Laparoscopic Splenectomy in Children

The main indications for splenectomy in the pediatric population include traumatic splenic rupture, hereditary spherocytosis, hereditary elliptocytosis, sickle cell anemia, chronic immune thrombocytopenic purpura (ITP) with failure to respond to medical management, splenic vein thrombosis, Echinococcal cyst, splenic abscess and select leukemias and lymphomas [1].

The epidemiology is often based on the condition that necessitates splenectomy each of which necessitates their own workup.  All patients should undergo a thorough history and physical examination and often times imaging to define the anatomy.  On physical examination, the normal spleen is soft, non-tender, and often not palpable, though it can extend up to 1-2 cm below the left costal margin.  Light pressure should be used to palpate the spleen in young children because it can be pushed away with the fingers.  An enlarged spleen is firm and more easily palpable at least two centimeters below the costal margin and extending as far down as the hemipelvis [2].

A CBC, CMP and reticulocyte count are often part of the primary evaluation of patients with splenic pathology but also help with what products if any may be needed before or during the operation.  Patients with severe anemia may require blood transfusion with the exception of patients with congenital hemolytic icterus to avoid hemolytic crisis.  Blood products should be ready for the operating room.  Additionally, the more massive the splenomegaly, the more accessible circulating blood volume will be removed with the splenectomy if the artery and vein are transected simultaneously [3].  Thrombocytopenic patients may require platelet transfusion on the morning of, or during the operation given their short half-life.  If the patient was on long term steroids, as is often the case in ITP, they should be continued peri-operatively to avoid adrenal insufficiency [4].  As most laparoscopic splenectomies are planned, this allows for preoperative immunization to avoid overwhelming post splenectomy infection.  All patients should receive polysaccharide pneumococcal, conjugate Haemophilus influenza type b, and polysaccharide meningococcal vaccinations two weeks prior to surgery.  If the procedure is performed emergently, the patient should receive the vaccinations prior to discharge.

Laparoscopic approach and technique:

Laparoscopic splenectomy has been described from both an anterior and lateral approach.  Although originally described as an anterior approach, the lateral approach was soon shown to be advantageous [5,6].  The advantages of the lateral approach arise from the improved exposure gained due to gravity.  Having the patient in the right lateral decubitus position allows the viscera fall away, placing the peritoneal attachments to the spleen on tension and making the dissection easier.  This enhances visualization of the vasculature and decreases the number of ports needed as fewer instruments are needed solely for retraction.  Being able to better visualize the vasculature allows for a safer dissection with less blood loss and thus a decreased conversion rate to an open procedure.

To perform the lateral approach, the patient is placed in the right lateral decubitus position.  The shoulders are placed in flexion over the front of the chest with padding between the arms.  The right leg is straight while the left leg is placed in slight flexion for stability.  The legs are padded accordingly.  A small bump is placed under the right flank to allow the left flank to open up by separating the inferior costal margin from the iliac crest.  The abdomen and flank are then prepped and draped from the xiphoid down to the pubis.

Insufflation can be achieved by the operator’s preferred method.  Port placement is variable depending on the degree of the splenomegaly and operative plan.  Typically anywhere from three to five ports are utilized.  An umbilical port is placed and should be able to accommodate an endovascular stapler and the endosurgical catch bag (10-15mm).  Typically one or two 5mm ports are placed in the left upper quadrant two finger breadths from the costal margin and act as ports for additional traction and dissection.  A 5mm port is placed in the left lower quadrant and is the primary working port through which the ultrasonic or radiofrequency dissection device will be used.  A 30-degree telescope is utilized and can be utilized through the left lower quadrant and umbilical ports.

The first maneuver is to divide the splenocolic ligament.  This is a relatively avascular attachment and allows the splenic flexure of the colon to fall away from the inferior pole of the spleen.  The dissection continues with the division of the gastrosplenic ligament.  This attachment contains the short gastric vessels and thus care should be taken with the ultrasonic device to be completely across the vessels with each bite as a partial transection of these vessels can result in bleeding that is difficult to control.  During this portion of the dissection, the stomach may be very closely approximated to the spleen and the dissection should ride the splenic surface to avoid incidental injury to the greater curvature of the stomach.  The stomach should fall further away from the operative field at this point, exposing the anterior surface of the splenorenal ligament and the splenic vessels.  The spleen is then rolled medially, exposing the posterior surface of the splenorenal ligament.  This layer is divided all the way up to the upper pole of the spleen taking care not to damage either the tail of the pancreas or the splenic vessels.  This removes extraneous tissue to accommodate the endovascular stapler when dividing splenic vessels.  If the tail of the pancreas extends to the hilum, this should be carefully dissected away from the vessels.  With the spleen mobilized and now only attached by the hilar vessels, an endovascular stapler is passed through the umbilical port and the vessels divided.  Occasionally the hilar vessels can be very short with the tail of the pancreas in close proximity, necessitating the individual vessels with clips or energy devices.  The endosurgical catch bag is then placed through the umbilical port into which the spleen is placed.  The opening of the bag is then brought out through the umbilical incision.  Using finger fracture or ring forceps, the spleen is then morselated and delivered from the abdomen.  If the spleen proves too large to fit in any of the currently available devices, a lower pelvic or pfannenstiel incision can be utilized for delivery of the spleen while maintaining cosmesis.

In the instance of blood dyscrasias such as hereditary spherocytosis and ITP, careful inspection searching for accessory spleen is necessary.  Failure to remove such accessory spleens will result in recurrence.  The most common location for accessory spleen to occur is in the splenorenal ligament, followed by the greater omentum, the retroperitoneal bed around the tail of the pancreas, the splenocolic ligament, and finally the mesentery of the large and small intestines.  After all accessory spleen has been removed and hemostasis has been achieved, the ports are removed and the fascia at the umbilical site closed [5,6].

 

 

 

References:

  1. Crary SE, Buchanan GR.Vascular complications after splenectomy for hematologic disorders. Oct 1 2009;114(14):2861-2868.
  2. Bickley LS, Szilagyi PG, Bates B. Bates’ guide to physical examination and history taking. 9th ed.Philadelphia: Lippincott Williams & Wilkins; 2007.
  3. Zollinger RM, Ellison EC, Zollinger RM.Zollinger’s atlas of surgical operations : Robert M. Zollinger Jr., E. Christopher Ellison ; illustrations for ninth editions by Marita Bitans and Jennifer Smith. 9th ed. New York: McGraw-Hill Medical; 2011.
  4. Sabiston DC, Townsend CM.Sabiston textbook of surgery : the biological basis of modern surgical practice. 18th ed. Philadelphia: Saunders/Elsevier; 2008.
  5. Coran AG, Adzick NS. Pediatric surgery. 7th ed. Philadelphia, PA: Elsevier Mosby; 2012.
  6. Podevin G, Victor A, De Napoli S, Heloury Y, Leclair MD. Laparoscopic splenectomy: comparison between anterior and lateral approaches. J Laparoendosc Adv Surg Tech A. Nov 2011;21(9):865-868.
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