Laparoscopic Appendicectomy in all Trimesters of Pregnancy

Background:

The laparoscopic approach for appendicectomy in pregnancy was not considered the preferred procedure until recently. The aim of this study was to examine our experience with laparoscopic appendicectomy in pregnancy and review the scientific evidence available in the medical literature.

Method:

The clinical data of all patients who underwent laparoscopic appendicectomy during pregnancy at our hospital between 1999 and 2007 were collected and retrospectively analyzed. A Medline literature search restricted to English language articles on laparoscopic appendicectomy in pregnancy was carried out.

Result:

Twenty patients underwent laparoscopic appendicectomy during pregnancy. Of these, 8 were in the first trimester, 9 in the second trimester, and 3 in the third trimester. Fifteen patients had histologically confirmed appendicitis. The mean operating time was 45 minutes, and the average postoperative stay in the hospital was 1.5 days. All patients except one had a full-term normal delivery. Literature search: An additional 637 patients from the English literature were reviewed and summarized.

Conclusion:

Our results demonstrate that laparoscopic appendicectomy can be safely performed during all trimesters of pregnancy. The literature search suggests that although laparoscopic appendicectomy in pregnancy is associated with a low rate of intraoperative complications in all trimesters it may be associated with a significantly higher rate of fetal loss compared with open appendicectomy.     

REDUCE PORT LAPAROSCOPIC SPLENECTOMY FOR GIANT EPITELIAL CYST

Background:

Delaitre and Maignien performed the first successful laparoscopic splenectomy in 1991. After that, laparoscopic splenectomy has become one of the most frequently performed laparoscopic solid organ procedures.

Aim:

To demonstrate the surgical techique of laparoscopic splenetomy with reduced portals.

Methods:

A reduce port laparoscopic splenectomy was performed by using a 10 mm and two 5 mm trocars. To entered the abdomen a trans-umbilical open technique was done and a 10 mm trocar was placed. A subcostal 5 mm trocar was placed under direct vision at the level of the anterior axillary line and another 5 mm port was inserted at the mid-epigastric region. Once it was completely dissected and freed from all of its attachments the hilum, splenic artery and vein, was clipped with hem-o-lock and divided with scissors. Then an endobag was used to retrieve the spleen after being morcellated trough the umbilical incision.

Results:

This technique was used in a 15 years old female with epigastric and left upper quadrant pain. An abdominal ultrasound demonstrated a giant cyst located in the spleen. Laboratory tests findings were normal. The CT scan was also done, and showed a giant cyst, which squeeze the stomach. The patient tolerated well the procedure, with an unremarkable postoperative. She was discharge home 72 h after the surgery.

Conclusion:

The use of reduce port minimizes abdominal trauma and has the hypothetical advantages of shorter postoperative stay, greater pain control, and better cosmesis. Laparoscopic splenectomy for giant cysts by using reduce port trocars is safe and feasible and less invasive.     

Non-Gynecologic Laparoscopy in Second and Third Trimester Pregnancy: Obstetric Implications

Purpose:

To review the effect of non-gynecologic laparoscopic procedures performed during the second and third trimesters of pregnancy on pregnancy outcome.

Materials and Methods:

A review of the patient log for the antenatal obstetrical unit was used to identify the patients in this series from January 1, 1997 to December 31, 1997. Medical records were then analyzed to identify estimated gestational age at surgery and delivery, type of delivery, use of tocolysis, and complications from surgery.

Results:

Nine patients were identified as having non-gynecologic laparoscopic surgery (without conversion to laparotomy) during the second or third trimester of pregnancy. The median estimated gestational age at surgery was 25 weeks (mean 24 weeks). The most common procedure performed was laparoscopic cholecystectomy (6 patients). Five patients received tocolysis after the initial procedure. All patients delivered at greater than or equal to 37 weeks estimated gestational age (median 38 weeks). No infants were admitted to the neonatal intensive care unit.

Conclusions:

Laparoscopic procedures appear safe in second and third trimester pregnancy. In this study, laparoscopic cholecystectomies were performed as late as 34 weeks estimated gestational age without any adverse effects on pregnancy outcome.     

