Elective Laparoscopic Splenectomy Procedure

Laparoscopic splenectomy has emerged as the preferred approach for spleen resection in most clinical scenarios, offering advantages such as reduced hospital stays, faster recovery, and decreased postoperative pain compared to open splenectomy. This article provides a comprehensive review of the procedure, including indications, preoperative planning, surgical techniques, and postoperative considerations, tailored for surgical professionals.

Table of Contents

Indications for Laparoscopic Splenectomy

Laparoscopic splenectomy is indicated for a wide range of splenic pathologies, including benign conditions, malignant conditions, and other splenic pathology such as splenic cysts, abscesses, or symptomatic splenomegaly.

Benign conditions: Immune thrombocytopenia (ITP), hereditary spherocytosis, thalassemia, and idiopathic splenomegaly.
Malignant conditions: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and certain metastatic cancers.
Other indications: Splenic cysts, abscesses, and symptomatic splenomegaly.

Contraindications include massive splenomegaly (spleen weight >1600 g), severe portal hypertension, and significant medical comorbidities that increase surgical risk. In cases of trauma or massive splenomegaly, open splenectomy may be preferred.

Preoperative Planning

Thorough preoperative preparation is critical for successful laparoscopic splenectomy. Key considerations include:

Imaging: Preoperative CT imaging is essential to assess spleen size, detect accessory splenic tissue, and evaluate surrounding anatomy. However, CT scans may not reliably identify accessory spleens, necessitating careful intraoperative exploration to prevent disease recurrence, particularly in ITP.
Hematologic Evaluation: Working with a hematologist is important for patients who have ITP or other blood disorders. Preoperative interventions, such as steroids, immunoglobulins, or platelet transfusions, may be necessary to make the surgical conditions the best they can be.
Vaccinations: Patients should receive vaccinations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae at least 14 days before elective splenectomy or 14 days after emergency splenectomy to mitigate the risk of overwhelming postsplenectomy infection (OPSI).

Surgical Technique

Patient Positioning

The patient is typically positioned in a right lateral decubitus position (60-degree tilt) or supine position, depending on surgeon preference and patient anatomy. The lateral position allows gravity to retract surrounding organs, providing optimal exposure of the spleen. The kidney rest is elevated to maximize the space between the iliac crest and costal margin, and the patient is tilted in a reverse Trendelenburg position to facilitate retraction of the viscera away from the left upper quadrant.

Trocar Placement

Pneumoperitoneum is established using a Veress needle or open (Hasson) technique, with an initial trocar placed medial to the left anterior axillary line, 2-3 cm below the costal margin.
Three to four additional ports are placed, including a 10-12 mm port for the camera and working ports for instruments such as graspers, ultrasonic scalpels, and linear staplers.

Steps of the Procedure

Exploration: A thorough exploration of the abdominal cavity is performed to identify and remove any accessory splenic tissue.
Mobilization: The spleen is mobilized by dividing the splenocolic, gastrosplenic, and phrenosplenic ligaments. Care is taken to avoid injury to the greater curvature of the stomach during dissection of the short gastric vessels.
Hilar Dissection: The splenic artery and vein are carefully dissected and divided using a linear stapler or energy device. In cases of splenomegaly, early control of the splenic artery may facilitate mobilization.
Specimen Removal: The spleen is placed in a retrieval bag and extracted through one of the port sites, which may be extended if necessary.

Advantages of Laparoscopic Splenectomy

Reduced blood loss: Minimally invasive techniques result in less intraoperative bleeding.
Shorter hospital stay: Patients typically recover faster and are discharged sooner compared to open surgery.
Faster recovery: Patients experience less postoperative pain and resume normal activities more quickly.

Complications

While laparoscopic splenectomy is generally safe, potential complications include:

Intraoperative bleeding: The most common reason for conversion to open surgery, particularly in cases of massive splenomegaly or prohibitive adhesions.
Pancreatic injury: Unrecognized injury to the pancreatic tail during hilar dissection may lead to pancreatic leak or fistula, requiring percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.
Thromboembolism: Postsplenectomy thrombocytosis, particularly in patients with myeloproliferative disorders, increases the risk of splenic, mesenteric, and portal vein thrombosis. Management typically involves systemic anticoagulation, with an increasing role for interventional radiology in severe cases.
Gastric perforation: Inadvertent injury to the greater curvature of the stomach during dissection of the short gastric vessels may necessitate reoperation.

Postoperative Care

Monitoring: Patients should be closely monitored for signs of bleeding, infection, or thromboembolism.
Pain Management: Minimally invasive techniques reduce postoperative pain, but analgesics may still be required.
Immunization: Ensure patients receive all recommended vaccines, including pneumococcal, meningococcal, and Haemophilus influenzae vaccines, to prevent OPSI.
Antibiotic Prophylaxis: Lifelong antibiotic prophylaxis may be indicated for high-risk patients, such as children or immunocompromised individuals.

Special Considerations

Portal Hypertension: Laparoscopic splenectomy can be performed in select patients with portal hypertension using advanced techniques and energy devices.
Pregnancy: Laparoscopic splenectomy is generally safe during the second trimester for refractory ITP. The first trimester is associated with fetal loss, and the third trimester is technically challenging due to loss of operative domain.
Massive Splenomegaly: Hand-assisted laparoscopic techniques or open splenectomy may be required for very large spleens (craniocaudal dimension >22 cm or weight >1600 g).

Long-Term Risks of laparoscopic splenectomy

Thrombocytosis: Patients with myeloproliferative disorders are at higher risk for thromboembolic events, including mesenteric, portal, and renal vein thrombosis.
OPSI: Lifelong vigilance is required to prevent overwhelming postsplenectomy infection, particularly in high-risk groups such as children and patients with thalassemia or sickle cell disease. The mortality rate for OPSI is 40-50%, emphasizing the importance of patient education and vaccination.

Conclusion

Laparoscopic splenectomy is a safe and effective procedure for most splenic diseases, offering significant advantages over open surgery. Careful preoperative planning, adherence to surgical techniques, and comprehensive postoperative care are essential for optimal outcomes. Surgeons should remain vigilant for potential complications and ensure patients receive appropriate vaccinations and follow-up care to mitigate long-term risks.