Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Laparoscopic versus open pediatric splenectomy for massive splenomegaly

Laparoscopic splenectomy (LS) has rapidly evolved into the technique of choice compared with open splenectomy (OS) because of the advantages of the minimally invasive approach. Splenomegaly increases the technical difficulties of LS. LS for massive splenomegaly has generally been found to fail in adults and children. With improvements in laparoscopic technique and accumulation of laparoscopic experience, however, concerns about completing the procedure in pediatric cases with even massive splenomegaly have been lowered. A retrospective review (April 1997-October 2009) of databases at 2 institutions identified 145 children undergoing splenectomy, 79 laparoscopic and 66 open. We defined splenic margin below the umbilicus or anteriorly extending over the midline as massive splenomegaly. By this definition, 22 cases of pediatric laparoscopic and 17 cases of open splenectomies for massive splenomegaly were performed. Perioperative and follow-up data of laparoscopic pediatric splenectomies were compared with those of open splenectomies, including operative time, bleeding, spleen size, complications, and hospital stay. There were no deaths, wound infections, or instances of pancreatitis. No accessory spleen was missed by laparoscopic; accessory spleens were missed in 2 patients in open splenectomies. The complication rate of laparoscopic versus open was 13.6% versus 41.2%. No subsequent surgery was necessary for dealing with complications both in laparoscopic and open series. Laparoscopic pediatric splenectomy for massive splenomegaly is a feasible, effective, and safe procedure and is associated with low morbidity and a short hospital stay.     

Laparoscopic versus open splenectomy in children

BACKGROUND: The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period. METHODS: The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively. RESULTS: Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically. CONCLUSION: LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.     

Laparoscopic excision of accessory spleen

BACKGROUND: Laparoscopic splenectomy has become an accepted procedure in the management of several hematologic diseases. Less clear is the effectiveness of laparoscopic excision of accessory spleens after initial splenectomy in the management of recurrent hematologic disease. We report here our early experience of this technique. METHODS: All patients who underwent laparoscopic excision of accessory spleens (LEAS) after initial splenectomy were reviewed for preoperative studies, technical success, and effects on either platelet count or hemoglobin level. RESULTS: In 5 patients LEAS was attempted. Two patients had initial open splenectomies, and 3 had initial laparoscopic splenectomies. Hematologic diagnoses were immune thrombocytopenic purpura (3), chronic lymphocytic leukemia-induced thrombocytopenia (1), and autoimmune hemolytic anemia (1). All patients underwent preoperative damaged red blood cell scintigraphy, which demonstrated functioning splenic tissue, and abdominal computed tomography scans, which demonstrated a nodule in 4 of 5 patients. LEAS was technically successful in 4 patients, with the 1 failure also being the patient in whom the computed tomography scan could not demonstrate the accessory spleen. However, only 2 of the 4 patients after LEAS had durable hematologic responses to surgery, despite follow-up damaged red blood cell scintigraphy showing no residual functioning splenic tissue. CONCLUSION: LEAS can be technically successful when the accessory spleen is demonstrated on both damaged red blood cell scintigraphy and computed tomography scan; therefore, adequate visualization in both studies is required. However, hematologic response to excision may be less effective than with the initial splenectomy. Further study is needed to determine the causes of these outcomes.     

Accessory spleens--diagnostic and therapeutic problem of the laparoscopic splenectomy in idiopathic thrombocytopenic purpura patients

The preoperative detection of accessory spleens (AS) is essential in ITP patients. The aim of this study was to evaluate the reasons of failure and long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP). Thirty-four ITP patients (27 females and 7 males) underwent LS between June 1998 and January 2001. Computed Tomography (CT) and sonography (US) were performed preoperatively to evaluate the size of the spleen and to detect the presence of possible accessory spleens which were found in two cases. AS were seen during laparoscopy in three cases. During follow-up (median time = 23 months), in three patients a low platelet count was seen after 5 months, 1.5 and 1.8 years pop. In all these cases scintigraphy was performed, which revealed in one case the residual accessory spleen. In the two other patients, inspite of thrombocytopenia no residual spleens were found. The authors conclude that laparoscopic splenectomy is a safe and effective procedure in patients with ITP. The problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy. The use of the preoperative imaging techniques for detection of accessory spleens is limited by the insufficient sensitivity of the examination.     

Steep learning curve of laparoscopic splenectomy

BACKGROUND AND PURPOSE: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned. METHODS: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed. RESULTS: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy. CONCLUSION: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.     

Outcome of laparoscopic splenectomy based on hematologic indication

BACKGROUND: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. METHODS: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty's syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 +/- 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. CONCLUSIONS: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.     

