Laparoscopy for Splenic Laparoscopy for Splenic ConditionsConditions

George W. Holcomb, III, M.D., MBA

Surgeon-in-ChiefChildren’s Mercy Hospital

Kansas City, Missouri

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

Laparoscopic Splenectomy

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Single Site Umbilical Laparoscopic Surgery

Umbilical Portals (U.S.)

SSULS Splenectomy

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SSULS Splenectomy

Prospective Randomized Trial

SSULS vs 4-Port Laparoscopic Splenectomy

• Alpha – 0.05• Power – 0.80• 60 patients total• 10 patients to date

www.cmhclinicaltrials.com

Issues

• How large is too large?

• 28 cm. – 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

Laparoscopic Splenic Cystectomy

• First step is decompression of cyst

Laparoscopic 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

Wandering Spleen

Wandering Spleen

Laparoscopic Splenopexy

J Pediatr Surg 42:E23-27, 2007J Pediatr Surg 42:E23-27, 2007Please use this link if you experience problems viewing the video above.

I.U. Experience1995 - 2006

231 patients

• Mean age 7.7 yrs

• Lap splenectomy – 223• 211 - total• 12 - partial

• Lap splenic cystectomy – 6

• Lap splenopexy - 2Ann Surg, in PressAnn Surg, in Press

I.U. Experience1995 – 2006

Complications

• Ileus - 5

• Bleeding - 4

• Acute chest syndrome- 5

• Pneumonia - 2

• Portal vein thrombosis - 1

• HUS - 1

• Diaphragm perforation 2

• Colon injury - 1

• Port site hernia - 1

• Total splenectomy after partial - 1

• Recurrent cyst - 1

11% overall, 22% in SCD

Ann Surg, in PressAnn Surg, in Press

QUESTIONS

www.cmhmis.com