Laparoscopic Splenectomy Technique

In the performance of a laparoscopic splenectomy, it is essential always to be mindful that conversion to open surgery may be warranted, possibly on an emergency basis. To prepare for this possibility, when the patient is placed in the lateral position, a wide field should be prepared to allow access to the midline in the event that upper-midline or hand-assist access is needed. Also, it may be helpful to mark the skin two fingerbreadths below the left costal margin before insufflation, in the event that a left subcostal incision proves necessary.

Before splenic mobilization is initiated, diagnostic laparoscopy should be used to look for accessory spleens, which are present in 12-16% of patients and as many as 32% of patients with immune (idiopathic) thrombocytopenia purpura (ITP). ^{[23, 24, 25]} Accessory spleens are commonly found in the splenic hilum, along the splenic vessels, in the greater omentum, and in the splenorenal ligament. For large spleens and early in the experience of surgeons undertaking laparoscopic splenectomy, a hand-assisted technique may reduce conversion rates and operating time. ^[26]

Single-port approaches to laparoscopic splenectomy have been described that appear to be safe and effective, ^{[27, 28]} even in massive splenomegaly ^[29] ; however, it remains to be established whether they have clear and substantial advantages over conventional approaches. ^[30] Robotic-assisted techniques have also been described. ^{[31, 32]} These techniques will not be addressed further here.

There is increasing interest in performing partial splenectomy as a means of avoiding the consequences of total splenectomy and preserving the function of the organ. ^{[33, 34]} A study by Makansi et al found laparoscopic partial splenectomy to have perioperative outcomes comparable to those of the equivalent open procedure in children and adolescents. ^[35] Partial splenectomy also will not be addressed further in this article.

For the lateral approach, the operation begins with safe laparoscopic abdominal access. This can be accomplished with an open or a closed technique, in accordance with the skill, experience, and comfort level of the surgeon.

Although an open cutdown technique for the direct insertion of the first trocar is sometimes favored, an optical trocar technique with preinsufflation using a Veress needle can be quite useful, especially in patients who are obese. The use of the Veress needle is contraindicated in patients with massive splenomegaly or severe thrombocytopenia and in children because of the limited working space and risk of splenic injury and bleeding.

The first trocar, either a 5- or a 12-mm port, is usually placed in the midclavicular line 2-6 cm below the costal margin, depending on the size of the spleen. Preoperative imaging with computed tomography (CT) or ultrasonography (US) can facilitate operative planning by assessing splenic size, locating accessory spleens, and aiding in decisions regarding port placement and surgical technique (laparoscopic, hand-assisted, or open).

Subsequent trocars are placed after diagnostic laparoscopy; placement varies, depending on the patient’s body habitus and spleen size. All ports should be placed 3-4 cm below the inferior tip of the spleen to allow adequate working space for visualization and safe instrument exchange. A medial trocar is placed just off the midline/subxiphoid region in the left subcostal position. A third trocar is placed in the anterior axillary line in the left subcostal region. (See the images below.)

A fourth trocar (placed laterally off the tip of the 11th rib) is often needed and can assist greatly in manipulating large spleens. This trocar is inserted after mobilization of the splenic flexure and is placed lateral to the other ports. Trocar size can range from 5 to 12 mm, depending on the surgeon’s preference.

A 12-mm trocar is needed for extraction of the specimen and an endoscopic stapling device (if one is to be used to divide the splenic hilum). One potential strategy is to start with all 5-mm trocars and a 30° 5-mm laparoscope when visualization is satisfactory. After initial dissection and splenic mobilization, the port that gives the best angle for hilar ligation can be "upsized" to 12 mm for use of the endoscopic stapler. Alternatively, all ports may be 12 mm, allowing the use of of a 10-mm laparoscope and stapler that can be interchanged between ports.

These choices are surgeon-dependent and are made on the basis of the difficulty of the case and the surgeon’s experience.

Once the trocars have been placed, diagnostic laparoscopy is again performed to look for accessory spleens, which can be found in the hilum, omentum, mesocolon, or mesentery (see the image below).

