Laparoscopic Splenectomy

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Laparoscopic splenectomy was first reported in the 1990s and quickly became the preferred method for splenectomy as well as for the management of other splenic disorders such as splenic cysts and wandering spleen. Laparoscopic partial splenectomy (LPS) has also been utilized in children with heredity spherocytosis (HS) and sickle cell disease (SCD). The main advantages of laparoscopic splenectomy include less pain, shorter length of hospitalization, faster return to regular activities, and smaller scars. In the early comparative series from the 1990s and 2000s, laparoscopic splenectomy was associated with a longer operative time compared with open splenectomy. However, in the current era, laparoscopic splenectomies can often be performed faster than the historic open times. Alternatively, the laparoscopic technique can be associated with difficulty in patients with marked splenomegaly. The primary advances in splenectomy have been related to smaller instrumentation and the development of advanced energy devices. Although concern has been raised about the detection of accessory spleens, comparison studies have demonstrated similar rates of detection between the laparoscopic and open approaches.

Indications for Workup and Operation

Splenectomy in children is most frequently required for HS, idiopathic thrombocytopenic purpura (ITP), and SCD with splenomegaly and splenic sequestration.

Hereditary Spherocytosis

Hereditary spherocytosis affects approximately 1 in 3000 Caucasian individuals. Total splenectomy alleviates hemolysis in this condition. However, potential postoperative complications include an increased incidence of postsplenectomy sepsis and future thrombotic events. To decrease these complications, some hematologists have advocated for partial splenectomy in children with HS, particularly in younger children with HS. The role of partial splenectomy is to remove approximately 85% to 90% of the splenic tissue. A large multicenter trial evaluating partial splenectomy demonstrated that this procedure is effective in improving the hemoglobin level. However, the postoperative rise in hemoglobin was not as great as with total splenectomy. In addition, regrowth of the residual tissue occurs in most children, and for some, this requires subsequent total splenectomy.

In general, children with HS should undergo an ultrasound to evaluate for associated gallstones. If gallstones are present, a laparoscopic cholecystectomy is typically performed at the same time. In our center, we have found that children younger than 10 years of age with HS have a 27% incidence of gallstones, compared to 56% in the group older than 10 years of age.

Idiopathic Thrombocytopenic Purpura

The management of ITP includes steroids as a typical first-line agent, but numerous other therapeutic strategies are now available including intravenous immunoglobulin, rituximab (monoclonal antibody against CD20-positive B cells), and thrombopoietic agents such as romiplostim. Other therapeutic agents include azathioprine, cyclophosphamide, danazol, and mycophenolate mofetil. In ITP, it is essential to evaluate for accessory spleens thoroughly as this can be a cause of recurrent ITP.

Sickle Cell Disease

Sickle cell disease results from an amino acid substitution of the β chain of normal hemoglobin AA, resulting in hemoglobin S. Children may be homozygous (sickle cell disease) or have less severe heterozygous types (such as sickle C or sickle thalassemia). These red blood cells are rigid and lead to splenic sequestration when they pass through the spleen. Severe sequestration can lead to anemia, splenomegaly, and thrombocytopenia, known as an acute splenic sequestration crisis. In general, the development of one crisis at a young age usually leads to splenectomy. Preoperative preparation with a hemoglobin of at least 10 g/dL is generally recommended.

Other Preoperative Considerations

Massive splenomegaly can be a relative contraindication to the laparoscopic approach for splenectomy. The Endo Catch II 15-mm retrieval bag (Covidien, Mansfield, MA) is 23 cm in depth, allowing removal of nearly all pediatric spleens. If splenosis from an intraperitoneal spill is not a concern, a large spleen can be divided and removed in two pieces. Importantly, all children should be appropriately immunized preoperatively.

Operative Technique

General endotracheal anesthesia is administered with the child in the supine position. An orogastric tube is inserted, which is removed at the end of the procedure. The child is placed on the operating table with the left side bumped up approximately 45 degrees. A small roll or raised kidney rest placed under the left flank helps to increase the distance between the left iliac crest and the 12th rib ( Fig. 17-1 ). The table is tilted to the patient’s left side to obtain a near-supine position for port placement and then is rotated to the right to achieve a right lateral decubitus position for the operation ( Fig. 17-2 ). The surgeon stands on the right side of the patient, with the surgical assistant cephalad. The monitor is situated over the patient’s left abdomen, with the spleen between the surgeon and monitor ( Fig. 17-3A ).

Access is initiated with an open 15-mm vertical umbilical incision. A small umbilical fascial defect is usually present, allowing introduction of a hemostat to help enlarge the fascial incision. A 15-mm cannula (chosen because of the 15-mm size of the retrieval bag) is inserted, and pneumoperitoneum is created to 12 to 15 mm Hg with a CO ₂ flow of 6 to 15 L/min. A 15-mm cannula is quite large for a small child. However, we have generally placed it easily with a vertical incision through the umbilical base, often with division of the inferior umbilical ring. If the spleen is small, a 12-mm port can be placed for use with the 10-mm endoscopic bag (Endopouch, Ethicon Endosurgery Inc., Cincinnati, OH). We always place at least a 12-mm cannula in case a stapling device must be urgently introduced.

Diagnostic laparoscopy is performed with a 5-mm, 30-degree angled telescope using the 5-mm reducer attachment to the cannula. Three additional incisions are then created. A 5-mm port is placed in the left lower quadrant (LLQ) for insertion of the energy device such as the Harmonic Scalpel (Ethicon Endosurgery Inc., Cincinnati, OH), Ligasure (Medtronic, Minneapolis, MN), Enseal (Ethicon Endosurgery Inc., Cincinnati, OH), or another 5-mm energy device. The telescope and camera are inserted through this port at the time of specimen removal through the umbilical incision. Two additional incisions are created in the midline, one just below the xiphoid process and the other midway between the xiphoid and the umbilicus ( Fig. 17-3B ). Because the instruments at these sites are not exchanged during the procedure, they may be inserted through small stab incisions without the use of a cannula. In children younger than 5 years and in older patients with small spleens, 3-mm instruments can be used at these sites. In patients with large spleens, usually one of these epigastric sites will need 5-mm instruments to provide adequate splenic elevation and retraction. If a concomitant cholecystectomy is needed, an additional incision is created on the patient’s right flank for traction of the gallbladder. We usually use a MiniLap/MiniGrip Alligator Grasper (Teleflex Medical, Wayne, PA) through a 2-mm incision at this site. In this instance, the lower midline port is shifted to the right for use by the surgeon during the cholecystectomy.

For the splenectomy, the operating surgeon holds the camera in the left hand and the energy device in the right. The first assistant uses instruments inserted through the upper abdominal sites to provide elevation to the spleen and traction on surrounding structures ( Fig. 17-4A ). The table is rotated to the patient’s right to achieve a right lateral decubitus position, leaving the spleen “hanging” in the left upper quadrant. Accessory spleens in the omentum, the gastrosplenic ligament, or other sites can usually be removed through the umbilical port using the energy device to divide its vasculature.