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INDICATIONS FOR LAPAROSCOPIC SPLENECTOMY




B Delaitre, MD , Hôpital Cochin, Paris, France




1. Introduction

2. Indications/laparoscopy

3. Indications/hematology

4. References


1. Introduction

The first laparoscopic splenectomy (LS) was reported by Delaitre and Maignien (1991) . It wasn’t until 1995, however, that studies presenting more than 16 cases were published ( Emmermann et al. , 1995; Flowers et al. , 1996; Gigot et al. , 1996; Katkhouda et al. , 1996; Delaitre et al. , 1995; Rhodes et al. , 1995; Park et al. , 1997 ). Recently, four studies were published, each presenting the results of more than 100 splenectomies (Table 1) ( Katkhouda et al. , 1998; Trias et al. , 2000; Park et al. , 1999; Delaitre et al. , 2000 ).

The indications for laparoscopic splenectomies depend on two correlating parameters:
  • technical possibilities of the laparoscopic approach;
  • hematological indications.

Table 1
Indications for laparoscopic splenectomy

Katkhouda et al. (1998)
Trias et al. (2000)
Park et al. (1999)
Delaitre et al. (2000)
Idiopathic thrombocytopenic purpura
67 (65%)
44 (39.6%)
90 (61%)
194 (70.5%)
ITP/HIV +
2
8
5
15
Thrombotic thrombocytopenic purpura
6
1
4
0
Hereditary spherocytosis
12
11
18
13
Auto-immune hemolytic anemia
10
8
5
24
Splenic cysts
0
1
4
0
Evans’ syndrome
0
3
1
2
Felty’s syndrome
0
0
0
2
Hypersplenism (portal hypertension)
0
0
7
0
Non Hodgkin’s lymphoma
0
17
1
12
Hodgkin’s lymphoma
1
0
7
0
Lymphocytic leukemia
0
2
3
0
Myelocytic leukemia
0
1
0
0
Tricholeukocytic leukemia
1
3
0
0
Myelocytic splenomegaly
1
2
0
2
Splenic tumor
2
3
0
6
Miscellaneous
2
7
2
5
Total
103
111
147
275




1. Introduction

2. Indications/laparoscopy

3. Indications/hematology

4. References


2. Indications related to the laparoscopic technique

2.1. Anterior approach

The initial technique was an anterior approach performed on a patient placed in a supine position ( Delaitre and Maignien, 1991 ). The spleen is located deep within the left hypochondrium. In order to expose it, traction must be exerted on the gastrosplenic ligament and on the splenic hilum which can cause hemorrhaging. This approach is particularly difficult to perform in obese patients. For these reasons, it is rarely used anymore.

2.2. Lateral approach

This technique, called the « Hanging Spleen » technique ( Delaitre, 1995 ) or the lateral approach ( Park et al. , 1997 ) is the usual LS procedure with the patient placed in lateral decubitus position. It has been adopted by most surgical teams. The spleen appears in the upper part of the operative field. The stomach, omentum and transverse colon are pulled toward the lower part of the operative field by their own weight, making the spleen perfectly visible. During the dissection, the spleen remains hanging by its splenodiaphragmatic attachments, facilitating access to the vascular pedicle. A comparative study of the anterior and lateral approaches ( Trias et al. , 1996 ) presents data in favor of the lateral approach with a shorter operative time, fewer trocars, fewer blood transfusions and a shorter hospital stay. This « Hanging Spleen » technique is also used in pediatric surgery.

2.3. Hand-assisted splenectomy

Massive splenomegaly may require special laparoscopic techniques, such as hand-assisted splenectomy ( Kusminsky et al. , 1995 ) which involves making an abdominal incision large enough to enable the surgeon to introduce a hand to assist in the dissection and control of the splenic vessels. If the dissection is performed using a pure laparoscopic approach, it is necessary to make a suprapubic incision or an incision in the left hypochondrium, measuring about 10 cm, to permit the extraction of the spleen. Splenomegaly is no longer considered to be an absolute contraindication. Targarona et al. (1998) has reported 19 splenectomies for spleens weighing over 400 g with a lower number of complications for the laparoscopic procedures as compared to open surgery.

2.4. Wall-lifting procedure

This recently published technique ( Nishizaki et al. , 1999 ) involves a small number of cases. The results are satisfying and comparable to those obtained after the establishment of a pneumoperitoneum.




1. Introduction

2. Indications/laparoscopy

3. Indications/hematology

4. References


3. Indications for laparoscopic splenectomy in hematology

There are no randomized trials comparing laparoscopic splenectomy to open surgery. However, several comparative retrospective studies have recently been published (Table 3: Rhodes et al. , 1995; Park et al. , 1999; Baccarani et al. , 1998; Brunt et al. , 1996; Delaitre and Pitre, 1997; Donini et al. , 1999; Friedman et al. , 1997; Glasgow et al. , 1997; Schlinkert and Mann, 1995; Smith et al. , 1996; Watson et al. , 1997 ). A distinction can be made between indications for which a consensus of experts exists (usually benign conditions) and those for which there is no real consensus (mostly hematological malignancies). Up until now, laparoscopic splenectomies have mostly been performed for benign conditions: idiopathic thrombocytopenic purpura and hemolytic anemias ( Klingler et al. , 1999 ) (Table 1).

