Pediatric Annals

Laparoscopic Splenectomy

Thom E Lobe, MD; Gerald J Presbury, MD; Baird M Smith, MD; Judith A Wilimas, MD; Winfred C Wang, MD

Abstract

Minimally invasive techniques are being used now for many pediatric procedures. These operations are associated with minimal pain, less restriction in postoperative activity, and a short postoperative hospitalization. The recent development of automatic tissue morcellators renders possible the removal of large structures such as the spleen while preserving the tissue sufficiently for accurate histological evaluation.1 A few investigators have applied laparoscopic techniques to splenectomies in adults.2'6 This article will discuss our experience with laparoscopic splenectomy in childhood.

TECHNIQUE

Patients with a hemoglobinopathy undergo an ultrasound evaluation of the gallbladder. We use the finding of cholelithiasis or "sludge" as an indication for concomitant cholecystectomy. Each patient receives vaccines against Streptococcus pneumoniae and Hemophilus influenzae preoperatively if they have not been immunized previously. The patient fasts the night before surgery and the day of surgery is given an oral osmotic bowel preparation to eliminate gaseous abdominal distension so that the dilated bowel will not obscure the view of the telescope, A penicillinclass antibiotic is given intravenously as needed in the operating room, and intravenous steroids are given if warranted by the patient's history.

The patient is prepped and draped in the supine position under general anesthesia. A Foley catheter and nasogastric tube are inserted to empty the bladder and stomach. A 1 -cm incision is made in the infraumbilical fold through which a retractable, blunt-tipped Veress needle is inserted into the peritoneal cavity. Carbon dioxide is introduced to create a capnoperitoneum of 10 to 12 mm Hg. However, if the spleen is large, an incision is made in the umbilical fascia for port insertion to avoid injuring part of a spleen that may lie directly beneath the umbilicus. Four surgical ports are then inserted (Figure IA). If cholecystectomy is to be performed, port placement is slightly different (Figure IB).

The patient is rotated into a steep reversed Trendelenburg position with the left side elevated. The short gastric vessels are then divided between endoscopic surgical clips. If easily visualized, the most superior branches are divided at this time, but usually it is easier to defer their division until the spleen is further mobilized.

Traditional splenectomy performed through an upper abdominal incision, is associated with a number of potential complications including: hemorrhage, atelectasis, pneumonia, ileus, subdiaphragmatic abscess, and incisional hernias. These may prolong hospital stay and convalescence. The laparoscopic approach eliminates many of these problems. Exposure is easily obtained by sliding the laparoscope beneath the costal margin to within centimeters of the operative field. Superior magnification and optics permit accurate dissection and meticulous hemostasis. Because the small incisions of laparoscopic surgery are less painful than an upper abdominal incision, patients require less narcotics, have fewer respiratory complications, and have improved return of pulmonary function.9 The duration of ileus is foreshortened10 and ventral hernias are very unlikely because of the small incisions.

The spleens removed from children are often of normal size, which facilitates the endoscopic procedure. Two of our children each had an enlarged spleen. The planned approach was to free the spleen and then to make a small incision between the two lateral trocar sites to extract the intact spleen. Ine extraction sac was large enough to hold each of these spleens, however, and extending the incisions was unnecessary.

The disadvantage of die laparoscopic approach is the increased duration of operation. In our 10 splenectomies, the median operating time was 31Zz hours. This figure should diminish with experience and better equipment.

A major complication of splenectomy in children is the syndrome of postsplenectomy infection, which is manifested as fulminating sepsis, often with no apparent focus of infection. It has an abrupt onset with…

Minimally invasive techniques are being used now for many pediatric procedures. These operations are associated with minimal pain, less restriction in postoperative activity, and a short postoperative hospitalization. The recent development of automatic tissue morcellators renders possible the removal of large structures such as the spleen while preserving the tissue sufficiently for accurate histological evaluation.1 A few investigators have applied laparoscopic techniques to splenectomies in adults.2'6 This article will discuss our experience with laparoscopic splenectomy in childhood.

