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Technique of Splenectomy
Since 1991 when it was first described by Delaitre, the laparoscopic approach has become the standard technique for most cases of elective splenectomy. An increased technical skill among surgeons has extended the application for laparoscopic splenectomy to safely include patients with massive splenomegaly. Some limitations to the laparoscopic approach remain for patients with splenomegaly, splenic trauma, and serious medical conditions.
Hematologic diseases, such as idiopathic thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP), are the most common indications for elective splenectomy. These patients typically present with normal or moderately enlarged spleens, and, as such, treatment by a minimally invasive technique is highly valuable. Following the procedure, as many as 85% will have long-term normalization of platelet counts with complete remission of disease. Other hematologic conditions, such as hereditary spherocytosis, myeloproliferative disorders (chronic and acute myeloid leukemia), and autoimmune hemolytic anemia, are general indications for splenectomy.
Malignant disease does not preclude the laparoscopic approach. Splenectomy for therapeutic or diagnostic purposes may be necessary in malignancies involving the spleen, such as myelofibrosis, Hodgkin lymphomas, and hairy cell leukemias. In addition, in the case of splenic cysts, spleen-conserving techniques, such as laparoscopic partial splenectomy, unroofing, or fenestration of the cyst, can be safely performed.
For elective splenectomy in patients with splenomegaly, the foremost limitation to a minimally invasive approach is the surgeon's experience. In addition, the laparoscopic approach may be contraindicated in emergent situations due to splenic trauma. The added time required to set up the laparoscopic equipment and position the patient, as well as the inability to effectively explore and pack the patient, may preclude a minimally invasive approach in emergent settings.
Preoperative Evaluation and Preparation
The preoperative evaluation is important in elective splenectomy to facilitate operative planning. A combination of abdominal exam and imaging is used to determine the exact size of the spleen. Preoperative abdominal computed tomography (CT) can accurately establish anatomic considerations, such as spleen size and vascular conditions. Moderate splenomegaly (>11 cm) or severe splenomegaly (>20 cm) may change the operative approach to either an anterior, hand-assisted, or open technique as described later. Preoperative imaging is not reliable in the detection of accessory splenic tissue, and therefore exploration at the onset of surgery is recommended to avoid disease recurrence, particularly in patients with autoimmune hematologic diseases.
The spleen plays a major role in elimination of encapsulated organisms. Overwhelming postsplenectomy infection in the form of life-threatening sepsis is a major risk with a mortality rate of 40% to 50%. Therefore vaccination against Streptococcus pneumoniae , Haemophilus influenzae type B, and Neisseria meningitides should be administered at least 2 weeks prior to elective splenectomy.
Because hematologic conditions are the most common indication for splenectomy, close communication with a hematologist in the perioperative period is important. For autoimmune thrombocytopenia (ITP), when the platelet count is below a certain threshold (generally <20 × 10 9 /L), preoperative steroids, immunoglobulins, and possibly intraoperative platelet transfusion are beneficial. Prednisone (1 mg/kg per day beginning 5 to 7 days before surgery) can be used to increase preoperative platelet counts. In addition, in certain cases, immunoglobulins (2 g/kg divided into two doses) may be given 48 hours prior to surgery. With thrombocytopenia (platelets <50,000), it is important to have platelets on standby for the operating room because it is most beneficial to transfuse platelets after ligation of the splenic artery.
Technical Considerations
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