Dissection for a laparoscopic splenectomy involves division of the splenocolic ligament, inferior pole vessels (splenorenal ligament), short gastric vessels (gastrosplenic ligament), and phrenic attachments (splenophrenic ligament), along with control and division of the splenic hilum. The order of this dissection varies according to the surgeon’s preference.

The authors' preference is to begin initial dissection with the patient in a steep reverse Trendelenburg position and to perform splenic flexure mobilization by dividing the splenocolic ligament (see the video below).

The splenorenal dissection and the division of lateral attachments to the spleen proceed along the entire craniocaudal length of the spleen, with care taken not to violate the Gerota fascia (see the videos below).

Although these planes are relatively avascular, the use of an energy source such as an ultrasonic coagulation shears or an electrothermal bipolar sealing device can aid in hemostasis. In the dissection of the splenocolic and splenorenal ligaments, it is important to leave a 1- to 2-cm remnant of the ligament, which will be used as a handle, and to avoid grasping the fragile splenic capsule (see the video below).

The spleen is rotated laterally, and the gastrosplenic ligament containing the short gastric vessels is carefully divided (see the videos below).

This dissection affords access to the lesser sac. When a difficult hilar dissection is anticipated, the splenic artery can be controlled here, proximal to the splenic hilum, along the superior border of the pancreas. If clips are used for control of the splenic vasculature, care should be taken in dividing the hilum with an endoscopic stapler because clips can interfere with staple firings and cause inadequate hemostasis.

After the gastrosplenic ligament and the short gastric vessels are divided, the spleen is elevated to expose the hilum. This can be done with fan retractors, snake retractors, or long atraumatic bowel graspers. In elevating the spleen, care should be taken not to injure the parenchyma and cause bleeding.

With elevation of the spleen, the hilum and the tail of the pancreas are usually visible. When the hilum is not adequately visualized, the splenophrenic ligament can be divided superiorly to facilitate splenic mobilization. After the splenic hilum and the tail of the pancreas are well visualized, an endoscopic stapler with a vascular load can be used for ligation and division of the splenic vasculature (see the video and images below).

One potentially helpful maneuver before staple firing is using an atraumatic bowel grasper to mimic the proposed staple transection line so as to ensure feasibility, appropriate angulation, and a suitable trajectory (see the image below).

Care should be taken to avoid injuring the tail of the pancreas. Alternatively, electrosurgical devices can be used to divide the hilar vessels. The electrothermal bipolar sealing device has been reported to be a safe means of ligating splenic hilar vessels as large as 7 mm, ^{[19, 20, 21, 22]}  with one pediatric series reporting the use of the ultrasonic shears for safely ligating and dividing the splenic hilum. ^[36]

Following division of the splenic hilum, hemostasis is ensured, and staple-line bleeding can be controlled with clips or hemostatic agents. After firing the stapling device and opening the jaws, the surgeon should be prepared to close the jaws again on the hilum to control significant bleeding from the transected vessels.

Another popular dissection technique is to divide the gastrosplenic ligament first, then the splenocolic and splenorenal ligaments. This allows the spleen to be suspended by the lateral and posterior attachments. The remainder of the dissection and control of the splenic hilum is similar to that described previously.

When the splenic hilum is controlled and divided (with visual confirmation, as the splenic parenchyma becomes discolored and appears devascularized), the spleen can be grasped by the handle of the splenocolic ligament left on the inferior border of the spleen and flipped onto its ventral surface with the hilum facing up. At this time, an impervious retrieval sac can be advanced through the 12-mm port and unfolded in the left upper quadrant.

The process of placing the spleen into the bag can be difficult and frustrating. Several different retrieval sacs are available. The surgeon should make sure that these sacs are sturdy enough to prevent rupture and large enough to envelop the entire spleen. Opening the bag widely and having a handle (either the perihilar tissue or portion of the splenocolic ligament) can greatly facilitate placement of the spleen into the retrieval sac. Gravity can also be used by placing the patient in Trendelenburg position as the spleen is carefully advanced into the bag (see the video below).

After the spleen is in the retrieval sac, the purse-string suture is pulled tight and brought up through the 12-mm trocar (see the images below). The 12-mm trocar is then removed, pulling the neck of the bag up through the abdominal wall.

