Equipment

A standard laparoscopic tray is used for a laparoscopic splenectomy, including laparoscopic scissors and atraumatic graspers.

Telescopes, including a 30° or 45° 5- or 10-mm laparoscope, are used, depending on the surgeon’s preference and need for visualization.

Three or four trocars are usually needed; one trocar should be a 12-mm port that can be used for laparoscopic stapler introduction and specimen removal.

Electrosurgical devices such as an electrothermal bipolar sealing device (Ligasure; Covidien, Mansfield, MA) or ultrasonic coagulation shears (Harmonic; Ethicon Endo-Surgery, Cincinnati, OH) can be used to assist with splenic mobilization and dissection.

Typically, the splenic hilar vasculature is divided by using an endoscopic stapling device with a vascular load; however, reports have described the safety and efficacy of the electrothermal bipolar sealing device.^{[19, 20, 21, 22]}

An impervious retrieval bag is needed for morcellation and removal of the specimen. Usually, sacs made from ripcord nylon are used because materials such as polyurethane are vulnerable to perforation.

Special items such as a suction/irrigator and fan or snake retractors for elevation of the spleen are sometimes needed; however, this is left to the discretion of the surgeon.

Ring forceps are useful for morcellating the spleen in the retrieval sac.

Anesthesia

General anesthesia is required for laparoscopic splenectomy. Adjuncts for pain management are left to the discretion of the surgeon and anesthesiologist.

Positioning

There are two major approaches to laparoscopic splenectomy: lateral and anterior.

Lateral approach

For the lateral or semilateral approach, the patient is positioned in the right lateral decubitus position at an angle of approximately 45-90° (see the images below).

Laparoscopic splenectomy. Patient positioning for lateral approach with port placement.

View Media Gallery

Laparoscopic splenectomy. Patient positioning for lateral approach.

View Media Gallery

Positioning and stabilization of the patient are facilitated by the use of a beanbag mattress, though various rolls and pads may be used. The patient is positioned with the umbilicus at or near the break in the table. This allows more distance between the lower ribs and iliac crest when the table is flexed and the bolster/kidney rest is elevated. All pressure points must be adequately padded. The surgeon and camera operator stand on the patient's right side, with the video monitors above and lateral to the patient’s left shoulder (see the image below).

Laparoscopic splenectomy. Port placement for lateral approach.

View Media Gallery

Anterior approach

For the less frequently used anterior approach, the patient is placed supine in the modified lithotomy position; this allows the surgeon to operate while standing between the patient’s legs or on the right side of the patient.

