Laparoscopy for Splenic Conditions

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital

Kansas City, MO

Splenic Conditions

• ITP

• Spherocytosis

• Splenic cysts

• Wandering spleen

J Pediatr Surg 28:689-692, 1993J Pediatr Surg 28:689-692, 1993

Pre-Operative Preparation• Ultrasound

• Often done by pediatrician, hematologist• Rarely needed for splenectomy, except may be useful for

extremely large spleen

• CT Scan – Useful in planning splenic cystectomy

• WinRho• Bone marrow stimulant• Usually used to platelet count• Useful pre-operatively to platelet count in ITP pt.

• Immunizations –Pneumococcus (Prevnar, Pneumovax)

Patient Positioning

Patient Positioning

Personnel Positions

Laparoscopic Splenectomy

• ITP, spherocytosis

• Port placement• (2) cannulas (5, 12)• (2) stab (3 mm) incisions

• Instruments• Harmonic scalpel (5 mm)• Articulating stapler (12 mm)

Laparoscopic Splenectomy

Operative Steps• Divide spleno-colic

ligament, then short gastrics

• Clip artery• Autotransfuse pt• Protects stapler malfxn

Laparoscopic Splenectomy

Operative Steps

• Divide spleno-renal lig.

• Articulating stapler across hilum

• Bag specimen, morcellate extracorporally

Issues

• How large is too large?

• Measurement (LeClair)

• Earlier splenic artery ligation helpful

• Can divide spleen (spherocytosis) with harmonic, if necessary

Issues

• Postoperative platelet ct. > 500,000

• Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic)

• Baby aspirin ( 81 mg) QD for 6 mos

• Re-check at 3 months & 6 months

Splenic Cysts

• Primary

• epithelial lining

• Pseudocysts (secondary)

• no epithelial lining

• often develop after trauma

Splenic Cystectomy

• First step is decompression of cyst

Splenic Cystectomy

• Excise cyst as close as possible to splenic parenchyma with harmonic scalpel

• Coagulate lining with Argon beam coagulator

• ? Place omentum adjacent to exposed cyst lining

European Experience

• 3 European centers (Mainz, Mannheim, Hannover)

• 1995 - 2005

• 14 pts (median 8.5 yr)

• 10 recurrences (71%)

APSA 2006APSA 2006

CMH Experience1990 - 2006

• 8 pts (6 – 18 yrs)

• 4 open, 4 laparoscopic

• ALOS: 2.75 days (open)1.75 days (laparoscopic)

• No recurrences ( 6 CT scans)

Laparoscopic Cystectomy

Wandering Spleen

Wandering Spleen

? ? ?