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.     

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.     

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     

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.     

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 removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy

The clinical success of therapeutic splenectomy for idiopathic thrombocytopenic purpura depends on the complete removal of all functional splenic tissue. Among reasons for poor response to splenectomy, failure to remove accessory spleens is mentioned. We present our experience with laparoscopic removal of accessory spleen from retroperitoneal space in a patient with relapse of ITP 30 years after classical splenectomy. A 45-year-old female patient underwent in 1972 classical splenectomy for ITP. Progressive decline in thrombocyte count was observed 7 years ago. Scintigraphy, CT, and ultrasound revealed residual splenic tissue. A laparoscopic approach was proposed. Four trocars placed along left costal margin were used. After dissection of all the adhesions behind the pancreatic tail deep in the retroperitoneal space a round structure 4 cm in diameter, macroscopically resembling splenic tissue, was found. The accessory spleen was removed intact. The patient recovered well; 2 months later steroids were discontinued while the thrombocyte level was 251 x 10(9)/L. Identification of accessory spleen seems to be major intraoperative problem. We believe that accessory spleen can be safely removed laparoscopically, avoiding a major open procedure, and a satisfactory postoperative result could be expected.     

Use of a laparoscopic hand-assist device for accessory splenectomy

Background The use of a laparoscopic hand-assist device may aid in the identification of accessory spleens (ASs) and provide similar benefits to a conventional laparoscopic procedure. A patient with previous splenectomy for immune thrombocytopenic pupusa (ITP) and recurrent thrombocytopenia is reported.Method A computed tomography scan and RBC scan identified several nodules consistent with ASs. Initial laparoscopic exploration could not identify all the ASs seen on preoperative imaging. A hand-assist device was placed and a total of five nodules of splenic tissue were identified without conversion to laparotomy.Results The patient had a brief and uncomplicated postoperative course with a return of platelet counts to 350,000 at 1-month follow-up.Conclusion We propose that in the scenario of recurrent ITP following laparoscopic splenectomy, repeat laparoscopy is the first step once an AS is identified by preoperative imaging. If the AS is not identified at laparoscopy, the insertion of a hand-assist device is an alternative to a full laparotomy.Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, California, USA, March 2003     

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 surgery of the spleen: state of the art

INTRODUCTION: Laparoscopic splenectomy (LS) offers superior visualization and access to the spleen and avoids the major laparotomy incision necessary in open splenectomy (OS). This review summarizes the current knowledge of laparoscopic techniques for splenectomy from the perspective of surgeons whose combined experience now totals 340 cases. BACKGROUND AND DISCUSSION: While LS has been applied across the spectrum of splenic diseases, it is most indicated in treatment of a benign hematologic condition with a normal or slightly enlarged spleen as seen in autoimmune thrombocytopenic purpura (ITP), autoimmune deficiency syndrome-related ITP, hemolytic anemia, or spherocytosis. Both anterior and lateral approaches have been used for LS. While benefits of the anterior approach include access to the splenic artery along the superior border of the pancreas within the lesser sac, thus securing vascular control early in the procedure, the lateral approach allows for improved exposure of and access to the splenic pedicle. Also, mechanics and sequence of dissection are enhanced and more intuitive to the surgeon using the lateral approach, and the tail of the pancreas is more easily identified. Potential perioperative complications of LS include hemorrhage, injury to the tail of the pancreas, and deep vein thrombosis. The most common criticisms facing LS are the potential for missed accessory spleens, longer operating time, and greater operating room costs compared to OS. However, while LS requires a longer operating time than OS, studies indicate shorter postoperative hospital stays for LS versus OS patients in comparable cases, which can, in turn, reduce the total hospital cost for the procedure. CONCLUSION: Although LS continues to pose certain technical challenges--such as management of the massive spleen, specimen extraction, and identification of remotely located accessory spleens--its advantages over OS in terms of faster postoperative recovery, shorter hospital stay, and equivalent or lower perioperative morbidity are now well established. Indications for LS and more laparoscopic spleen-conserving surgery are likely to broaden.     

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.     

Hematological long-term results of laparoscopic splenectomy for patients with idiopathic thrombocytopenic purpura: a case control study

Background Laparoscopic splenectomy (LS) for idiopathic thrombocytopenic purpura (ITP) appears, when compared to open splenectomy (OS), associated with immediate important advantages. However, in a number of patients splenectomy does not lead to an adequate response, or after initial adequate response a relapse occurs after some time. A relapse may be associated to the presence of accessory spleens and splenosis. The purpose of this study was to compare the operative outcome and the hematological results on the long term of a series of LS with a historic series of OS for the treatment of ITP.Methods A retrospective review was done of 50 consecutive patients who underwent LS for ITP. Patient characteristics, outcome of surgery, and hematological results were compared to a historical group of patients who underwent conventional splenectomy for ITP (n = 31). Response to splenectomy was defined in three groups: complete remission, partial remission, and no response. Grouping was based on hematological data.Results Concerning operative outcome and postoperative complications, there was a significant difference in favor of LS. Moreover, the hematological outcome of both groups showed no differences after a median period of 66 months (OS) and 35 months (LS), respectively.Conclusions Hematological results after laparoscopic splenectomy for ITP are comparable to those after open splenectomy in both the short and the long term.     

Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases

BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.     

腹腔镜脾切除对难治性ITP治疗的应用价值

目的探讨腹腔镜脾切除术(LS)治疗难治性特发性血小板减少性紫癜(ITP)的可行性和疗效。方法回顾性分析2 0 0 2年9月—2 0 0 6年3月1 8例难治性ITP(血小板计数<5 0×1 09/L)行LS的临床资料。结果1例中转传统开腹手术。1 7例完成LS,手术时间为5 2~1 7 2m in,平均9 2m in;术中出血量3 0~5 0 0mL,平均1 0 2mL。3例术中发现副脾并切除。术后1周内血小板上升,胃肠蠕动恢复时间为1 2~2 4 h,平均住院时间为8 d。发生并发症2例(腹壁静脉刺破出血)。1 7例随访2~3 7个月,1例复发。结论腹腔镜脾切除术治疗ITP是安全可行的,且临床疗效显著。     

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     

Laparoscopic splenectomy for hematological diseases

Background: We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens. Methods: Between June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n = 23), hemolytic anemia (HA) (n = 5), and hematological malignancy (HM) (n = 15). Statistical analyses were done to compare the three groups. Results: LS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure. Conclusions: The statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.     

Laparoscopic splenectomy for ITP

Background: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. Methods: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. Results: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 ± 35 min) significantly shorter than for the first ten (p= 0.01) and also shorter than for OS (103 ± 45 min). Postsurgical hospital stay was 2.9 ± 1.3 days for LS and 6.9 ± 3.0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 ± 0.5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 ± 3,636 for LS and $9,031 ± 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. Conclusions: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS. Received: 26 March 1996/Accepted: 11 May 1996     

Laparoscopic splenectomy

PURPOSE: To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with hematologic disorders requiring surgical intervention. PATIENTS AND METHODS: A series of 103 consecutive adult patients underwent LS between 1992 and 1997 at our teaching hospital. Data were collected prospectively. The indications for splenectomy included idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, and thrombotic thrombocytopenic purpura. RESULTS: The mean spleen size was 14 cm (range 8.5-24 cm) and the mean weight was 263 g (range 40-210 g). Accessory spleens were detected in 12 patients with ITP and 17 patients in the study overall. In 12 patients, LS was combined with a laparoscopic cholecystectomy for gallstones. There were four conversions to open splenectomy, all for hemorrhage and all occurred in the first 50 patients. We have not converted a single patient in the last 2 years. The mean operative time was 161 minutes and was greater in the first 10 cases than the last 10. There were no deaths. Postoperative complications occurred in six patients, one necessitating a second procedure for a small-bowel obstruction. The average length of stay in the hospital was 2.5 days. After surgery, thrombocytopenia resolved in 84% of patients with ITP and anemia resolved in 92% of the patients with hereditary spherocytosis. After a mean follow-up of 38 months (range 2-565 months), four patients (6%) showed a relapse of ITP, three within 12 months of surgery. CONCLUSIONS: Laparoscopic splenectomy can be performed safely and effectively in a teaching institution. LS in comparison with open surgery offers the same efficacy in the control of hematologic disease with the additional benefits of a minimally invasive approach. Laparoscopic splenectomy should therefore be considered the technique of choice and should prompt earlier consideration of surgery for patients with selected hematologic disorders.     

Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura and hemolytic anemia

BACKGROUND: Laparoscopic splenectomy is an effective treatment for idiopathic thrombocytopenic purpura (ITP) and hemolytic anemia that has a remission rate of 80-90%. In some patients in whom the disease persists or recurs, a diagnosis of accessory spleen is made. The long-term efficacy of laparoscopic accessory splenectomy is unknown. METHODS: Patients who underwent laparoscopic accessory splenectomy were followed in the outpatient clinic. The perioperative course, blood counts, and need for medical therapy to maintain a normal count were recorded. RESULTS: Eight patients underwent laparoscopic accessory splenectomy. All procedures were completed laparoscopically, and all patients were discharged on the 1st postoperative day. Patients were available for a follow-up period of 15 months range, (3-27). None of the ITP patients achieved a complete remission. Two of them had a partial remission, and five ITP patients are now being treated with chronic corticosteroids to maintain a platelet count of >100,000/ml. CONCLUSION: Laparoscopic accessory splenectomy is associated with a low rate of morbidity and a short hospital stay. Despite its success in removing all residual splenic tissue, most patients will probably not enjoy a complete remission.     

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.     

Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients.

OBJECTIVE: To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders. SUMMARY BACKGROUND DATA: The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce. METHODS: One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients. RESULTS: Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months. CONCLUSIONS: LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.