Accessory spleens: preoperative diagnostics limitations and operational strategy in laparoscopic approach to splenectomy in idiopathic thrombocytopenic purpura patients

Aim The preoperative detection of accessory spleen (AS) is still a very important and serious problem. The aim of the study was to assess the reasons for failure and the long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP).Method Fifty-eight ITP patients underwent LS between June 1998 and December 2002. There were 42 women and 16 men. Preoperatively, we performed computed tomography (CT) and sonography to evaluate the size of the spleen and possibly to recognize the presence of the accessory spleens, which were found preoperatively in three cases.Results Intraoperatively, ASs were found in the course of laparoscopy in six cases overall, three preoperatively false negative. During follow-up (median time 31 months), in three patients the low platelet count was recognized, respectively after 5 months and 1.5 and 1.8 years. In all those cases scintigraphy was performed and in one case the residual accessory spleen, missed both in preoperative examination and during laparoscopy, was revealed. In two other patients, in spite of thrombocytopenia, no residual spleens were found.Conclusion We conclude that the problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy, while the use of preoperative imaging techniques in detection of accessory spleens is still limited by the insufficient sensitivity of the examination.     

Experience with laparoscopic splenectomy

BACKGROUND/PURPOSE: The laparoscopic splenectomy (LS) often is adopted to treat children affected by hematologic diseases. Many of the pitfalls of LS are related to the 2 steps-dissection and extraction. Although various methods have been adopted, the conversion rate still is too high during the learning curve period. The authors analyse their experience in 54 laparoscopic splenectomies performed by their teams in 3 European countries. METHODS: From 1995 to 1999, 54 children underwent laparoscopic splenectomy, 4 of whom also underwent a concomitant cholecystectomy. There were 29 girls and 25 boys with ages ranging between 4 and 19 years (median, 8.1 years). All patients underwent an elective laparoscopic splenectomy: Thirty children had hereditary spherocytosis, 13 had an idiopathic thrombocytopenic purpura, 10 were affected by a beta thalassemia, and 1 child had sickle cell disease. RESULTS: Mean operating time was 140 minutes (range, 100 to 250 minutes). Hospital stay ranged from 2 to 6 days (median, 3 days). In 7 patients the spleen was removed through a 7-cm minilaparotomy; in another 46 cases the spleen was captured into an extraction bag, fragmented, and then removed through the umbilical or left orifice. There was one conversion to open surgery because of a camera failure during the operation. CONCLUSIONS: On the basis of our experience we believe that the operating time of LS is still too long compared with open surgery, and the extraction phase still not simple enough. A perfect control of hemostasis is fundamental because severe complications can arise from even a slight bleeding episode. It also is very important to search for and remove any accessory spleens. In our series this occurred in 7 patients, one of whom had 3 accessory spleens. The laparoscopic approach is today a good alternative to open splenectomy.     

Laparoscopic splenectomy for hematologic malignancies

BACKGROUND: Patients with hematologic malignancy (HM) tend to have large spleens. The purpose of this study was to compare the outcomes of laparoscopic splenectomy for patients with HM to those with benign disease (BD). METHODS: A review was conducted of a prospectively accumulated database of 64 consecutive, unselected laparoscopic splenectomies performed by two surgeons between March 1992 and August 1997. RESULTS: Of 14 patients with HM (7 lymphoma, 6 leukemia, 1 myeloid metaplasia), three required conversion to open splenectomy (21%). In the remaining 11 patients, two had postoperation complications (18%), including one death from sepsis (9%). Of 50 patients with BD (36 idiopathic thrombocytopenic purpura [ITP], 5 spherocytosis, 4 hemolytic anemia, and 5 others), three were converted to open surgery (6%). Complications developed in 5 (11%) of the remaining 47 patients. No deaths occurred. All patients who had spleens larger than 27 cm in diameter required conversion. Patients undergoing laparoscopic splenectomy for HM were older (54 +/- 16 years vs. 36 +/- 18 years; p = 0.002), had larger spleens (median 17.0 cm vs. 11.0 cm; p < 0.001), and had lower preoperation hemoglobin levels (113 +/- 30 g/L vs. 132 +/- 23 g/L; p = 0.03) than patients with BD. The HM group required longer operation time (239 +/- 73 min vs. 180 +/- 61 min; p < 0.01), but showed no differences with respect to operation blood loss (median, 100 vs. 165 mL), requirement for transfusion (median, 0.0 vs. 0.0 units), and length of hospital stay (median 3.0 vs. 3.0 days). CONCLUSIONS: Although patients with HM had larger spleens and required longer operation time for laparoscopic splenectomy, surgical outcomes were equivalent. The laparoscopic approach should be preferred, even for patients with HM. The only limitation appears to be splenic size greater than 27 cm.     