Technique

Coon WW. The spleen and splenectomy. Surg Gynecol Obstet. 1991 Nov. 173 (5):407-14. [QxMD MEDLINE Link].
Uranues S, Alimoglu O. Laparoscopic surgery of the spleen. Surg Clin North Am. 2005 Feb. 85 (1):75-90, ix. [QxMD MEDLINE Link].
Misiakos EP, Bagias G, Liakakos T, Machairas A. Laparoscopic splenectomy: Current concepts. World J Gastrointest Endosc. 2017 Sep 16. 9 (9):428-437. [QxMD MEDLINE Link]. [Full Text].
Delaitre B, Maignien B. [Splenectomy by the laparoscopic approach. Report of a case]. Presse Med. 1991 Dec 21-28. 20 (44):2263. [QxMD MEDLINE Link].
[Guideline] Habermalz B, Sauerland S, Decker G, Delaitre B, Gigot JF, Leandros E, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2008 Apr. 22 (4):821-48. [QxMD MEDLINE Link].
Huscher CG, Mingoli A, Sgarzini G, Brachini G, Ponzano C, Di Paola M, et al. Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients. Surg Endosc. 2006 Sep. 20 (9):1423-6. [QxMD MEDLINE Link].
Deng Y, Zhang X, Li A, Zhao Y, Ye L. Effects of laparoscopic splenectomy on surgical site wound infection in patients with spleen rupture: A meta-analysis. Int Wound J. 2023 Oct 23. [QxMD MEDLINE Link].
Shamim AA, Zafar SN, Nizam W, Zeineddin A, Ortega G, Fullum TM, et al. Laparoscopic Splenectomy for Trauma. JSLS. 2018 Oct-Dec. 22 (4):[QxMD MEDLINE Link]. [Full Text].
Fransvea P, Costa G, Serao A, Cortese F, Balducci G, Sganga G, et al. Laparoscopic splenectomy after trauma: Who, when and how. A systematic review. J Minim Access Surg. 2021 Apr-Jun. 17 (2):141-146. [QxMD MEDLINE Link].
Hao X, Dai K, He Y, Tao L, Yu H. Laparoscopic splenectomy via the spleen bed in combination with selective esophagogastric devascularization for patients with cirrhotic portal hypertension: a single-institution experience. Wideochir Inne Tech Maloinwazyjne. 2020 Sep. 15 (3):462-468. [QxMD MEDLINE Link]. [Full Text].
Zhu JH, Wang YD, Ye ZY, Zhao T, Zhu YW, Xie ZJ, et al. Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Surg Laparosc Endosc Percutan Tech. 2009 Jun. 19 (3):258-62. [QxMD MEDLINE Link].
Wang Y, Zhan X, Zhu Y, Xie Z, Zhu J, Ye Z. Laparoscopic splenectomy in portal hypertension: a single-surgeon 13-year experience. Surg Endosc. 2010 May. 24 (5):1164-9. [QxMD MEDLINE Link].
Cobb WS, Heniford BT, Burns JM, Carbonell AM, Matthews BD, Kercher KW. Cirrhosis is not a contraindication to laparoscopic surgery. Surg Endosc. 2005 Mar. 19 (3):418-23. [QxMD MEDLINE Link].
Kawanaka H, Akahoshi T, Kinjo N, Harimoto N, Itoh S, Tsutsumi N, et al. Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension. J Am Coll Surg. 2015 Aug. 221 (2):354-66. [QxMD MEDLINE Link].
Somasundaram SK, Massey L, Gooch D, Reed J, Menzies D. Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens. Ann R Coll Surg Engl. 2015 Jul. 97 (5):345-8. [QxMD MEDLINE Link].
Tsamalaidze L, Stauffer JA, Permenter SL, Asbun HJ. Laparoscopic Splenectomy for Massive Splenomegaly: Does Size Matter?. J Laparoendosc Adv Surg Tech A. 2017 Oct. 27 (10):1009-1014. [QxMD MEDLINE Link].
Casaccia M, Sormani MP, Palombo D, Dellepiane C, Ibatici A. Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines?. Surg Laparosc Endosc Percutan Tech. 2019 Jun. 29 (3):178-181. [QxMD MEDLINE Link].
Li Y, Wang C, Chen W, Chen C, Tang X, Wang H, et al. Selection of surgical modality for massive splenomegaly in children. Surg Endosc. 2023 Oct 5. [QxMD MEDLINE Link].
Misawa T, Yoshida K, Iida T, Sakamoto T, Gocho T, Hirohara S, et al. Minimizing intraoperative bleeding using a vessel-sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy. J Hepatobiliary Pancreat Surg. 2009. 16 (6):786-91. [QxMD MEDLINE Link].
Canda AE, Ozsoy Y, Yuksel S. Laparoscopic splenectomy using LigaSure in benign hematologic diseases. Surg Laparosc Endosc Percutan Tech. 2009 Feb. 19 (1):69-71. [QxMD MEDLINE Link].
