LAPAROSCOPIC

LAPAROSCOPIC SPLENECTOMY
SPLENECTOMY
 INDICATIONS
Thrombocytopenia
1.Idiopathic Thrombocytopenic Purpura
a. Adults: if a trial of glucocorticoid therapy fails to
produce a persistent improvement in platlet count.
b. Children : if there are important consequences of
abnormal bleeding (ie. Intracranial hemorrhage)
2.Thrombotic Thrombocytopenic Purpura
The role for splenectomy in TTP is currently
unclear. It may have a role in those resistant to
plasmapheresis
Anemias
1.Erythrocyte Structural abnormalities
a. Hereditary Spherocytosis- splenectomy at 6
to 8 yrs of age.
b. Hereditary Eliptocytosis- if have symptoms
of severe anemia.
c. Hereditary Pyropoikilocytosis- if severe,
usually required as a child.
 C. Hypersplenism
(Most of these patients will have splenomegaly, and will
not be candidates for laparoscopic splenectomy. Although
no size guidelines exist, we have had limited success with
spleens over 18 to 20 cm in the long axis, and recommend
open splenectomy in these patients.)
1. Primary Hypersplenism
2. Secondary Hypersplenism
a. Splenic Vein Thrombosis
b. Gaucher Disease
c. Felty Syndrome
d. SLE

In general, indications remain same as for Conventional surgery

D. Malignancy
Malignancy often confers splenomegaly, which increases
the need for an open procedure. Although no real
guidelines exist, laparoscopic splenectomy is not
recommended for moderate and large sized spleens, as
discussed for hypersplenism.
1. Hairy Cell Leukemia
2. Chronic Myelogenous Leukemia
Justified for compressive symptoms, or sequestration
of cellular elements.
3. Chronic Lymphocytic Leukemia
For splenomegaly
4. Primary Splenic Tumors
 CONTRAINDICATIONS
A. Spleen Size - No real consensus on exactly what is too
large. Large spleens decrease the likelihood of successful
laparoscopic removal. Borderline sized spleens can be
attempted, if the dissection is successful, often placement
in the removal bag can be difficult. If this occurs a small
incision is made to avoid intra-abdominal fracture.

B. Physiologic Limitations - Those who cannot tolerate

operation, or have uncorrectable severe bleeding
dyscrasias.
 Pre operative
• Vaccination
• Optimise Blood parameters
• Arrange for blood components like for ITP
 Position
• Modified Lithotomy ( Semi frog leg )
• Right Lateral

• Position : Surgeon preference

• We use the second position
 Mod. Lithotomy
• Liver retraction necessary ( Extra port )
• Can combine with cholecystectomy in
patients with congenital hemolytic anaemia
 Setup
• Right Lateral Position
• Monitor – Left side near Head End
• Surgeon – Right side
• 1st and 2nd Assistant – Right side
• Scrub nurse – Right side
 Modified Lithotomy
Disadvantage : Liver retraction necessitates an extra port

Advantage : Can combine with cholecystectomy without

change in position especially in patients with
Congenital Hemolytic Anaemia
 Patient Position
Reverse Trendelenburgh with Left side up
( Right tilt )
 Ports
• Camera ( 10 mm ) – Midline Supraumbilical
• Right Hand Working ( 10 mm ) – Left
Midclavicular
• Left Hand Working ( 5 mm ) – Midline
Epigastric
• Retractor ( 10 mm ) – Midline Subxyphoid
 Determination of Port Position
• Preoperatively confirm Spleen size
• Exact port position depends on patient habitus
and Spleen size
• In general, Smaller the Speen – Ports tend to be
closer to the costal margin like ITP
 Instruments ( 10 mm )
• 30 degree Telescope
• Fan Blade Retractor
• Babcock Forceps
• Clip Applicator
 Instruments ( 5 mm )
• Dissecting Forceps - Curved
• Atraumatic Forceps
• Neddle holder
• Scissor – Regular, Hook
• Suction / Irrigation
 Additional
• 10 mm Harmonic Scalpel
• 10 mm Ligasure
• 12 mm Endoscopic Stapling device
• Retrieval Bag
 Technique
• Pneumoperitoneum – Veress
• Adequate distension
• First, Camera port
• Note findings
• Rest of the ports
 Technique
• Mobilise Splenic flexure of Colon inferiorly
• Divide Splenocolic ligament to mobilise
lower pole
• Divide Splenorenal attachment
 Technique
• Divide Gastrosplenic ligament
• Retract Stomach superiorly and to the right
with Babcock forceps
• Make a small opening in Gastrosplenic
ligament to enter the lesser sac
 Technique
• Continue division of the ligament superiorly
along the greater curvature to divide the
short gastric vessels by clipping and
cautery. We use Harmonic Scalpel
• Reposit the Babcock forceps frequently to
maintain visibility during the above step
 Technique
• Highest short gastric vessels will be best
visualised by gentle retraction of the spleen
• Some prefer Gastrosplenic ligament
division first followed by posterior
mobilisation of the Splenic attachments
 Technique – Vasculature
• Carefully dissect adipose tissue to visualise
Splenic vessels and Distal Pancreas
• Create a window around the Splenic artery
• Doubly ligate the artery with Silk before
division
• Similarly divide the vein
 Technique – Vasculature
• Look for branches especially to the upper
pole
• Also note the change in colour to confirm
the absence of branches
• Usually the upper pole has a separate
branch
 Technique – Vasculature
• Another method of division is Endoscopic
Linear Stapling device passed through a left
lateral port.
• Stapler is passed cephalad along the left
colic gutter so as to lie perpendicular to the
vein
• NEVER Open the device repositioning
without firing as this may tear the vein
• Another option is Ligasure
 Technique
• Divide the posterior attachments of the
upper pole using Stapler, Cautery or
Harmonic
• Check for Haemostasis
 Extraction
• Extend Right hand working port incision
• Supraumbilical Midline Minilaparotomy
incision
• Pfannensteil incision
 Extraction
• Retrieval Bag
• Extend incision
• Morcellize Spleen using Kocher’s clamp
• Remove Spleen in pieces, suctioning blood
from bag as needed
• Take care not to damage the bag
• This may be a time consuming process so
be patient
 Closure & Drainage
• Approximate defect with 1-0 prolene suture
• Re-insert the Right hand working port with
clamp on the skin incision to prevent leak
• Haemostasis confirmed
• Wash given
• Large bore drain through left axillary line –
fix drain immediately
 Closure
• Abdomen deflated
• Close all ports
• Approximate linea in midline ports
• Subcuticular sutures
 Post operative orders
• Nil orally until patient passes flatus
• Peri-operative Antibiotic cover
• Analgesic ( Routine – Diclofenac suppository )
• IVF
• Monitor Drain output
 Complications
• Basal Atelectasis is less common as
compared to Open Surgery
• Bleeding
• Wound Infection
• OPSI
 Special Precautions
• Optimise Blood parameters pre-operatively
• Excellent visualisation of vessels
• We suggest suture ligation of vessels
• Haemorrhage is common reason for
conversion
• Gentle retraction of Spleen
• Look for Splenenculi
Thank You