Laparoscopic Resection of an Undifferentiated Pleomorphic Splenic Sarcoma

Background:

Splenic tumors are rare. Malignant fibrous histiocytoma (MFH) of the spleen is one of the least common primary splenic tumors. Review of the literature shows that a laparoscopic resection has never been tried.

Method:

We discuss the case of a 76-year-old man with a 7-cm MFH in the spleen and present a review of splenic sarcomas.

Results:

The patient underwent a successful laparoscopic splenectomy; pathology revealed a rare undifferentiated pleomorphic sarcoma of the spleen. A review of the international literature identified 15 additional cases of primary splenic MFH. Survival was rarely longer than 15 months.

Conclusion:

Malignant fibrous histiocytoma of the spleen is an exceedingly rare tumor with a poor prognosis. In experienced hands, laparoscopic splenectomy is a feasible operative choice for primary splenic sarcoma.     

Splenic torsion requiring splenectomy six years following laparoscopic Nissen fundoplication

Background:

Laparoscopic Nissen fundoplication has become a mainstay in the surgical treatment of gastroesophageal reflux disease, as it has proved to be a durable, well-tolerated procedure. Despite the safety and efficacy associated with this procedure, surgeons performing this advanced laparoscopic surgery should be well versed in the potential intraoperative and postoperative complications.

Methods:

A case is presented of a rare complication of splenic torsion following laparoscopic Nissen fundoplication. Diagnostic evaluations and intraoperative findings are discussed.

Results:

We present an otherwise healthy 41-year-old woman who underwent a laparoscopic Nissen fundoplication 6 years earlier at another medical center and presented with worsening chronic left upper quadrant abdominal pain. She was diagnosed with torsion of the splenic vascular pedicle, resulting in heterogenicity of perfusion with associated hematoma requiring open splenectomy.

Conclusion:

Surgeons should be aware of splenic torsion as a potential, albeit rare, complication related to laparoscopic Nissen fundoplication.     

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy

Background and Objectives:

Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.

Methods:

The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients'' postoperative courses are described.

Results:

The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.

Conclusions:

The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.     

Spontaneous Splenic Rupture Four Days after an Open Appendicectomy

Introduction

Spontaneous splenic rupture is a rare but dangerous event that requires prompt diagnosis and frequently an emergency splenectomy. Previous case reports have described the occurrence in patients with medical conditions, anticoagulant treatments, endoscopic procedures, laparoscopic surgery or no particular predisposing factor. Our report is the first to describe the occurrence of spontaneous spleen rupture following a laparotomy conducted in the lower abdomen.

Case History

A 62-year-old woman presented with a 10-day history of right iliac fossa pain radiating to the right leg and associated vomiting. Following a routine blood check and computed tomography (CT), she underwent an open appendicectomy through a lower midline laparotomy for an appendicular abscess. Four days later, she experienced haemorrhagic shock and a second CT scan diagnosed a spontaneous splenic rupture that required a prompt splenectomy.

Conclusions

Our case is the first that describes the spontaneous rupture of the spleen following an open procedure conducted in the lower quadrants. This entity must still be considered as a rare but potential cause for postoperative bleeding when no other obvious sources are identified.     

Oversized pseudocysts of the spleen: Report of two cases: Optimal management of oversized pseudocysts of the spleen

INTRODUCTION

Pseudocysts of the spleen are usually asymptomatic and associated with a history of trauma, infection or infarction. In this report, we present two uncommon cases of solitary, oversized pseudocysts of the spleen.

PRESENTATION OF CASE

Two patients (cases A and B), with symptoms of abdominal pain, were investigated. The laboratory and ultrasound examination confirmed the diagnosis of a large, non-parasitic splenic cyst in both cases. Computed tomography described an oversized pseudocyst occupying almost the entire splenic parenchyma in both cases and in patient A, the cyst was located in the splenic hilum. The medical history revealed a previous abdominal injury only in case A. The two patients underwent an open total splenectomy. The pathology examination verified the diagnosis of a non-parasitic splenic pseudocyst.

