Robotic splenectomy

Introduction

Minimally invasive splenectomy is now established as the standard of care in general surgery for almost all conditions requiring an elective splenectomy.

It was first reported in 1991 by Delaitre and Maignien, who performed a laparoscopic splenectomy. Subsequent literature has shown that minimally invasive splenectomy improves patient morbidity, reduces length of stay in hospital, reduces perioperative pain, and provides enhanced cosmesis. ^,

With the advent of robotic surgery and its growing presence in general surgery as an enhanced tool or instrument for minimally invasive surgery, there has been growth in the number of robot-assisted splenectomies performed nationwide.

In this chapter, we will outline step-by-step how to proceed with a robotic splenectomy and adding this enhanced tool to your armamentarium for this complex procedure.

Indications

It is easy to extrapolate the indications of laparoscopic splenectomy to robotics. The common criticism of the lack of haptic feedback in robotics does not affect the operative performance of expert robotic surgeons.

We recommend starting the robotic learning curve with less complex procedures to gain the visual cues necessary to replace the haptic feedback; this will evolve your practice to include more complex operations such as robotic splenectomy.

Most of the indications of splenectomy revolve around a malignant disease process, a hematologic disease that causes derangement in blood cell counts, or symptomatic enlargement of the spleen. Currently, minimally invasive splenectomy is successfully performed for a variety of conditions, including idiopathic thrombocytopenic purpura, hereditary spherocytosis, autoimmune hemolytic anemia, Hodgkin and non-Hodgkin lymphoma, chronic lymphocytic leukemia, hemangiomas, idiopathic myelofibrosis, myelodysplastic syndrome, hairy cell leukemia, splenic abscess or cyst, and tuberculosis.

One must weigh the pros and cons of a total versus a partial splenectomy or splenic cyst fenestration in case of benign simple cysts. Often, if the cyst extends to the hilum of the spleen or involves a major vessel, spleen preservation becomes difficult and one should be prepared to proceed with a total splenectomy if needed.

The contraindications to performing a minimally invasive splenectomy include uncorrected coagulopathies and severe portal hypertension from liver cirrhosis. ^, It has also been shown that increasing spleen size has a direct correlation with conversion to open splenectomy. ^{, ,} However, this is not an absolute contraindication to robotic splenectomy.

The experience of surgeons has allowed the success of minimally invasive splenectomy in many cases of splenomegaly. It is strongly suggested that when the spleen weighs up to 1000 g (or its maximal diameter is up to 15 cm), it should be removed using a minimally invasive approach. In a study by Targarona et al., as many as 77% of patients with spleens weighing up to 3200 g underwent successful laparoscopic splenectomy. However, in patients with a spleen weighing between 3200 and 3600 g, rates of conversion to open splenectomy exceeded 75%. The difficulty related to large spleens probably stems from two main issues: (1) handling a large floppy spleen that could somewhat obscure vision and (2) extraction of the diseased spleen. In splenectomy performed for malignant disease, it is preferable to retrieve the specimen without morcellation.

In our experience, enhanced vision, wristed instruments, and a stable platform allow us to push the limit for the minimally invasive approach using the robotic platform.

Robotic surgery in morbidly obese patients offers improved ergonomics to the operating surgeon and a stable operative platform, which, in turn, offers better vision and less torque on the abdominal wall and translates into less postoperative pain. Although blood loss may be greater and duration of surgery may be longer, particularly in patients with a body mass index (BMI) greater than 40, there is no evidence to suggest significantly different perioperative and postoperative differences for morbidly obese patients undergoing a minimally invasive splenectomy.