Laparoscopic splenectomy was first described in 1992 and has since become the preferred technique for almost all indications, provided that it is performed in a hospital that has the equipment and expertise for such techniques.
The indications for the operation are the following:
1. Hematological disorders: Hereditary Spherocytosis, Thalassemia, Sickle Cell Anemia, Autoimmune Hemolytic Anemia.
2. Thrombocytopenias: Idiopathic thrombocytopenic purpura, Thrombotic thrombocytopenic purpura, etc.
3. Myeloproliferative Disorders.
4. Neoplasms: Hairy cell leukemia, Hodgkin’s and non-Hodgkin’s lymphoma, Chronic lymphocytic leukemia.
5. Various other causes: Sarcoidosis, tumors or cysts of the spleen, splenic vein thrombosis, splenic artery aneurysm, splenic abscesses, etc.
Relative contraindications for laparoscopic splenectomy include trauma, portal hypertension, and ascites. Stronger contraindications include marked splenomegaly (weight>2000 gr, length>30cm) and acute coagulation disorder.
Preoperative preparation includes:
1. Abdominal CT and MRI examination, for better estimation of spleen size and for detection of accessory splenoids, which if left untreated can lead to recurrence of thrombocytopenia. Accessory splenoids occur in 10-20% of cases and are located in the splenic hilum, tail of pancreas, greater omentum, mesentery, left broad ligament and Douglas space. However, many authors question the necessity of preoperative radiodiagnostic examination, as they believe that knowledge of the possible locations of splenoids makes their non-operative detection extremely unlikely.
2. Transfusions of the patient with blood and platelets, so that Hgb>10 g/dL and PLT>50000. It is also considered self-evident that blood and its derivatives are secured for possible intraoperative use.
3. In case of malignancy, preoperative chemotherapy is recommended, followed by a 2-3 week wait before surgery. With this strategy, there is a possibility that the spleen size will be reduced by half during surgery.
4. In elective splenectomy, the patient is vaccinated with a polyvalent vaccine for meningococcal, pneumococcal and haemophilus 2 weeks before surgery. In emergency splenectomy, the corresponding vaccination is done before discharge.
Intraoperatively, there are three techniques
The anterior technique, in which the patient is in a supine position with the legs in abduction and the surgeon is positioned between the patient’s legs (image 1).
The lateral technique, in which the patient is in a right lateral position.
In cases of marked megasplenia, there is the assisted laparoscopic splenectomy, in which the surgeon inserts one hand into the peritoneal cavity, through a 7-10 cm incision made in the midline, in the right hypochondrium, in the left iliac fossa, or transversely in the hypogastrium (Pfannestiel incision). In this way, the surgeon better manages the large spleen.
The complications that can occur postoperatively are:
1. Post-splenectomy sepsis. Occurs in 3.2% of patients and has a mortality rate of 1.4%. It is characterized by fever and leukocytosis. Any patient who, after the 5th postoperative day, exhibits an atypical postoperative course, has more than 15,000 white blood cells, or a platelet to white blood cell ratio greater than 20, should be considered suspected of developing post-splenectomy sepsis and treated immediately with high doses of penicillin or cephalosporin.
2. Portal vein thrombosis. A rare complication but potentially fatal, as it can cause intestinal ischemia and infarction. Risk factors include coagulation disorders, splenomegaly, myeloproliferative syndromes and thrombocytosis. It manifests with abdominal pain, anorexia, fever and diarrhoea. Once the diagnosis is confirmed, immediate treatment with local or systemic thrombolytic therapy is required.
3. Subphrenic abscess. Successfully treated with percutaneous drainage.
4. Pancreatic fistula. Here too, treatment is most often conservative with percutaneous drainage, waiting, and nutritional support for the patient.
Finally, the conversion rate of the operation to an open one is 5%, while in cases of megasplenia it can reach 15%.
The overall complication rate is almost 50%, while the mortality rate reaches 10%.
Here are some images of the basic stages of laparoscopic splenectomy:
Dissection of the short gastric vessels.
Dissection of the splenic artery.
Removal of the spleen from the peritoneal cavity into a special collection bag.
