Since the first laparoscopic splenectomy (excision of the spleen) was reported in 1992, laparoscopic splenectomy has been performed for a variety of indications including: immune thrombocytopenia, hemolytic anemia, lymphoma, and splenic artery aneurysm. However, marked enlargement of the spleen, and uncontrolled bleeding disposition are contraindications to laparoscopic surgery.
The operation is performed from a flank approach using four 10-mm ports. After routine exploration to exclude accessory spleens, the splenic hilar vessels and short gastric vessels are isolated and divided. The proximal splenic artery is also ligated or stapled. After the spleen is freed, it is morcellated in an entrapment sac. The fragmented specimen is removed from the abdominal cavity.
A liquid diet is begun the night of or the morning after surgery if there is no anesthetic-related nausea, and the diet is advanced as tolerated. On average, patients resume a regular diet and are discharged from the hospital by the second postoperative day. Within two weeks of the operation patients are usually able to return to work. If the splenectomy is performed on a patient with a deficiency in the number of any of the cellular blood elements that has been managed preoperatively with short-term corticosteroid therapy, and there is satisfactory normalization of cell counts postoperatively, the steroid dosages can be tapered rapidly and then discontinued.
Intraoperative complications of laparoscopic splenectomy include uncontrollable bleeding that necessitates conversion to an open surgical procedure and injury to regional organs during dissection. A recent review of the literature suggests conversion rates for intraoperative bleeding in the 0-19 percent range. In these published reports, conversion to an open procedure was more likely with larger spleens (>500 g). Delayed postoperative complications include minor wound infections and postoperative ileus. Recurrent or persistent decrease in the number of blood platelets can be seen in patients with ITP and may be caused by accessory splenic tissue not recognized or removed at the time of splenectomy. However, most patients with persistently low platelet counts represent as failure of splenectomy to control the disease. These patients are said to have chronic ITP. As with open operation, laparoscopic splenectomy is curative in about 50-60 percent of patients, improves another 20-35 percent, and fails to help 5-10 percent of patients.
One other potential postoperative complication of splenectomy, open or laparoscopic is; overwhelming infection by bacteria. Measures that can reduce the risk of postsplenectomy infection include preoperative administration of polyvalent Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis vaccine, penicillin prophylaxis for all subsequent invasive procedures, early initiation with antibiotic therapy for documented infection, and provision of a medical alert identification tag.
As laparoscopic splenectomy is a relatively new procedure, there is limited outcome analysis data available for review. Published data suggests that laparoscopic splenectomy is a somewhat longer operation than an open splenectomy with operating times averaging two to three hours. However, more recent studies by experienced surgeons report operative time comparable to open surgery if; the spleen is normal size or slightly enlarged. Since medically stable patients who undergo uncomplicated laparoscopic splenectomy may be discharged from the hospital setting on the first postoperative day, there is the potential for significant cost savings that may offset the increased expense of longer operative procedures. Economic benefits also may be derived from the patient's more rapid return to full activity and employment postoperatively.
Splenectomy is rapidly becoming accepted as the procedure of choice for ITP, hereditary spherocytosis, and other benign disorders of the spleen. It is also increasingly applied to treatment of hematologic malignancies. Technical advances include improvements in extraction techniques, better methods of identifying accessory spleens intraoperatively, and the application of advanced laparoscopic suturing methods that may render laparoscopic splenorrhaphy (repair of injured spleen) or partial splenectomy possible.