Figure
Table 3
Series comparing laparoscopic splenectomy (lap) and open surgery (o)

3.1. Idiopathic thrombocytopenic purpura (ITP)

In the large published series, ITP represents 44% to 76% of cases reported (Table 1). The preoperative platelet count varies from 3,000 to 444,000 and the preoperative treatment usually results in an average platelet count >30,000 ( Katkhouda et al. , 1998; Delaitre et al. , 2000 ). This treatment can either be cortisone therapy with a dosage of 1 mg/kg for the 10 days preceding the operation, or gammaglobulin injections 3 days before the operation (this latter method is no longer used). A vaccination against pneumococcus, hemophilus and sometimes meningococcus is given preoperatively. The size of the spleen, evaluated by ultrasonography, is usually normal in this pathology. Prophylactic intraoperative and postoperative antibiotic therapy with Penicillin is usually recommended.

3.2. Hemolytic anemia

Hemolytic anemia is the second common indication for laparoscopic splenectomies in patients with hematological diseases, with an occurrence rate of 13.4, 17 and 21% respectively in the three series ( Katkhouda et al. , 1998; Trias et al. , 2000; Delaitre et al. , 2000 ). Hemolytic anemia includes hereditary spherocytosis (35 to 54% of cases: Katkhouda et al. , 1998; Delaitre et al. , 2000 ) and auto-immune hemolytic anemia (AIHA). Hereditary spherocytosis is an ideal indication for splenectomy which is usually performed for young patients over six years of age. Warm antibody AIHA is a good indication for splenectomy, contrary to cold anti-i AIHA. Because the spleen is often considerably enlarged in hemolytic anemia, the laparoscopic approach may be difficult.

LS is also performed for other benign hematological diseases: splenic infarct, Felty’s syndrome ( Trias et al. , 2000; Park et al. , 1999; Delaitre et al. , 2000 ), Vaquez’s disease ( Delaitre et al. , 2000 ), Evans’ syndrome ( Delaitre et al. , 2000 ), Gaucher’s disease ( Rhodes et al. , 1995; Katkhouda et al. , 1998 ), tuberculosis ( Rhodes et al. , 1995 ), aneurysm of the splenic artery ( Trias et al. , 2000 ), tumor (angioma, hamartoma) ( Trias et al. , 2000 ), hydatid cyst ( Trias et al. , 2000 ).

3.3. Thrombotic thrombocytopenic purpura (TTP)

Splenectomies are sometimes indicated for TTP ( Katkhouda et al. , 1998; Moake, 1991 ); however, the results reported in a recent study were disappointing ( Bell et al. , 1991 ). TTP is currently considered a borderline indication for splenectomy.

HIV infection is not a contraindication: 2% of cases reported by Katkhouda et al. (1998) and 7.1% of cases in the French study ( Delaitre et al. , 2000 ). In Castelman’s syndrome, the size of the spleen requires the use of particular techniques; either hand-assisted LS and/or laparotomy for extraction.

For cysts of the spleen, unroofing (partial splenectomy) should be preferred over splenectomy ( Targarona et al. , 1995 ).

3.4. Laparoscopic splenectomy and malignant disease

A consensus cannot be reported due to the small number of patients who have undergone this surgery. Nevertheless, four recent studies ( Rhodes et al. , 1995; Trias et al. , 2000; Donini et al. , 1999; Schlachta et al. , 1999 ) have given encouraging results. The limits of laparoscopy in the setting of malignant disease are related to several factors:
  • the large number of lymph nodes in the region of the hilus, especially in lymphomas which make access to the splenic vessels difficult.
  • splenomegaly, which requires an incision of about 10 cm in order to keep the spleen intact during extraction. Hand-assisted laparoscopy may also be performed, requiring a parietal incision of the same length.
  • the age of the patients, who are generally older than patients with benign conditions.

Currently, the indications for laparoscopic splenectomy in patients with malignancies remain restricted. The use of LS has been reported for non-Hodgkin’s lymphomas ( Rhodes et al. , 1995; Trias et al. , 2000; Delaitre et al. , 2000; Donini et al. , 1999; Schlachta et al. , 1999 ), Hodgkin’s lymphomas (although splenectomies have practically been abandoned in the management of this disease [ Emmermann et al. , 1995; Rhodes et al. , 1995; Katkhouda et al. , 1998; Park et al. , 1999 ]), a few cases of lymphocytic leukemia ( Trias et al. , 2000 ), myelocytic leukemia ( Trias et al. , 2000 ), very few rare cases of adenocarcinoma ( Rhodes et al. , 1995 ), and massive myeloid splenomegaly ( Katkhouda et al. , 1998; Targarona et al. , 1998 ).

3.5. Contraindications

In addition to the general contraindications for laparoscopy (major cardiac failure), contraindications mainly include portal hypertension (though Park et al. , 1999 has reported a few cases).




1. Introduction

2. Indications/laparoscopy

3. Indications/hematology

4. References


4. References

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