Minimally Invasive Techniques in Splenectomy: A Surgeon’s Guide

Introduction to Laparoscopic Splenectomy

Laparoscopic splenectomy has revolutionized the approach to splenic surgery, providing a minimally invasive alternative to the traditional open splenectomy. This procedure is increasingly preferred for its reduced postoperative pain, shorter hospital stays, quicker recovery times, and better cosmetic outcomes. It is indicated in various hematological, oncological, and traumatic conditions where spleen removal is necessary.

Indications for Laparoscopic Splenectomy

Laparoscopic splenectomy is indicated for several conditions, including:

1. Hematological Disorders:
   • Idiopathic Thrombocytopenic Purpura (ITP): One of the most common indications, particularly when medical management fails.
   • Hereditary Spherocytosis: Where splenectomy can alleviate hemolysis.
   • Thalassemia and Sickle Cell Disease: In cases of hypersplenism or recurrent splenic sequestration.
   • Autoimmune Hemolytic Anemia: As a second-line treatment when steroids and immunosuppressants are ineffective.
2. Oncological Indications:
   • Splenic Marginal Zone Lymphoma: When the spleen is the primary site of disease.
   • Hairy Cell Leukemia: For symptomatic splenomegaly and cytopenias.
   • Chronic Lymphocytic Leukemia (CLL): When splenomegaly causes significant discomfort or cytopenias.
3. Trauma:
   • Splenic Rupture: In hemodynamically stable patients where the spleen cannot be conserved.
   • Post-Traumatic Splenic Cysts or Pseudocysts: When symptomatic or large.
4. Other Indications:
   • Splenic Abscess: In patients not responding to antibiotics and drainage.
   • Splenic Artery Aneurysm: Particularly in women of childbearing age due to the risk of rupture during pregnancy.

Preoperative Evaluation

A thorough preoperative evaluation is critical to the success of a laparoscopic splenectomy:

1. Imaging:
   • Abdominal Ultrasound: Initial evaluation of splenic size and pathology.
   • CT Scan: To assess splenic anatomy, identify accessory spleens, and evaluate surrounding structures.
   • MRI: Used occasionally for better delineation of splenic lesions.
2. Laboratory Tests:
   • Complete Blood Count (CBC): To assess baseline cytopenias or anemia.
   • Coagulation Profile: To rule out coagulopathies that may increase surgical risk.
   • Liver Function Tests: To evaluate for portal hypertension or other liver pathologies.
3. Vaccination:
   • Preoperative Vaccination: Against encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis is essential due to the increased risk of post-splenectomy sepsis.
4. Risk Assessment:
   • Anesthetic Evaluation: For assessing the patient's fitness for surgery.
   • Thromboembolism Risk: Patients may need prophylaxis against venous thromboembolism.

Contraindications

Laparoscopic splenectomy, while generally safe, has certain contraindications:

1. Absolute Contraindications:
   • Uncontrolled Coagulopathy: Due to the risk of excessive bleeding.
   • Severe Cardiopulmonary Disease: Where the patient cannot tolerate pneumoperitoneum.
   • Extremely Large Spleen: Where laparoscopic access and manipulation are not feasible.
2. Relative Contraindications:
   • Previous Abdominal Surgeries: That may have caused extensive adhesions.
   • Morbid Obesity: Which can complicate access and visibility.

Surgical Techniques and Steps

The laparoscopic splenectomy is a technically demanding procedure that requires careful planning and execution. Here’s a step-by-step overview:

1. Patient Positioning:
   • The patient is positioned in a right lateral decubitus position with the left arm extended, allowing for better access to the left upper quadrant.
2. Port Placement:
   • Typically, 4 to 5 ports are used: a 10-12 mm camera port at the umbilicus, a 5 mm working port in the midline below the xiphoid process, and additional 5-12 mm ports in the left lower quadrant and left lateral abdomen.
3. Pneumoperitoneum Creation:
   • A Veress needle or Hasson technique is used to create a pneumoperitoneum, inflating the abdomen with carbon dioxide to allow visualization and manipulation.
4. Splenic Mobilization:
   • The spleen is mobilized by dividing the ligaments attaching it to surrounding structures, including the splenocolic, splenorenal, and splenophrenic ligaments. This step is facilitated by lateralizing the colon and elevating the spleen.
5. Dissection of the Splenic Hilum:
   • The splenic artery and vein are dissected and divided, typically using an energy device like the Harmonic Scalpel or LigaSure to minimize blood loss.
6. Extraction of the Spleen:
   • Once fully mobilized and detached, the spleen is placed into an endoscopic retrieval bag, morcellated if necessary, and extracted through one of the ports.
7. Hemostasis and Closure:
   • After ensuring hemostasis, the ports are removed, and the incisions are closed. A drain may be placed depending on the intraoperative findings.