TECHNIQUE

Patients with a hemoglobinopathy undergo an ultrasound evaluation of the gallbladder. We use the finding of cholelithiasis or "sludge" as an indication for concomitant cholecystectomy. Each patient receives vaccines against Streptococcus pneumoniae and Hemophilus influenzae preoperatively if they have not been immunized previously. The patient fasts the night before surgery and the day of surgery is given an oral osmotic bowel preparation to eliminate gaseous abdominal distension so that the dilated bowel will not obscure the view of the telescope, A penicillinclass antibiotic is given intravenously as needed in the operating room, and intravenous steroids are given if warranted by the patient's history.

The patient is prepped and draped in the supine position under general anesthesia. A Foley catheter and nasogastric tube are inserted to empty the bladder and stomach. A 1 -cm incision is made in the infraumbilical fold through which a retractable, blunt-tipped Veress needle is inserted into the peritoneal cavity. Carbon dioxide is introduced to create a capnoperitoneum of 10 to 12 mm Hg. However, if the spleen is large, an incision is made in the umbilical fascia for port insertion to avoid injuring part of a spleen that may lie directly beneath the umbilicus. Four surgical ports are then inserted (Figure IA). If cholecystectomy is to be performed, port placement is slightly different (Figure IB).

The patient is rotated into a steep reversed Trendelenburg position with the left side elevated. The short gastric vessels are then divided between endoscopic surgical clips. If easily visualized, the most superior branches are divided at this time, but usually it is easier to defer their division until the spleen is further mobilized.

Figure 1. Cannula placement for children undergoing laparoscopic splenectomy alone (A) and laparoscopic splenectomy in association with laparoscopic cholecystectomy (B). The numbers indicate the size of the incision necessary for each cannula.

Figure 1. Cannula placement for children undergoing laparoscopic splenectomy alone (A) and laparoscopic splenectomy in association with laparoscopic cholecystectomy (B). The numbers indicate the size of the incision necessary for each cannula.

Figure 2. The mobilized spleen, attached only by the splenic vessels, is in close relationship with the tail of the pancreas.

Figure 2. The mobilized spleen, attached only by the splenic vessels, is in close relationship with the tail of the pancreas.

Figure 3. An abdominal view of the nylon sac containing the spleen, which is being morcellated.

Figure 3. An abdominal view of the nylon sac containing the spleen, which is being morcellated.

The patient is then repositioned into a right lateral decubitus position and the splenocolic and lienorenal ligaments are divided. The splenic hilum is now exposed, permitting visualization and removal of any accessory spleen (Figure 2). About half of the children on whom this surgery was performed have had one or more accessory spleens. The pancreas is carefully avoided and an endoscopic linear stapler is applied across the splenic hilar vessels and fired. Should a small piece of the pancreatic tail be included, the triple line of staples provides secure closure of the pancreatic duct. The vessels are inspected for active bleeding and any remaining short gastric vessels or ligaments are divided. The patient is then returned to the supine position.

Through the 12-mm port site, an 8x5 inch reinforced nylon pouch is rolled tightly and inserted into the abdomen. There it is unfurled and the spleen is mobilized into the bag. The neck of the bag is exteriorized through the largest port site and tissue is morcellated, or diced into small pieces, until the entire sac can be removed from the abdomen (Figure 3). The splenic bed and pancreas are re-inspected for hemostasis, all cannulas are removed, and the wounds are closed with subcuticular sutures.

Patients are offered fluids the evening of their surgery and usually take solids the following day. Intramuscular metoclopramide or a scopolamine patch are given to prevent nausea. Patients are discharged, usually on the second postoperative day, with a prescription for penicillin (or erythromycin in instances of penicillin allergy) and analgesics as needed.

Most patients return to unrestricted activities the week of discharge. Patients and their families seem to find the small scars cosmetically preferable to a large subcostal or midline scar (Figure 4). The laparoscopic approach appears to be at least as safe as the open approach.