Romano F, Gelmini R, Caprotti R, Andreotti A, Guaglio M, Franzoni C, et al. Laparoscopic splenectomy: ligasure versus EndoGIA: a comparative study. J Laparoendosc Adv Surg Tech A. 2007 Dec. 17 (6):763-7. [QxMD MEDLINE Link].
Gelmini R, Romano F, Quaranta N, Caprotti R, Tazzioli G, Colombo G, et al. Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device. Surg Endosc. 2006 Jun. 20 (6):991-4. [QxMD MEDLINE Link].
Mortelé KJ, Mortelé B, Silverman SG. CT features of the accessory spleen. AJR Am J Roentgenol. 2004 Dec. 183 (6):1653-7. [QxMD MEDLINE Link].
Park AE, Birgisson G, Mastrangelo MJ, Marcaccio MJ, Witzke DB. Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases. Surgery. 2000 Oct. 128 (4):660-7. [QxMD MEDLINE Link].
Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Poulin EC. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). Surg Endosc. 2003 Jan. 17 (1):95-8. [QxMD MEDLINE Link].
Wang KX, Hu SY, Zhang GY, Chen B, Zhang HF. Hand-assisted laparoscopic splenectomy for splenomegaly: a comparative study with conventional laparoscopic splenectomy. Chin Med J (Engl). 2007 Jan 5. 120 (1):41-5. [QxMD MEDLINE Link].
Han ES, You YK, Kim DG, Lee JS, Kim EY, Lee SH, et al. Clinical significance of single-port laparoscopic splenectomy: comparison of single-port and multiport laparoscopic procedure. Ann Surg Treat Res. 2015 Aug. 89 (2):55-60. [QxMD MEDLINE Link].
Barbaros U, Aksakal N, Tukenmez M, Agcaoglu O, Bostan MS, Kilic B, et al. Comparison of single port and three port laparoscopic splenectomy in patients with immune thrombocytopenic purpura: Clinical comparative study. J Minim Access Surg. 2015 Jul-Sep. 11 (3):172-6. [QxMD MEDLINE Link].
Wang C, Su C, Chen C, Tang X, Wang H, Li W, et al. Single-incision laparoscopic splenectomy in children with massive splenomegaly: A prospective, monocentric pilot study. Front Pediatr. 2022. 10:1097416. [QxMD MEDLINE Link]. [Full Text].
Wu S, Lai H, Zhao J, Deng X, Wei J, Liang J, et al. Systematic review and meta-analysis of single-incision versus conventional multiport laparoscopic splenectomy. J Minim Access Surg. 2018 Jan-Mar. 14 (1):1-8. [QxMD MEDLINE Link]. [Full Text].
Bai DS, Jin SJ, Xiang XX, Qian JJ, Zhang C, Zhou BH, et al. Robotic-assisted versus laparoscopic approach of Bai-Jiang-style vagus nerve-preserving splenectomy and azygoportal disconnection. Updates Surg. 2022 Oct. 74 (5):1773-1780. [QxMD MEDLINE Link].
Baz C, Pozza G, Di Pangrazio M, Toti F, Dreifuss NH, Cubisino A, et al. Robotic surgery: extending the minimally invasive approach in patients with splenomegaly. A case report. J Surg Case Rep. 2023 Jun. 2023 (6):rjad325. [QxMD MEDLINE Link]. [Full Text].
Xing D, Li P, Yang Y, Yao J. Retrospective assessment of the clinical efficacy of laparoscopic partial splenectomy. Exp Ther Med. 2023 May. 25 (5):210. [QxMD MEDLINE Link]. [Full Text].
Babala J, Pini Prato A, Zahradnikova P, Beder I. Minimally Invasive Partial Spleen Resection Preserving the Lower Pole in Children: A Technical Report on Feasibility and Safety. J Laparoendosc Adv Surg Tech A. 2021 Nov 9. [QxMD MEDLINE Link].
Makansi M, Hutter M, Theilen TM, Fiegel HC, Rolle U, Gfroerer S. Comparison of perioperative outcomes between laparoscopic and open partial splenectomy in children and adolescents. World J Gastrointest Surg. 2021 Sep 27. 13 (9):979-987. [QxMD MEDLINE Link]. [Full Text].
Schaarschmidt K, Kolberg-Schwerdt A, Lempe M, Saxena A. Ultrasonic shear coagulation of main hilar vessels: A 4-year experience of 23 pediatric laparoscopic splenectomies without staples. J Pediatr Surg. 2002 Apr. 37 (4):614-6. [QxMD MEDLINE Link].
Rosen M, Brody F, Walsh RM, Ponsky J. Hand-assisted laparoscopic splenectomy vs conventional laparoscopic splenectomy in cases of splenomegaly. Arch Surg. 2002 Dec. 137 (12):1348-52. [QxMD MEDLINE Link].
