Handheld gamma probe used to detect accessory spleens during initial laparoscopic splenectomies

Background Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention. Methods This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure. Results In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination. Conclusion Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.     

Laparoscopic accessory splenectomy using intraoperative gamma probe guidance

In cases of accessory splenic tissue in postsplenectomy patients, it is of utmost importance to localize the accessory spleen prior to surgery. Several studies have shown the feasibility of laparoscopic resection of accessory splenic tissue using preoperative scintigraphy. We present the cases of three postsplenectomy patients with accessory splenic tissue causing relapsing hematologic disease. Accessory spleens were diagnosed and localized preoperatively by positive uptake of heat-damaged Tc99m-labeled red blood cells using scintigraphy. Two patients with relapse of immune thrombocytopenic purpura and one with hemolytic anemia underwent handheld gamma probe-assisted laparoscopic accessory splenectomy. One patient with immune thrombocytopenic purpura recovered his platelet count at 3-year follow-up. The other patient had a relapse of disease within 3 months despite successful removal of the accessory spleen. The patient with hemolytic anemia had postoperative relapse; two accessory spleens were identified on radionuclide investigation. The use of intraoperative nuclear imaging can greatly aid in localization and provide confirmation of complete laparoscopic excision of the nuclear focus. The technique is especially useful in cases of a small accessory spleen, by avoiding a major open procedure and contributing to good postoperative results.     

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.     

Preoperative computed tomography and scintigraphy to facilitate the detection of accessory spleen in patients with hematologic disorders

Accessory spleens of 1.5 cm in size were preoperatively identified by the combined use of computerized tomography and splenic scintigraphy in two patients with hematologic diseases. After the accessory spleen had been removed from the first patient, who had persistent hereditary spherocytosis and had undergone a splenectomy 15 months before, a postoperative decrease in hyperbilirubinemia was noted. In the other patient who had idiopathic thrombocytopenic purpura, a successful accessory splenectomy was done at the same time as her splenectomy, and was followed by 6 months' complete remission. These events indicate that preoperative investigations using computerized tomography and scintigraphy are indispensable for ruling out an accessory spleen in those patients for whom splenectomy needs to be done in order to alleviate hematologic disorders.     

Preoperative computed tomography and scintigraphy to facilitate the detection of accessory spleen in patients with hematologic disorders

Accessory spleens of 1.5 cm in size were preoperatively identified by the combined use of computerized tomography and splenic scintigraphy in two patients with hematologic diseases. After the accessory spleen had been removed from the first patient, who had persistent hereditary spherocytosis and had undergone a splenectomy 15 months before, a postoperative decrease in hyperbilirubinemia was noted. In the other patient who had idiopathic thrombocytopenic purpura, a successful accessory splenectomy was done at the same time as her splenectomy, and was followed by 6 months' complete remission. These events indicate that preoperative investigations using computerized tomography and scintigraphy are indispensable for ruling out an accessory spleen in those patients for whom splenectomy needs to be done in order to alleviate hematologic disorders.     

Symptomatic pelvic accessory spleen

Accessory spleens are found most commonly at the splenic hilum, however, they rarely are symptomatic. An 18-year-old man presented with lower abdominal pain. Cross-sectional imaging studies with 3-dimensional reconstruction suggested the presence of a mass that was associated with the spleen. A nuclear medicine radioisotope scan confirmed that the mass was a pelvic accessory spleen. Laparoscopic excision was performed with excellent results. This accessory spleen was unusual in its size and location. Accessory spleens should be removed if symptomatic or if they are identified at splenectomy for hematologic disease.     

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.     

An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy. METHODS: Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups. RESULTS: A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group. CONCLUSIONS: The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.     

Handheld gamma probe localization of accessory splenic tissue in recurrent idiopathic thrombocytopenic purpura

Recurrent idiopathic thrombocytopenic purpura due to residual splenic tissue after splenectomy is uncommon. Location of the offending splenic tissue can be technically demanding. A small accessory spleen was localized intraoperatively with a handheld gamma probe after standard technetium-labeled heat-damaged red blood cell scan of the liver and spleen.     