Laparoscopic splenectomy for treatment of patients with idiopathic thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy (LS) is one of the advanced laparoscopic procedures that benefit most from minimally invasive surgery. This study was undertaken to compare the operating time, blood loss, length of hospital stay, and platelet count response for patients with idiopathic thrombocytopenic purpura (ITP) undergoing open splenectomy (OS) versus LS. METHODS: We performed OS in 20 cases before 1992 and LS in 14 cases after 1993 for the treatment of ITP. RESULTS: The operating time was significantly shorter for OS than for LS (126 +/- 52 min versus 203 +/- 83 min, p < 0.01). Blood loss was less for OS than for LS (321 +/- 264 ml versus 524 +/- 648 ml, p = 0.287). None of the patients who underwent LS were converted to open surgery. Accessory spleens were found in four OS patients (20.0%) and four LS patients (28.6%). The postoperative hospital stay was significantly longer for OS patients than for LS patients (15.2 +/- 5.8 days versus 8.9 +/- 2.9 days, p < 0.0005). No significant difference was noted in the long-term results of splenectomy. CONCLUSIONS: Compared with OS, LS required more operating time, had the potential to cause greater blood loss, had a comparable incidence of accessory spleen and response rate, and appeared to shorten the postoperative stay.     

Refining the selection criteria for laparoscopic versus open splenectomy for splenomegaly

BACKGROUND: Although laparoscopic splenectomy is considered the procedure of choice for patients with normal-sized spleens, the benefits are less clear in the presence of splenomegaly, which represents a heterogeneous patient population with a variety of underlying diseases. The aim of this study was to compare the outcomes of laparoscopic (LS) and open splenectomy (OS) for spleens between 15 and 25 cm in length in order to identify strategies for patient selection for the laparoscopic approach. STUDY DESIGN: The medical records of concurrent patients undergoing splenectomy for splenomegaly (>15 cm in the long axis) from 2000 to 2005 were reviewed at two hospitals. At one hospital, LS was performed unless the spleen was >25 cm in length, while the other hospital used OS exclusively. Demographic, intraoperative, and postoperative variables were compared for patients potentially eligible for LS. Data are expressed as median (interquartile range) and were analyzed by using nonparametric tests. A value P < 0.05 was considered statistically significant. RESULTS: Sixty-five laparoscopic and 25 open splenectomies were performed at the two hospitals, of which 34 were for splenomegaly. Five open cases involved spleens >25 cm and were excluded, leaving 18 LS (13 hand assisted) and 11 OS for further analysis. The groups were similar in comorbidity score, spleen length, hematologic diagnosis, and intraoperative blood loss. The open group was younger, included more females, and had a shorter operative time. Time to oral intake (1 vs. 2 days; P = 0.04) and length of hospital stay (3 vs. 6 days; P = 0.01) were shorter in the LS group. Postoperative complications occurred in 7 (39%) LS and 6 (55%) OS patients (P = 0.47); these were major in 3 LS patients and 1 OS patient (P = 1.0). All 3 major complications after LS occurred in the 3 patients with myelofibrosis and involved a conversion or reoperation by laparotomy for bleeding. CONCLUSIONS: Laparoscopic splenectomy confers benefit for most patients with splenomegaly between 15 and 25 cm, as it is associated with faster time to oral intake and a shorter hospital stay. Major morbidity after laparoscopic splenectomy was mostly related to surgery for myelofibrosis. These patients did not derive any benefit from the laparoscopic approach due to bleeding complications, requiring a conversion or relaparotomy.     

Laparoscopic splenectomy

Laparoscopic splenectomy was attempted in 16 patients and was performed successfully in 13 (81%) patients with the diagnosis of idiopathic thrombocytopenic purpura (ITP), AIDS-related thrombocytopenia, Hodgkin's disease, or lymphoma. The operative time averaged 157 min, and autologous transfusion was required in four patients. The postsurgical stay averaged 3 days in patients with completely laparoscopic splenectomies and 4 days in patients whose spleens were removed through small counterincisions. No major complications secondary to the procedure itself occurred postoperatively. Conversion to open operation was necessary in three (19%) patients because of bleeding or splenomegaly. With careful selection of patients and mastery of the technique, laparoscopic splenectomy can be safely performed on normal or slightly enlarged spleens. The advantages are less pain, shorter hospitalization, and reduced disability as compared to open splenectomy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Phoenix, Arizona, USA, 3 April 1993     

Hand-assisted laparoscopic splenectomy versus open splenectomy for massive splenomegaly: 20-year experience at a Canadian centre

Background

Multiple techniques for splenectomy are now employed and include open, laparoscopic and hand-assisted laparoscopic splenectomy (HALS). Concerns regarding a purely laparoscopic splenectomy for massive splenomegaly (> 20 cm) arise from potentially longer operative times, higher conversion rates and increased blood loss. The HALS technique offers the potential advantages of laparoscopy, with the added safety of having the surgeon’s hand in the abdomen during the operation. In this study, we compared the HALS technique to standard open splenectomy for the management of massive splenomegaly.