Morcellation or piecemeal extraction of the spleen is then undertaken, unless the spleen must be removed intact for pathologic purposes. A finger-fracture technique can be used for morcellation, though ring forceps also work well. Suction may also be used to aspirate blood and aid in the removal of the specimen. Occasionally, depending on the size of the spleen, the 12-mm fascial incision must be enlarged to allow the removal of the morcellated spleen in the bag. In morcellating the spleen, care must be taken not to rupture the bag and spill splenic tissue.

After removal, the abdomen is reinsufflated, and diagnostic laparoscopy is performed to evaluate for hemostasis and accessory spleens. The ports are removed under direct vision to ensure hemostasis, and the 12-mm fascial incisions are closed, followed by routine skin closure. Closed-suction drains are rarely indicated unless injury to the pancreatic tail is a concern.

The anterior approach was the first technique described for laparoscopic splenectomy; however, it is seldom used today, except when the spleen is very large and, occasionally, when the hand-assist technique is to be employed.

For the anterior approach, the patient is placed in the lithotomy position to allow the surgeon to operate while standing between the patient’s legs with the assistants on either side of the patient.

Safe abdominal access, as described earlier, is obtained at the umbilicus and typically involves placement of a 12-mm trocar that will accommodate a 10-mm 30° scope for visualization. Port sites vary according to individual surgeon preference but generally include three or four additional ports in a semicircle adjacent to the left upper quadrant.

Briefly, the technique involves liver retraction and medial retraction of the stomach.

After a search for accessory spleens, the splenocolic ligament is incised near the lower pole of the spleen with a hook cautery, scissors, or an electrosurgical device. The lower pole of the spleen is elevated gently to expose the splenic hilum and tail of the pancreas.

The branches of the splenic artery can then be carefully dissected and clipped as close to the spleen as possible to avoid injury to the tail of the pancreas. Although a stapling device or electrosurgical device may be used for splenic hilar ligation, caution is recommended, since it is usually much harder to distinguish the plane between the tail of the pancreas and the splenic hilum in the anterior approach.

After control of the hilum, the short gastric vessels are ligated, and the spleen is detached and placed in a retrieval sac as previously described.

Hand-assisted laparoscopic surgery (HALS) is another technique for laparoscopic splenectomy that offers benefits of both open and laparoscopic techniques and has proved helpful in patients with splenomegaly (craniocaudal length >22 cm or width >19 cm). ^{[37, 38, 26]} For inexperienced surgeons, HALS may shorten the learning curve; for experienced surgeons, it may facilitate minimally invasive splenectomy for massively enlarged spleens that otherwise would not be amenable to a purely laparoscopic approach. ^{[37, 39]}

HALS splenectomy can be used with the anterior or the lateral approach and positioning as described previously. It is generally agreed that the nondominant hand should be placed into the abdomen. Many commercial hand-assist devices are available.

Trocar positions can vary, depending on the hand dominance of the surgeon. For right- or left-hand-dominant surgeons, the hand-assist device can be placed in the midline at or slightly below the inferior pole of the spleen. The incision should be 7-8 cm (or 1 cm less than the surgeon's glove size) and should be located 2-4 cm caudal to the inferior pole of the enlarged spleen (see the image below).

The surgeon stands on the patient's right side, and the nondominant hand is inserted through the hand-assist device, allowing medial retraction, rotation, and elevation of the spleen (see the image below).

Laparoscopic ports are placed as described previously for the lateral approach; however, when the spleen is extremely large, the trocars must be placed more inferiorly than normal (see the images below).

When all of the anterior and posterior attachments have been divided, the hilum is ligated with an endoscopic stapling device as described previously. The spleen is placed in a retrieval sac, brought up through the hand-assist incision, and, if necessary, morcellated.

