Laparoscopic partial splenectomy in children

The description of the laparoscopic partial splenectomy in children covers all aspects of the surgical procedure used for the management of primarily benign tumoral pathologies and cases of hypersplenism. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligation, transection of parenchyma, end of procedure. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   partial   splenectomy   in   children

Authors
G Podevin, Y Héloury
Abstract
The description of the laparoscopic partial splenectomy in children covers all aspects of the surgical procedure used for the management of primarily benign tumoral pathologies and cases of hypersplenism.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligation, transection of parenchyma, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2003-02
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WeBSurg.com, Feb 2003;3(02).
URL: http://www.websurg.com/doi-ot02en243.htm

Laparoscopic   partial   splenectomy   in   children

1. Introduction
Partial splenectomy is preferable to total splenectomy. The major long-term risk of total splenectomy is sudden overwhelming infection (septicemia and meningitis). This risk is especially significant for children less than 5 years old (Nelson Textbook of Pediatrics, 2000).
Laparoscopy is our preferred approach for this procedure, because it is minimally invasive, and allows for good control of the vascular pedicles (Reinberg, 2001).
2. Anatomy
• Topography
• Diaphragmatic surface
The spleen is situated in the left upper abdominal quadrant. Its axis corresponds to the axis of the 10th left rib, but can vary with the patient's body habitus.
The diaphragmatic or posterior external surface is convex and entirely covered with peritoneum.
• Renal surface
The renal or inferior internal surface is concave, faces caudally and medially, and is covered with peritoneum.
The superior pole or posterior internal surface is curved and lies in the region of the 10th intercostal space.
• Gastric surface
The gastric or anterior internal surface is concave, faces medially and anteriorly, and contains the splenic hilum.
• Colonic surface
The colonic or anterior inferior surface (the base of the spleen's irregular pyramid shape) is slightly concave, and faces caudally, medially and slightly anteriorly.
• Ligaments
• Pancreaticosplenic
1. Pancreaticosplenic ligament
The spleen is fixed in the left hypochondrium to neighboring anatomical structures by ligaments.
The pancreaticosplenic ligament attaches the posterior margin of the hilum to the tail of the pancreas and to the splenic vessels on the lower renal surface of the spleen. This peritoneal fold is referred to as the mesentery of the spleen. It measures 3 to 8 cm in length. The longer the ligament, the easier the splenectomy.
• Gastrosplenic
1. Gastrosplenic ligament
The gastrosplenic ligament attaches the anterior margin of the hilum to the greater curvature of the stomach, on the gastric surface of the spleen. It contains the short gastric vessels and the gastro-omental artery, which are branches of the splenic artery.
• Phrenicosplenic
1. Phrenicosplenic ligament
The phrenicosplenic ligament attaches the diaphragm to the superior pole of the hilum.
• Splenocolic
1. Splenocolic ligament
The splenocolic ligament attaches the base of the hilum to the left transverse mesocolon and to the splenic flexure, on the colonic surface of the spleen.
• Phrenicocolic
1. Phrenicocolic ligament
The phrenicocolic ligament is a triangular fold of peritoneum attaching the left flexure of the colon and the diaphragm to the lower extremity of the spleen.
• Vasculature
• Arteries
1. Celiac trunk
2. Superior polar artery
3. Inferior polar artery
The major blood supply to the spleen comes from the splenic artery, which originates from the celiac trunk. It divides on the anterior surface of the tail of the pancreas into a superior and an inferior trunk. The distance between this division and the hilum is variable (Poulin and Thibault, 1993). Each of these 2 terminal branches gives rise to 2 or 3 rami in the hilum, and often to a superior polar artery and to one or more inferior polar arteries (Liu et al., 1996).
The vascular supply is terminal with no anastomosis.
Short gastric vessels can arise from all of the preceding arteries.
• Veins
1. Splenic vein
2. Short gastric vein
3. Left gastro-omental vein
The veins, which are equal in number to the arteries, arise from the hilum. They are located posterior to the arteries in a similar pattern. The splenic vein receives drainage from the short gastric veins and the left gastro-omental vein, and courses along the posterior surface of the pancreas.
3. Indications
Indications
The indications are primarily benign tumoral pathologies and, for certain authors, cases of hypersplenism.

Benign tumoral indications:
- hamartoma or splenoma (Diebold et al., 1987);
- epidermoidal cyst;
- localized lymphangioma or hemangioma.