Kercher KW, Matthews BD, Walsh RM, Sing RF, Backus CL, Heniford BT. Laparoscopic splenectomy for massive splenomegaly. Am J Surg. 2002 Feb. 183 (2):192-6. [QxMD MEDLINE Link].
Kaban GK, Czerniach DR, Cohen R, Novitsky YW, Yood SM, Perugini RA, et al. Hand-assisted laparoscopic splenectomy in the setting of splenomegaly. Surg Endosc. 2004 Sep. 18 (9):1340-3. [QxMD MEDLINE Link].
Glasgow RE, Mulvihill SJ. Laparoscopic splenectomy. World J Surg. 1999 Apr. 23 (4):384-8. [QxMD MEDLINE Link].
Brodsky JA, Brody FJ, Walsh RM, Malm JA, Ponsky JL. Laparoscopic splenectomy. Surg Endosc. 2002 May. 16 (5):851-4. [QxMD MEDLINE Link].
Targarona EM, Espert JJ, Bombuy E, Vidal O, Cerdán G, Artigas V, et al. Complications of laparoscopic splenectomy. Arch Surg. 2000 Oct. 135 (10):1137-40. [QxMD MEDLINE Link].
Kercher KW, Novitsky YW, Czerniach DR, Litwin DE. Staple line bleeding following laparoscopic splenectomy: intraoperative prevention and postoperative management with splenic artery embolization. Surg Laparosc Endosc Percutan Tech. 2003 Oct. 13 (5):353-6. [QxMD MEDLINE Link].
Legrand A, Bignon A, Borel M, Zerbib P, Langlois J, Chambon JP, et al. [Perioperative management of asplenic patients]. Ann Fr Anesth Reanim. 2005 Jul. 24 (7):807-13. [QxMD MEDLINE Link].
Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ. 1996 Feb 17. 312 (7028):430-4. [QxMD MEDLINE Link].
Stanek A, Stefaniak T, Makarewicz W, Kaska L, Podgórczyk H, Hellman A, et al. Accessory spleens: preoperative diagnostics limitations and operational strategy in laparoscopic approach to splenectomy in idiopathic thrombocytopenic purpura patients. Langenbecks Arch Surg. 2005 Feb. 390 (1):47-51. [QxMD MEDLINE Link].
Gigot JF, Jamar F, Ferrant A, van Beers BE, Lengele B, Pauwels S, et al. Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases. Surg Endosc. 1998 Feb. 12 (2):101-6. [QxMD MEDLINE Link].
Katkhouda N, Manhas S, Umbach TW, Kaiser AM. Laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A. 2001 Dec. 11 (6):383-90. [QxMD MEDLINE Link].
Velanovich V, Shurafa M. Laparoscopic excision of accessory spleen. Am J Surg. 2000 Jul. 180 (1):62-4. [QxMD MEDLINE Link].
Rattner DW, Ellman L, Warshaw AL. Portal vein thrombosis after elective splenectomy. An underappreciated, potentially lethal syndrome. Arch Surg. 1993 May. 128 (5):565-9; discussion 569-70. [QxMD MEDLINE Link].
Harris W, Marcaccio M. Incidence of portal vein thrombosis after laparoscopic splenectomy. Can J Surg. 2005 Oct. 48 (5):352-4. [QxMD MEDLINE Link].
Romano F, Caprotti R, Conti M, Piacentini MG, Uggeri F, Motta V, et al. Thrombosis of the splenoportal axis after splenectomy. Langenbecks Arch Surg. 2006 Sep. 391 (5):483-8. [QxMD MEDLINE Link].
Huang D, Tao M, Cao L, Wang X, Zheng S, Cao Y. Risk Factors and Anticoagulation Effects of Portal Vein System Thrombosis After Laparoscopic Splenectomy in Patients With or Without Cirrhosis. Surg Laparosc Endosc Percutan Tech. 2019 Dec. 29 (6):498-502. [QxMD MEDLINE Link].
de'Angelis N, Abdalla S, Lizzi V, Esposito F, Genova P, Roy L, et al. Incidence and predictors of portal and splenic vein thrombosis after pure laparoscopic splenectomy. Surgery. 2017 Dec. 162 (6):1219-1230. [QxMD MEDLINE Link].
Swinson B, Waters PS, Webber L, Nathanson L, Cavallucci DJ, O'Rourke N, et al. Portal vein thrombosis following elective laparoscopic splenectomy: incidence and analysis of risk factors. Surg Endosc. 2022 May. 36 (5):3332-3339. [QxMD MEDLINE Link].
Wang D, Chen X, Lv L, Yang T, Huang B, Cao Y, et al. The Early Initiation of Perioperative Anticoagulation Therapy in Cirrhotic Patients with Portal Hypertension After Laparoscopic Splenectomy Plus Esophagogastric Devascularization: A 10-Year Single-Center Experience. J Laparoendosc Adv Surg Tech A. 2023 Oct 17. [QxMD MEDLINE Link].