Complications related to laparoscopic splenectomy are similar to those of open splenectomy or other major abdominal procedures and include the following:

• Intraoperative and postoperative hemorrhage
• Infection, including wound infection, pneumonia, and overwhelming postsplenectomy infection (OPSI; also referred to as postsplenectomy sepsis syndrome or overwhelming postsplenectomy sepsis [OPSS])
• Injury to other structures, such as the colon, stomach, or, most notably, the pancreatic tail

Other complications specifically associated with laparoscopic and open splenectomy include the following:

• Risk of missed accessory spleens
• Portal vein thrombosis

Bleeding

Bleeding is one of the most common and feared complications related to laparoscopic splenectomy and is the most common reason for conversion to an open approach. ^{[40, 41]}

Postoperative bleeding after laparoscopic splenectomy occurs in approximately 3% of patients. ^[42] Bleeding can be encountered following technical misadventures such as tearing the splenic capsule or failing to achieve adequate control of the splenic hilar vessels. Meticulous dissection around the splenic capsule can limit parenchymal tears. The surgeon should try to avoid grasping the spleen. Staplers, clips, and electrosurgical devices can be used to control the splenic hilar vessels, though the surgeon should be prepared if these instruments fail.

Subsequent bleeding can usually be controlled with additional clips or ligation of the vessels more proximal, if adequate dissection of the hilar vessels has been carried out. Treatment of postoperative bleeding from the staple line is more challenging and may require a return to the operating room, though the use of postoperative splenic artery embolization has been described with success in one patient. ^[43]

Pancreatic tail injury

Pancreatic tail injury is another feared complication of both open and laparoscopic splenectomy, which can cause pancreatic abscesses or fistulas. Careful dissection of the splenic hilum and adequate visualization of the pancreatic tails are mandatory before vessel ligation. It is generally believed that the lateral approach makes this dissection easier and the plane between the pancreatic tail and splenic hilum more visible than is the case with the anterior approach.

Drains are rarely necessary in laparoscopic splenectomy; however, if the surgeon is concerned about a possible pancreatic tail injury, a closed suction drain should be used.

Overwhelming postsplenectomy infection

OPSI is a well-known major long-term risk for splenectomy patients. Patients are at lifelong risk for the development of OPSI; however, the highest risk is in the first 2 years after surgery. Although the reported risk of OPSI is relatively low (3.2%), associated mortalities as high as 40-50% have been described. ^[5]

Therefore, in patients undergoing elective splenectomy, vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections at least 15 days before the procedure is recommended. ^[5] In patients undergoing emergency splenectomy, vaccination is recommended within 30 days after the procedure. ^{[5, 44, 45]} The pneumococcal vaccine should be repeated every 5 years, and patients should receive an influenza vaccine annually.

Missed accessory spleens

Accessory spleens are present in as many as 12-32% of patients, and a thorough evaluation for accessory spleens should be made after initial trocar placement. ^{[23, 24, 25]} Accessory spleens are typically located in the splenic hilum, along the splenic vessels, in the greater omentum, and along the splenorenal ligament and are usually accessible via both the lateral and the anterior approach.

Although the risk of missing accessory spleens was once a proposed shortcoming of the laparoscopic approach, the detection rates for accessory spleens with laparoscopy appear to be similar to those with the open approach. ^{[25, 46, 47, 48, 49]}

Portal vein thrombosis

Portal vein thrombosis is increasingly being recognized as a complication of splenectomy and should be considered in patients suffering from postoperative anorexia, abdominal pain, ileus, low-grade fevers, and elevated platelet and leukocyte counts. Portal vein thrombosis has been reported to occur in 0.7-14% of patients. ^{[50, 51]}

Risk factors associated with portal vein thrombosis include splenomegaly, myeloproliferative disorders, and hemolysis, with incidences reported to be as high as 80% in these high-risk patients. ^[52]  In one study, a platelet count increasing to more than eight times the baseline preoperative level after surgery was a risk factor for portal vein thrombosis after laparoscopic splenectomy. ^[53] A preoperative splenic vein diameter of 8 mm or greater has also been suggested as a risk factor for portal or splenic vein thrombosis. ^[54] A study by Swinson et al found specimen weight, myelofibrosis, and mean platelet count to be predictive of portal vein thrombosis after elective laparoscopic splenectomy. ^[55]

Whether the technique of surgery (ie, open or laparoscopic) affects the rate of portal vein thrombosis remains unclear. Anticoagulation therapy is recommended for all symptomatic patients. ^{[56, 5, 52]}