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
? ? ?
