Laparoscopic Splenectomy - An Overview

Introduction:

Since the 1990s, laparoscopic splenectomy has emerged as a surgical procedure with a track record of exceptional outcomes, boasting low rates of postoperative and intraoperative complications. Pioneered by Delaitre and Maignien in 1991, this technique has become the preferred method for treating a wide range of spleen-related conditions, be they malignant or benign. The scope of this article delves into a comprehensive exploration of the indications, contraindications, various surgical approaches, and the corresponding outcomes associated with this innovative procedure.

What Is Laparoscopic Splenectomy?

Laparoscopic splenectomy, a minimally invasive surgical procedure, involves the removal of the spleen, an organ situated in the upper left abdomen. The spleen plays a crucial role in blood filtration and support for the immune system. During this procedure, small incisions are made in the abdominal region, and a flexible tube equipped with a camera and light is inserted for visualization. Specialized surgical instruments are then used to remove the spleen. Unlike traditional methods, laparoscopic splenectomy does not require reconstruction after removal.

This approach offers several advantages, including smaller incisions leading to smaller scars and reduced postoperative pain. It also results in less bleeding during the procedure. Patients experience shorter hospital stays and quicker returns to normal activities, leading to a faster overall recovery. The use of smaller incisions also reduces the risk of infections.

What Are the Indications of Laparoscopic Splenectomy?

Laparoscopic splenectomy serves as a crucial medical intervention for various conditions, both benign and malignant, as well as structural anomalies:

Benign Hematologic Diseases: Within this category of non-cancerous disorders impacting the circulatory system, laparoscopic splenectomy finds application in the following scenarios:

1. Immune Thrombocytopenic Purpura (ITP): An autoimmune condition where the immune system mistakenly targets platelets. Laparoscopic splenectomy is often preferred due to the spleen's role in the destruction of antibody-bound platelets. It serves as a secondary treatment for cases exceeding one year of chronic ITP, with initial options being high-dose corticosteroids and intravenous immunoglobulin. Even in relapsed thrombocytopenia, laparoscopic splenectomy remains a viable consideration.

2. Hereditary Spherocytosis: A genetic ailment resulting in fragile, misshapen red blood cells. Primary therapy typically consists of medical management and reserving splenectomy for severe presentations.

3. Thrombotic Thrombocytopenic Purpura (TTP): Initial treatment primarily involves plasma therapy, making indications for laparoscopic splenectomy quite rare in this context.

4. Sickle Cell Anemia: A genetic disorder leading to misshapen red blood cells that can obstruct blood vessels, causing pain and organ damage.

5. Thalassemia: A genetic condition affecting hemoglobin production, resulting in anemia. Laparoscopic splenectomy can be a suitable option in such cases.

Malignant Hematologic Diseases: These are blood cancers characterized by uncontrolled cell growth within the bone marrow and blood. Laparoscopic splenectomy may be considered in the following scenarios:

1. Hodgkin's Lymphoma: Often, patients may have an enlarged spleen (splenomegaly), requiring an additional 3 to 4 inches incision or considering a Hand-assisted laparoscopic splenectomy (HALS).

2. Myeloproliferative Diseases: Conditions such as myelofibrosis.

3. Lymphoproliferative Diseases: This category encompasses chronic myelogenous leukemia and chronic lymphocytic leukemia.

Structural Anomalies and Other Conditions: These include:

1. Splenic Cysts: These fluid-filled sacs, occurring inside the spleen, can be infectious, abscess-filled, nonparasitic, congenital, post-traumatic, or even malignant. Symptoms tend to manifest when the cyst size exceeds 1.9 inches.

2. Splenic Artery Aneurysms: An enlargement of the splenic artery that can lead to rupture if left untreated.

3. Splenomegaly: Removal of a spleen weighing up to 35 ounces is feasible using the laparoscopic approach. When the spleen tips the scales at over 70 ounces, it raises a red flag for laparoscopic splenectomy.

What Is the Procedure Involved in Laparoscopic Splenectomy?

Before surgery, it is crucial to evaluate the spleen's size and volume through abdominal sonography. In elective surgical procedures, it is recommended to administer vaccinations for Haemophilus influenzae, Streptococcus pneumonia, and Neisseria meningitidis at least fifteen days prior to the operation. In instances where autoimmune thrombocytopenia leads to diminished platelet counts, patients should undergo corticosteroid or immunoglobulin treatment to reduce blood loss during the surgery.

The surgery usually commences with the administration of general anesthesia, and the patient is positioned laterally, which aids in the separation of short gastric vessels and enhances the reach to the rear surface of the spleen and the perisplenic ligaments. The procedure involves the use of either an open cut-down technique or a Veress needle, along with a diagnostic laparoscopy. Small abdominal incisions, known as trocars, are strategically placed, typically with one just below the left ribcage, slightly off the midline, and another along the left side. If the spleen is enlarged, an extra trocar may be necessary.

The surgeon meticulously separates the spleen from its adjacent structures, paying special attention to the short gastric vessels, and then proceeds to cut the hilum using a specialized endoscopic stapler that can control the bleeding. Hemostasis, the control of bleeding, is maintained by employing clips. The spleen is then inserted into a durable container, often requiring removal in smaller portions.

Hand-assisted laparoscopic splenectomy (HALS) is utilized in cases of markedly enlarged spleens. In HALS splenectomy, a hand-assist device is employed to allow the surgeon to insert their non-dominant hand into the surgical site, streamlining the spleen's removal, usually without the requirement to divide it into smaller pieces.

What Are the Complications of Laparoscopic Splenectomy?

Potential intraoperative complications during laparoscopic splenectomy encompass:

• Hemorrhage, which can result from trauma or damage to the hilar or short gastric vessels, splenic parenchyma, or the splenic capsule, may transpire during ligation or dissection.

• Laceration or injury to neighboring structures such as gastric walls, pancreatic tissues, or diaphragmatic walls.

• Pancreatic injury, although a rare occurrence, may lead to the formation of a pancreatic fistula. In cases where pancreatic injury is suspected, the placement of a drainage tube is advisable.

The postoperative aftermath of laparoscopic splenectomy brings forth a range of potential complications:

• Early complications, such as bleeding, deep vein thrombosis, abscess formation, or infections, can manifest immediately post-surgery.

• Abdominal wall hernia can occur when an organ protrudes through a weakened section of the abdominal wall.

• Abdominal wall hematoma denotes the gathering of blood within the layers of the abdominal wall.

• Portal or splenic vein thrombosis (PSVT) entails the formation of blood clots within both the portal and splenic veins. This condition may develop in the months following the surgery, necessitating postoperative anticoagulation therapy for individuals at a higher risk.

• Overwhelming post-splenectomy infection (OPSI) typically presents as a sudden, severe bacterial infection, frequently involving the bloodstream (sepsis).

Conclusion:

In summary, laparoscopic splenectomy is a notable progression in surgical methods, presenting multiple benefits compared to the conventional open splenectomy. This less invasive approach has gained preference for spleen removal in various medical situations, encompassing benign and malignant hematologic disorders, structural irregularities, and beyond. Typically, laparoscopic splenectomy leads to smaller incisions, decreased postoperative discomfort, swifter recovery periods, and shorter patient hospitalizations.