Media Gallery

Laparoscopic splenectomy. Division of splenocolic ligament with clear visualization of pancreas.
Laparoscopic splenectomy. Division of lateral attachments to spleen.
Laparoscopic splenectomy. Continued mobilization and takedown of lateral attachments of spleen.
Laparoscopic splenectomy. Medial dissection of spleen.
Laparoscopic splenectomy. Division of short gastric vessels.
Laparoscopic splenectomy. Division of short gastric vessels with use of endoscopic stapling device.
Laparoscopic splenectomy. Ligation of splenic hilum.
Laparoscopic splenectomy. Placement of spleen in retrievable sac.
Laparoscopic splenectomy. Patient positioning for lateral approach with port placement.
Laparoscopic splenectomy. Patient positioning for lateral approach.
Laparoscopic splenectomy. Port placement for lateral approach.
Laparoscopic splenectomy. Port positioning.
Laparoscopic splenectomy. Port positioning for normal-sized spleen.
Laparoscopic splenectomy. Accessory spleen found in splenocolic ligament.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler. Blunt retractor is used to elevate spleen.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
Laparoscopic splenectomy. Blunt grasper used to mimic proposed staple line for transection of hilum.
Laparoscopic splenectomy. Placing spleen in retrievable sac.
Laparoscopic splenectomy. Pulling spleen up to 12-mm trocar site to allow morcellation and removal.
Laparoscopic splenectomy. Patient positioning and port/hand placement for hand-assisted technique.
Laparoscopic splenectomy. Technique of hand-assisted technique.
Laparoscopic splenectomy. Port and hand placement for hand-assisted approach for enlarged spleen.
Hand-assisted laparoscopic splenectomy. Enlarged spleen may be removed in total from hand-assist incision.

of 24

Author

William W Hope, MD Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center

William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cr bard, WL Gore, Intuitive Surgical<br/>Received research grant from: CR bard, WL Gore, Intuitive surgical, Allergan, Medtronic<br/>Received income in an amount equal to or greater than $250 from: CR Bard, WL Gore, Intuitive surgical, Medtronic, Allergan<br/>Received grant/research funds from CR Bard, WL Gore, Intuitive, Medtronic, and Allergan for consulting.

Coauthor(s)

Damon E Sheneman, DO Trauma Director, Valley Hospital, Spokane Valley, WA

Damon E Sheneman, DO is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Kent W Kercher, MD, FACS Clinical Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Chief of Minimal Access Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center

Kent W Kercher, MD, FACS is a member of the following medical societies: American Association of Endocrine Surgeons, American College of Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Ethicon Inc, Bard Inc<br/>Received honoraria from Ethicon Inc for speaking and teaching; Received honoraria from Davol Inc for speaking and teaching; Received honoraria from Cooper Surgical for speaking and teaching. for: Ethicon, Bard, Cooper Surgical.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors thank Cissy Swartz for her assistance with manuscript preparation and editing.