RESULTS

To date, we have performed laparoscopic splenectomy on eight girls and three boys, ages 1 lfi years to 13 years, after failure to control their hematologic disease with medical therapy (Table 1 ). They weighed between 11 kg and 55 kg. Among them were an 18-month-old male infant with sickle cell disease who developed life-threatening sequestration crises, five girls with idiopathic thrombocytopenic purpura (ITP), and five children with hereditary spherocytosis, four of whom had symptomatic cholelithiasis necessitating concomitant cholecystectomy. Trie operative time ranged from 21Zz to 4 hours. Trie longer procedures were those with concomitant cholecystectomy and operative cholangiogram.

The postoperative platelet count rose satisfactorily in all patients with ITP. Patients 2 and 9 had a 24-hour period of ileus, prolonging their hospital stay by an extra day. The operation on patient ? was initially complicated by a resolving hemoperitoneum believed to be secondary to a ruptured ovarian cyst that occurred because of thrombocytopenia. After suction evacuation of the old blood, her operation proceeded without difficulty until uncontrollable bleeding arose from the most superior short gastric vessel. The procedure was then converted to an open operation for hemostasis.

Table

TABLE 1Characteristics of Splenectomy Patients

TABLE 1

Characteristics of Splenectomy Patients

Table

TABLE 2Indications for Splenectomy in Children

TABLE 2

Indications for Splenectomy in Children

Eight of the 11 patients left the hospital on the second postoperative day and returned to unrestricted diet and activity. The other three patients spent extra time in the hospital resolving their mild ileus.

INDICATIONS AND COMPLICATIONS

Indications for splenectomy in hereditary spherocytosis, sickle-cell disease, and ITP are related to a complication of, or a change in, the clinical severity of the disease (Table 2). In hereditary spherocytosis, splenectomy is recommended for a persistently low hemoglobin, failure to thrive due to anemia, and for severe hemolysis. If the hemoglobin can be maintained >10 g/dL, splenectomy is usually not recommended.

Figure 4. Three-year-old girl's abdomen, 1 week after a laparoscopic splenectomy.

Figure 4. Three-year-old girl's abdomen, 1 week after a laparoscopic splenectomy.

The major indication for splenectomy in sickle cell disease is splenic sequestration. One investigator reported that 50% of deaths from splenic sequestration occurred in children with recurrence; therefore, splenectomy is usually performed after the first episode.7 However, due to the risk of overwhelming sepsis in splenectomized children, other investigators recommend delaying the splenectomy until after the second episode.8 Emergency splenectomy is usually not indicated during acute episodes of sequestration.

Children with ITP may require splenectomy if the child has symptoms of hemorrhage, consistent thrombocytopenia, or failure to respond to other treatment (corticosteroids, intravenous immunoglobulin). Intravenous immunoglobulin may be given initially but emergency splenectomy is indicated in patients with life-threatening bleeding.

Table

TABLE 3Guidelines for Prophylaxis Against Postsplenectomy Sepsis

TABLE 3

Guidelines for Prophylaxis Against Postsplenectomy Sepsis

Traditional splenectomy performed through an upper abdominal incision, is associated with a number of potential complications including: hemorrhage, atelectasis, pneumonia, ileus, subdiaphragmatic abscess, and incisional hernias. These may prolong hospital stay and convalescence. The laparoscopic approach eliminates many of these problems. Exposure is easily obtained by sliding the laparoscope beneath the costal margin to within centimeters of the operative field. Superior magnification and optics permit accurate dissection and meticulous hemostasis. Because the small incisions of laparoscopic surgery are less painful than an upper abdominal incision, patients require less narcotics, have fewer respiratory complications, and have improved return of pulmonary function.9 The duration of ileus is foreshortened10 and ventral hernias are very unlikely because of the small incisions.

The spleens removed from children are often of normal size, which facilitates the endoscopic procedure. Two of our children each had an enlarged spleen. The planned approach was to free the spleen and then to make a small incision between the two lateral trocar sites to extract the intact spleen. Ine extraction sac was large enough to hold each of these spleens, however, and extending the incisions was unnecessary.

