Background
The spleen, originally called the organum plenum mysterii by Galen, has long been an important organ for surgeons. The first splenectomy was performed by Andirano Zaccarello in 1549 on a young woman with an enlarged spleen who survived for 6 years after surgery. [1, 2] Traditionally, surgical removal of the spleen was done via an open approach using either an upper midline or left subcostal incision.
With the advent of minimally invasive techniques, laparoscopic splenectomy became a standard procedure for elective removal of the spleen for most indications. [3] Since the first report of laparoscopic splenectomy by Delaitre and Maignien in 1991, [4] it has been increasingly used; however, several technical challenges remain related to removing this fragile, well-vascularized organ that lies close to the stomach, colon, pancreas, and kidney.
Indications
Indications for laparoscopic splenectomy are the same as those for open splenectomy except when emergency splenectomy and exploratory laparotomy for traumatic injuries are needed. Laparoscopic splenectomy is indicated for various benign hematologic diseases, malignant hematologic diseases, secondary hypersplenism, and other anatomic disorders of the spleen.
The most common benign hematologic disease treated with laparoscopic splenectomy is immune thrombocytopenic purpura (ITP), and the procedure is recommended when medical therapy, including steroids and intravenous gammaglobulin, fails or long-term steroids are needed. Laparoscopic splenectomy can also be warranted in other benign conditions, including other types of thrombotic purpura, hereditary spherocytosis, major and intermediate thalassemia with secondary hypersplenism or severe anemia, sickle cell disease, and refractory autoimmune hemolytic anemia.
Laparoscopic splenectomy for malignant diseases of the spleen can be performed for diagnostic or therapeutic reasons. Indications include myeloproliferative disorders, lymphoproliferative diseases, hairy cell leukemia, Hodgkin and non-Hodgkin lymphoma, malignant vascular tumors, malignant lymphomas, and lymphangiosarcomas. [5]
Although the use of laparoscopic splenectomy in trauma has been reported, [6] its role has been limited because most hemodynamically stable patients with splenic injuries are successfully treated nonoperatively, and unstable patients require emergency laparotomy for control of hemorrhage and to evaluate possible associated traumatic injuries. However, there is growing evidence that it can be a feasible option in the trauma setting in appropriately selected patients. [7, 8]
Contraindications
Contraindications for laparoscopic splenectomy are similar to those for all laparoscopic surgical procedures. They include the inability to tolerate general anesthesia, uncontrollable coagulopathy, and the need for laparotomy for associated procedures.
Although reports on the safety of laparoscopic splenectomy in patients with cirrhosis and portal hypertension have been published, [9, 10, 11, 12, 13] many have considered the presence of these conditions to be an absolute contraindication for laparoscopic splenectomy. [5]
Massive splenomegaly has been regarded as a relative contraindication; however, the hand-assisted technique may facilitate removal of large spleens in a minimally invasive fashion. Good results are being reported for laparoscopic removal of very large spleens, and it has been suggested that with advances in laparoscopic technology and expertise, laparoscopic splenectomy may become the gold standard operation even for massive spleens and splenic malignancies. [14, 15, 16]
Technical Considerations
Anatomy
The spleen is an wedge-shaped organ that lies in relation to ribs 9 and 11, located in the left hypochondrium and partly in the epigastrium; thus, it is situated between the fundus of the stomach and the diaphragm. The spleen is highly vascular and reddish purple; its size and weight are variable. A normal spleen is not palpable. For more information about the relevant anatomy, see Spleen Anatomy.
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Laparoscopic splenectomy. Division of splenocolic ligament with clear visualization of pancreas.
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Laparoscopic splenectomy. Division of lateral attachments to spleen.
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Laparoscopic splenectomy. Continued mobilization and takedown of lateral attachments of spleen.
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Laparoscopic splenectomy. Medial dissection of spleen.
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Laparoscopic splenectomy. Division of short gastric vessels.
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Laparoscopic splenectomy. Division of short gastric vessels with use of endoscopic stapling device.
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Laparoscopic splenectomy. Ligation of splenic hilum.
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Laparoscopic splenectomy. Placement of spleen in retrievable sac.
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Laparoscopic splenectomy. Patient positioning for lateral approach with port placement.
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Laparoscopic splenectomy. Patient positioning for lateral approach.
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Laparoscopic splenectomy. Port placement for lateral approach.
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Laparoscopic splenectomy. Port positioning.
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Laparoscopic splenectomy. Port positioning for normal-sized spleen.
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Laparoscopic splenectomy. Accessory spleen found in splenocolic ligament.
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Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
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Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler. Blunt retractor is used to elevate spleen.
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Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
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Laparoscopic splenectomy. Blunt grasper used to mimic proposed staple line for transection of hilum.
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Laparoscopic splenectomy. Placing spleen in retrievable sac.
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Laparoscopic splenectomy. Pulling spleen up to 12-mm trocar site to allow morcellation and removal.
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Laparoscopic splenectomy. Patient positioning and port/hand placement for hand-assisted technique.
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Laparoscopic splenectomy. Technique of hand-assisted technique.
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Laparoscopic splenectomy. Port and hand placement for hand-assisted approach for enlarged spleen.
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Hand-assisted laparoscopic splenectomy. Enlarged spleen may be removed in total from hand-assist incision.