Methods

We reviewed all splenectomies performed at 5 hospitals in the greater Vancouver area between 1988 and 2007 for multiple demographic and outcome measures. Open splenectomies were compared with HALS procedures for spleens larger than 20 cm. Splenectomy reports without data on spleen size were excluded from the analysis. We performed Student t tests and Pearson χ² statistical analyses.

Results

A total of 217 splenectomies were analyzed. Of these, 39 splenectomies were performed for spleens larger than 20 cm. We compared the open splenectomy group (19 patients) with the HALS group (20 patients). There was a 5% conversion rate in the HALS group. Estimated blood loss (375 mL v. 935 mL, p = 0.08) and the mean (and standard deviation [SD]) transfusion rates (0.0 [SD 0.0] units v. 0.8 [SD 1.7] units, p = 0.06) were lower in the HALS group. Length of stay in hospital was significantly shorter in the HALS group (4.2 v. 8.9 d, p = 0.001). Complication rates were similar in both groups.

Conclusion

Hand-assisted laparoscopic splenectomy is a safe and effective technique for the management of spleens larger than 20 cm. The technique results in shorter hospital stays, and it is a good alternative to open splenectomy when treating patients with massive splenomegaly.     

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders

BACKGROUND: Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. METHODS: We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. RESULTS: The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). CONCLUSIONS: Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.     

GS02LATERAL LAPAROSCOPIC SPLENECTOMY: THE AUCKLAND CITY HOSPITAL EXPERIENCE

Purpose To review the experience with laparoscopic splenectomy, to determine it’s efficacy for treating immune thrombocytopaenic purpura (ITP) and to highlight key technical issues with the operation. Methodology All splenectomies performed between 1992 and 2005 were identified from the Otago Surgical Audit and the clinical notes reviewed, including the laboratory records for follow‐up data related to the haematologic cases. Results There were 289 splenectomies performed over the 13 year period. The indications were trauma (111, 38%), haematologic disease (93, 32%), incidental (40, 14%) splenic malignancy (39, 13%), and other (8, 3%). Of the 68 patients with ITP, 49 (72%) had a lateral laparoscopic splenectomy (LLS) with no conversions, a 5% complication rate and one mortality. Based on platelet counts and the requirement for maintenance steroids there was a complete response in 44 (68%) patients at >6 months, a partial response in 16 (24%) and no response in 5 (8%) patients. A short video presentation will highlight the key steps for the safe and efficient performance of the LLS, including patient and port positioning, the use of ultrasonic dissection, splenic pedicle stapling, and morcellation. The indications for hand‐port assisted laparoscopic and open splenectomy will be discussed. Conclusions The LLS is the preferred approach to splenectomy for all but massive splenomegaly and can be performed safely with careful attention to key technical issues.     

Role of accessory spleen in recurrent chronic hematologic diseases]

Among 533 patients who were splenectomized between 1967 and 1981 for a chronic haemopathy, 8 were reoperated because of the reappearance of an accessory spleen, which was responsible for the relapse of the disease. Five patients were followed for idiopathic thrombopenic purpura (ITP), 2 for hereditary spherocytosis and 1 for a Hodgkin disease (this patient had been operated for an abdominal exploration and splenectomy). In all patients, a hepato-splenic scintigram with Tc 99 m permitted the discovery of the accessory spleens and the exploration was completed by the study of the half lifetime and sequestration of platelets or red blood cells. The disappearance of the haemorrhagic syndrome after removal of the accessory spleen was frank and didn't need any complementary treatment for 3 cases of ITP and 2 cases of spherocytosis and was incomplete and had to be completed by a secondary treatment for 2 cases of ITP and for the Hodgkin disease. The analysis and the interpretation of the results of this study can be helpful to establish the diagnosis and decide the treatment of accessory spleens which are discovered by a relapse of a chronic haemopathy, primarily treated by splenectomy.     

Gamma probe-confirmed laparoscopic accessory splenectomy

The simultaneous occurrence of idiopathic thrombocytopenic purpura (ITP) and Hodgkin's disease in the same patient is uncommon. There have been only a limited number of reported cases of newly diagnosed ITP following Hodgkin's disease. Even more uncommon is the development of ITP after splenectomy for Hodgkin's disease. Of the reported cases of ITP following splenectomy for Hodgkin's disease, all have been successfully treated with medical therapy. We report an unusual case of an accessory spleen causing ITP in a patient who had undergone a splenectomy for Hodgkin's disease 10 years earlier. The patient underwent hand-held gamma-probe-assisted laparoscopic accessory splenectomy.     

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy

Background: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown. Objective: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases. Methods: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS). Results: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12–44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence. Conclusions: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.