DISCUSSION

Both patients presented with symptoms, in contrast to the majority of patients with splenic cysts. The medical history of patients with splenic pseudocysts does not always reveal the cause of the pseudocyst formation. Any type of spleen-sparing procedure is not easy to perform in cases of surgical and anatomical difficulty, because of recurrence and the risk of intractable bleeding from the spleen.

CONCLUSION

Partial splenectomy is the recommended method for parenchymal preservation, but total splenectomy is preferred when the splenic cyst is oversized or cannot be excised with safety.     

Single Access Laparoscopic Splenectomy

Background:

Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars.

Methods:

A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed.

Results:

The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000.

Conclusions:

Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.     

Laparoscopic Surgery in the Pregnant Patient: Results and Recommendations

Background:

The complete experience of a single surgeon in a rural hospital over more than 11 years was evaluated with respect to laparoscopic operations performed on pregnant patients.

Methods:

A retrospective analysis of all laparoscopic operations was carried out with respect to number and types of operations, stage of pregnancy, complications, and fetal outcomes.

Results:

Between October 1995 and January 2007, 36 laparoscopic operations were conducted on 36 pregnant patients. This represents the largest single-surgeon case experience ever reported for nonobstetric laparoscopic surgery performed during pregnancy. The majority of cases were conducted for symptomatic gallbladder disease. There was one complication of uterine penetration by a cannula, early in the series, without fetal injury. Operations were conducted in each trimester, including the late third trimester, with 100% live births of normal infants.

Conclusion:

Laparoscopic surgery can be safely conducted in pregnant patients, in any trimester. Pregnancy should no longer be considered a contraindication to laparoscopic surgery. The limiting factor of prime importance is an awareness of one''s own capabilities and limitations. The surgeon must be skilled in advanced laparoscopic techniques and in surgical obstetrics. A rural hospital setting is suitable for this type of procedure if there is a strong support structure in place to deal with potential complications.     

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.     

Ruptured spontaneous splenic artery aneurysm: A case report and review of the literature

INTRODUCTION

Splenic artery aneurysm is a rare condition, however, potentially fatal. The importance of splenic artery aneurysm lies in the risk for rupture and life threatening hemorrhage.

PRESENTATION OF CASE

This is a case of a ruptured splenic artery aneurysm in a 58-year-old lady. She presented with hypovolemic shock and intra-peritoneal bleeding. Diagnosis was confirmed by CT angiography and she was managed by operative ligation of the aneurysm with splenectomy and distal pancreatectomy.

DISCUSSION

The literature pointed the presence of some risk factors correlating to the development of splenic artery aneurysm. In this article we discuss a rare case of spontaneous (idiopathic) splenic artery aneurysm and review the literature of this challenging surgical condition.

CONCLUSION

Splenic artery aneurysm needs prompt diagnosis and management to achieve a favorable outcome, high index of suspicion is needed to make the diagnosis in the absence of known risk factors.     

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments

Background and Objectives:

We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device.

Methods:

One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar.

Results:

Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery.

Conclusions:

LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.     

Laparoscopic radiofrequency ablation for traumatic splenic rupture

Background

Laparotomy was formerly the routine approach for treating traumatic splenic rupture. Traumatic splenic rupture has traditionally been treated with open splenectomy. The advent of laparoscopy and radiofrequency ablation (RFA) has ushered in new approaches to this surgical problem. The purpose of this study was to evaluate the use of laparoscopic RFA to treat traumatic splenic rupture.

Methods

Four patients with traumatic splenic ruptures underwent laparoscopic RFA-assisted spleen-preserving surgery between September 2011 and April 2012. RFA electrodes were used for traumatic rupture repair or partial splenectomies using classic laparoscopic procedures. Safety and efficacy parameters were documented, including surgery time, intraoperative blood loss, postoperative drainage quantities, and recovery conditions.