The disadvantage of die laparoscopic approach is the increased duration of operation. In our 10 splenectomies, the median operating time was 31Zz hours. This figure should diminish with experience and better equipment.

A major complication of splenectomy in children is the syndrome of postsplenectomy infection, which is manifested as fulminating sepsis, often with no apparent focus of infection. It has an abrupt onset with rapid progression to death, often in a matter of hours. The syndrome can be due to S pneumoniae, H influenzae type b, Neisseria meningitidis, Escherichia colt, Staphylococcus species, and Streptococcus species.11 To decrease the risks of this syndrome, patients are given penicillin prophylaxis, immunizations, and appropriate education (Table 3). Pneumococcal, H influenzae type b, and meningococcal immunizations are recommended before surgery, at the time of surgical referral (approximately 2 weeks before the procedure). If the splenectomy is performed emergently, the immunizations should be given at discharge from the hospital or, less preferably; at the first postoperative visit.

At our institutions, oral penicillin, 125 mg twice daily is administered to children under 3 years of age, and 250 mg twice daily is administered to children older than 3 years. Patients and their parents are informed to seek medical attention if there is a fever 5s38.5°C (101.50F), shaking chills, or lethargy. All of these may represent early signs of life-threatening infection.

SUMMARY

Splenectomy is easily amenable to laparoscopic technique. Compared with the open technique, its advantages include improved exposure, decreased pain, improved pulmonary function, shortened hospitalization, rapid return to unrestricted activities, and improved cosmetic appearance. These advantages are at the expense of prolonged operative time that, with experience and improved instruments, should diminish.

REFERENCES

1. Lobe TE, Schropp KP, Joyner R, Laster O, Jenkins J. The suitability of automatic tissue morcellation fot the endoscopic removal of large spécimens in pediatric surgery. ) Pediatr Surg, in press.

2. Cuschieri A, Shirrii S, Banting S, Vender Velpen G. Technical aspects of laparoscopic splenectomy: hilar segmental devascularization and instrumentation, ] R Coll Surg Edinb. 1992;37:414-416.

3. Carroll BJ, Phillips EH, Semell CJ, Fallas M, Morgenstern L. Laparoscopic splenectomy. Surg Endose. 1992:6:183-185. Letter.

4. Hashizume M, Sugimachi K, Ueno K. Laparoscopic splenectomy with an ultrasonic dissector. N Engl i Med. 1992;326:431.

5. Delaitre B, Maignien B. Splenectomy by the coelioscopic approach. Report of a case. Press Med. 1991 120:2263. Letter.

6. Bruni R, Santoro M, Caratozzolo M, La Banca Q, Rollo R, Furti R. Laparosplenectomy in Hodgkins disease. Giornale luàano Oncologia. 1988;8:127-129.

7. Simmons JF1 Gitani D, Johnson CS, Powers DR, Tañer D, Haywood LJ. The pattern of mortality in sickle cell disease. Presented at the National Sickle Cell Conference; November 8-11, 1978; San Juan, Puerto Rico.

8. Jenkins ME, Roland BS, Balrd RL. Studies in sickle cell anemia, XVI: sudden death during sickle cell anemia crises in young children. J Pediatr. 1960;56:30-38.

9. Schauer PR, Luna JR, Abraham A. Pulmonary function after laparoscopic cholecystectomy. Presented at the 54th Annual Meeting of the Society of University Surgeons; February 11-13, 1993; Seattle, Washington.

10. Schippers E, Oettinger AP, Anurov M, Polivoda M1 Schumpelick V. Intestinale motitaet nach laparoskopischer vs konventioneller cholezystektomie. Langenbech ArefiChw. 1992;377:14:18.

11. Singer DB. Postsplenectomy sepsis. Persoect. Pediatr Pathol. 1973; 1:285.

TABLE 1

Characteristics of Splenectomy Patients

TABLE 2

Indications for Splenectomy in Children

TABLE 3

Guidelines for Prophylaxis Against Postsplenectomy Sepsis

10.3928/0090-4481-19931101-07

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