of the upper pole using Stapler, Cautery or Harmonic Check for Haemostasis

Extraction Extend Right hand working port incision Supraumbilical Midline Minilaparotomy incision Pfannensteil incision

Extraction Retrieval Bag Extend incision Morcellize Spleen using Kocher’s clamp Remove Spleen in pieces, suctioning blood from bag as needed Take care not to damage the bag This may be a time consuming process so be patient

Closure & Drainage Approximate defect with 1-0 prolene suture Re-insert the Right hand working port with clamp on the skin incision to prevent leak Haemostasis confirmed Wash given Large bore drain through left axillary line – fix drain immediately

Closure Abdomen deflated Close all ports Approximate linea in midline ports Subcuticular sutures

Post operative orders Nil orally until patient passes flatus Peri-operative Antibiotic cover Analgesic ( Routine – Diclofenac suppository ) IVF Monitor Drain output

Complications Basal Atelectasis is less common as compared to Open Surgery Bleeding Wound Infection OPSI

Special Precautions Optimise Blood parameters pre-operatively Excellent visualisation of vessels We suggest suture ligation of vessels Haemorrhage is common reason for conversion Gentle retraction of Spleen Look for Splenenculi

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