Results

Three patients received laparoscopic splenic rupture repair and one patient received a partial splenectomy. Three surgeries were successful, based on 1-mo follow-up with computerized tomography and ultrasound examinations that indicated the restoration of satisfactory splenic blood supply. The fourth patient received a laparotomy for a total splenectomy because of massive postoperative bleeding 24 h after surgery.

Conclusions

Laparoscopic RFA-assisted spleen-preserving surgery is another modality that may be considered in the management of splenic trauma. This small sample size and limited clinical experience does not justify its use on a routine basis and requires additional clinical research to fully evaluate its efficacy in certain critical traumatic scenarios compared with traditional open splenectomy.     

Single Incision Laparoscopic Splenectomy in a 5-Year-Old With Hereditary Spherocytosis

Background:

Single incision laparoscopic surgery (SILS) is an emerging technique that has been used as an approach for appendectomy, cholecystectomy, and splenectomy. We describe the technique of single incision laparoscopic splenectomy for hypersplenism in a 5-year-old boy with spherocytosis.

Case Report:

The patient required blood transfusions for anemia secondary to hypersplenism. His spleen measured 9.8 cm in cranio-caudal length on ultrasound. SILS splenectomy was performed through a 2-cm umbilical incision by using 3 ports. The splenic attachments were taken down using an electrosurgical sealing and cutting device, and the hilum was transected with an endosurgical stapler. The spleen was placed in an endosurgical bag, morcellated, and removed from the abdomen via the umbilical incision without complications. Operative time was 84 minutes; blood loss was minimal.

Conclusion:

SILS splenectomy is feasible in pediatric patients. More experience is needed to assess advantages and disadvantages compared with the standard laparoscopic approach.     

Laparoscopic Appendectomy and Cholecystectomy During Pregnancy: Six Case Reports

Background:

Pregnancy was once considered a contraindication to laparoscopic cholecystectomy and appendectomy. The progression of laparoscopic techniques has resulted in a continued reassessment of laparoscopic procedures during pregnancy. There still exists some controversy as to the safety of laparoscopic procedures during pregnancy. This paper reviews our series of six pregnant patients treated laparoscopically for appendicitis and cholecystitis.

Methods:

Charts were reviewed of all pregnant patients who underwent laparoscopic cholecystectomy or appendectomy at St Clare''s Hospital Schenectady, New York between 1992 and 1996. Six patients were identified. Patients and obstetricians were contacted to investigate the results of the pregnancy.

Results:

All patients and fetuses survived the procedure. Two patients delivered prematurely but remote from the operative procedure. All infants were healthy postpartum. One patient underwent an elective abortion as she had planned. The abortion was remote from the surgical procedure.

Conclusion:

Our series adds to the growing evidence that laparoscopic cholecystectomy and laparoscopic appendectomy can be performed safely during pregnancy.     

Identification of Accessory Spleens During Laparoscopic Splenectomy Is Superior to Preoperative Computed Tomography for Detection of Accessory Spleens

Background:

Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy.

Methods:

A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS.

Results:

The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin''s lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005).

Conclusion:

Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.     

Post-splenectomy splenosis presenting as hepatocellular carcinoma in the left lateral section of the liver: A case report

INTRODUCTION

Defined as heterotrophic autotransplantation of splenic tissue after splenic trauma or surgery.

PRESENTATION OF CASE

We present a case of 45 years old female patient with past history of splenectomy for haemolyticanaemia. Complaining of abdominal pain the patient was investigated by abdominal CT scan which revealed a focal lesion in the left lateral section of the liver suspicious to be hepatocellular carcinoma and gall bladder stones. Serum α-fetoprotein was within normal range. Exploration revealed a well encapsulated lesion completely separable from the liver and the diaphragm. Histopathological examination confirmed the diagnosis of splenosis. Although it is a rare condition, we recommend that the diagnosis of splenosis should be put in consideration in every patient with past history of splenectomy for proper management.

DISCUSSION

Although several cases of hepatic splenosis have been reported in the literature, supra-hepatic splenosis as our case has been rarely described.

CONCLUSION

Considering patients past history of splenectomy or splenic trauma should add splenosis to the list of possible differential diagnosis to avoid unnecessary surgical intervention.