Postoperative Care

Postoperative management is crucial for a successful recovery:

1. Monitoring:
   • Vital signs and urine output are closely monitored in the immediate postoperative period.
   • Hemoglobin and hematocrit levels are checked to assess for bleeding.
2. Pain Management:
   • Postoperative pain is typically managed with non-opioid analgesics, though stronger medications may be required.
3. Early Mobilization:
   • Encouraging early ambulation helps reduce the risk of venous thromboembolism and speeds up recovery.
4. Diet:
   • Patients are usually started on a clear liquid diet, progressing to a regular diet as tolerated.
5. Vaccination and Prophylaxis:
   • Any missed preoperative vaccinations should be administered.
   • Lifelong prophylactic antibiotics may be considered, particularly in children and those with a high risk of sepsis.

Possible Complications

Despite being minimally invasive, laparoscopic splenectomy carries potential complications:

1. Intraoperative Complications:
   • Bleeding: Particularly from the splenic hilum or accessory spleens.
   • Injury to Surrounding Organs: Such as the stomach, colon, or pancreas.
   • Gas Embolism: A rare but serious complication from the introduction of carbon dioxide into the bloodstream.
2. Postoperative Complications:
   • Infection: Including surgical site infections and overwhelming post-splenectomy infection (OPSI).
   • Subphrenic Abscess: Due to residual blood or bile collection.
   • Thrombosis: Splenic vein thrombosis can occur, necessitating anticoagulation.

Different Techniques

Several variations of laparoscopic splenectomy exist, depending on the specific clinical scenario:

1. Hand-Assisted Laparoscopic Splenectomy (HALS):
   • Useful for very large spleens or in cases where tactile feedback is desired. The surgeon’s hand is introduced into the abdomen through a small incision, providing greater control.
2. Single-Port Laparoscopic Splenectomy:
   • A more recent innovation, using a single incision to reduce scarring and postoperative pain. However, it is technically more challenging and requires advanced laparoscopic skills.
3. Robotic-Assisted Laparoscopic Splenectomy:
   • Offers enhanced precision and dexterity, particularly useful in complex cases or when dealing with extensive adhesions. The robotic platform also provides superior visualization.

Prognosis and Outcome

The prognosis after laparoscopic splenectomy is generally excellent, with most patients experiencing a significant improvement in symptoms and quality of life:

1. Hematological Outcomes:
   • In conditions like ITP and hereditary spherocytosis, splenectomy often results in long-term remission or cure.
2. Oncological Outcomes:
   • For splenic malignancies, laparoscopic splenectomy can effectively control disease, though long-term outcomes depend on the underlying condition.
3. Trauma:
   • When performed in stable trauma patients, laparoscopic splenectomy can prevent complications associated with splenic preservation, such as delayed rupture or bleeding.

Alternative Options

For patients where laparoscopic splenectomy is contraindicated or not feasible, alternative treatments include:

1. Open Splenectomy:
   • Still the gold standard in cases of massive splenomegaly or when there are extensive intra-abdominal adhesions.
2. Partial Splenectomy:
   • Considered in cases where splenic preservation is desirable, such as in children or patients with mild hypersplenism.
3. Non-Surgical Management:
   • In trauma patients, non-operative management with close monitoring may be appropriate for minor splenic injuries.

Average Cost

The cost of laparoscopic splenectomy varies depending on geographic location, hospital setting, and the complexity of the procedure:

1. Hospital Charges:
   • The cost typically includes surgeon fees, anesthesia, operating room charges, and postoperative care. In the United States, the total cost can range from $15,000 to $40,000.
2. Insurance Coverage:
   • Many insurance plans cover laparoscopic splenectomy, especially when performed for medically necessary indications. Patients should check with their providers for specific coverage details.

Recent Advances

Recent advancements in laparoscopic splenectomy include:

1. Enhanced Recovery After Surgery (ERAS) Protocols:
   • Implementing ERAS protocols has been shown to reduce hospital stays, complications, and overall recovery time.
2. Use of Fluorescence Imaging:
   • Techniques like indocyanine green (ICG) fluorescence imaging are being explored to improve visualization of splenic vasculature and reduce complications.
3. Minimally Invasive Tools:
   • Continued development of energy devices and staplers has made the procedure safer and more efficient.

Conclusion

Laparoscopic splenectomy is a sophisticated and highly effective surgical procedure that offers numerous benefits over traditional open surgery. With proper patient selection, meticulous surgical technique, and careful postoperative management, it can be performed safely with excellent outcomes. Ongoing advancements in technology and surgical protocols continue to refine this procedure, making it an indispensable tool in modern surgical practice.