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 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 accessory splenectomy with intraoperative gamma probe localization for recurrent idiopathic thrombocytopenic purpura

Laparoscopic excision of retained splenic tissue has been described as a treatment of recurrent hematologic disease after formal splenectomy. It is associated with a shorter hospital stay, more rapid recovery, and lower or equivalent morbidity compared with open surgery. However, intraoperative identification of residual splenic tissue remains difficult, particularly when preoperative computed tomography or magnetic resonance imaging results are unremarkable. It has been suggested that the laparoscopic approach has a lower success rate due to the loss of tactile feedback. We report a case of successful laparoscopic excision of retained splenic tissue using technetium sulfur colloid injection and intraoperative gamma probe localization in a patient with recurrent idiopathic thrombocytopenic purpura, 12 years after open splenectomy. This represents the first report of this intraoperative adjunctive measure for the laparoscopic identification and excision of functional accessory splenic tissue.     

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.     

Results of laparoscopic and open splenectomy for nontraumatic diseases

The medical records of patients who had undergone splenectomy for nontraumatic diseases of the spleen between 1997 and 2000 were reviewed. The aim of the study was to evaluate the short-term outcomes of open and laparoscopic splenectomies and to determine whether some well-known benefits of laparoscopic surgery could be observed in patients who underwent laparoscopic splenectomy for nontraumatic splenic diseases. The data of 44 patients were available for analysis and included 20 patients (45.5%) who underwent laparoscopic splenectomy and 24 patients (54.5%) who underwent open splenectomy. Various parameters were reported for open and laparoscopic procedures separately, including associated surgical procedures, spleen weight, postoperative mortality and morbidity rates, perioperative blood transfusions, use and length of abdominal drainage, accessory spleen removal, operative times, length of hospital recovery, and hematologic parameters on admission to and discharge from the hospital. Laparoscopic splenectomy was successfully completed in all 20 considered patients with no conversion to open splenectomy. The supine position and four trocars were adopted in all patients. Accessory spleens were found in four (9.0%) patients: two (4.5%) during open splenectomy and two (4.5%) during laparoscopic splenectomy. The postoperative mortality rate was 2.7% (a case of myocardial infarction). The morbidity rate was 9% (four patients), but no postoperative complications occurred after laparoscopic splenectomy. A significant statistical difference was shown by the increase in platelet counts after open versus laparoscopic splenectomy. The open and laparoscopic mean operative times (73.70 +/- 13.42 minutes and 78.42 +/- 14.63 minutes, respectively) were comparable. These times were comparable also considering patients who underwent only splenectomy. Mean recovery time was shorter after laparoscopic splenectomy (3.95 +/- 0.60 days) than after open splenectomy (7.0 +/- 1.68 days). After open procedures, however, the mean recovery time was shorter in uncomplicated cases (6.68 +/- 1.49 days) than in the open group as a whole. Authors conclude that many well-known advantages of the laparoscopic approach. especially those related to its low invasiveness, can be observed in patients requesting splenectomy for nontraumatic diseases of the spleen, without lowering the efficacy of this operation. They suggest that such advantages can be entirely displayed when selection criteria of the patients are applied.     

Laparoscopic surgery for splenic disorders

Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April-1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with ^99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approach's safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted. Received: 29 January 1997/Accepted: 22 May 1997     

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.     

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.     

Unusual presentation of right-side accessory spleen mimicking a retroperitoneal tumor

Abstract:   An unusual case of right-side retroperitoneal accessory spleen is presented. A 68-year-old man visited our hospital for the management of incidentally detected retroperitoneal mass. The computed tomography scan of the abdomen revealed the presence of a retroperitoneal tumor (4.0 × 3.8 cm) at the right suprarenal space. Laparoscopic excision was carried out with excellent results. On histological examination, the tumor exhibited a structure typical of splenic tissue. This accessory spleen was unusual in its size and location. Though it existed at the right side, surgeons should be aware of the possible existence of accessory spleens for the differential diagnosis of retroperitoneal tumors.     

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.