Hematologic indications:
Partial removal is indicated in very young children, for whom total splenectomy is contraindicated due to the risk of septicemia (Idowu and Hayes-Jordan, 1998). The disorders concerned include congenital anemias (hereditary microspherocytosis, pyruvate kinase deficiency, sickle cell anemia, beta-thalassemia) and thrombocytopenias (idiopathic thrombocytopenic purpura). Recurrences of hypersplenism are common, but they occur when the patient is old enough to undergo a reoperation to complete the splenectomy (Reinberg, 2001). Partial splenectomy is nevertheless controversial because of a potential complication due to the remaining splenic tissue, ie hypersplenism with risk of secondary spontaneous rupture and massive hemoperitoneum.

Contraindications
Contraindications exist for partial splenectomy and for laparoscopy.

Partial splenectomy:
Partial splenectomy cannot be performed for tumors that are located medially because of the terminal blood supply of the spleen. In these cases, total splenectomy is indicated.

Laparoscopy:
Laparoscopic splenectomy is contraindicated in children suffering from congenital heart disease with a right-to-left shunt, because of the risk of massive gas embolism from intraperitoneal CO2 and the risk of hemodynamic instability (Sfez et al., 1996; Sfez, 1994).
4. Preoperative management
With hypersplenism or extensive exeresis of the spleen, vaccines for encapsulated organisms such as pneumococcus, meningococcus, and Haemophilus influenzae type b should be administered before splenectomy.
In patients with hemolytic anemia, an abdominal ultrasound is required to check for associated cholelithiasis, in which case a combined cholecystectomy is performed.
A complete blood count with coagulation profile is mandatory.
Blood or platelet transfusions may be required in case of intraoperative bleeding.
5. Operating room set-up
• Patient
The patient is placed in semi-lateral decubitus position.
• Team
1. The surgeon is on the patient’s right.
2. The first assistant is to the right of the surgeon.
3. The second assistant is on the patient’s left.
• Equipment
1. Operating table adapted for pediatric procedures (homeothermic maintenance)
2. Anesthetic equipment
3. Laparoscopic unit
4. Monitor on each side of the operating table
5. Monopolar or bipolar electrocautery
6. Instrument table
6. Trocar placement
• Trocar placement
The trocars are placed in a curved pattern, at a slight distance from the left costal margin, depending on the size of the patient.
Most pediatric teams establish the pneumoperitoneum with an open method. A moderate insufflation pressure, <= 10 mm Hg, is used. The smaller the child, the weaker the pressure required.
• Trocars A, B, C, D
• Trocar A
A 13 mm horizontal incision is made on the midline, between the xiphoid process and the umbilicus. The linea alba is incised transversally. The 10 mm optical trocar is introduced without a tip. In small children, the trocar and laparoscope may be 5 mm or 7 mm, but the view obtained must be excellent.
• Trocar B
A second, 12 mm trocar is inserted on the midclavicular line, under the left costal margin.
This is an operating trocar, through which the scissors, dissector, staplers, clip appliers, and extraction bag are introduced.
• Trocar C
A third, 5 mm trocar is inserted on the anterior axillary line, under the left costal margin.
It is used for retracting or operating instruments.
• Trocar D
A fourth, 5 mm trocar is inserted under the xiphoid process. This is an operating trocar, through which the grasping forceps are introduced.
• Trocar E
Trocar E (5 mm) is optional. It is inserted on the midclavicular line under the right costal margin. It is an operating trocar through which the atraumatic grasping forceps are introduced. In a small child, in whom the working space is reduced, these forceps retract the left transverse colon to expose the hilar area of the spleen. It should be considered the primary location for a fifth trocar, if needed in a difficult dissection or in a surgeon’s initial experience.
7. Instruments
• Optical devices
1. Visual axis
2. Visual field
3. 0° or 30° laparoscope
Most authors use laparoscopes with a 0° or 30° visual axis, and a 70° visual field.
• Operating devices
1. Grasping forceps
2. Ultrasonic dissectors
3. Scissors
4. Clip applier
5. Linear stapler
6. Dissector
• Retractors
1. Grasping forceps
2. Flexible retractor
3. Peanut swab
• Other devices
1. Suction-irrigation device
2. Extraction bag
An extraction bag is used. When the operative specimen is bulky, large bags that require a 15 mm trocar are used.
8. Exploration
Video-assisted surgery permits complete exploration of the abdominal cavity.
The surgeon can check the mobility of the spleen and identify any perisplenic adhesions during the exploration.
It is also important to make sure that there is no associated or generalized pathology and, in the case of a hematologic indication, that there is no accessory spleen that would need to be removed.
9. Exposure
• Freeing of adhesions
The spleen is often hidden by omental adhesions or by the stomach or splenic flexure.
The adhesions must be freed to better expose the spleen.
• Gastrosplenic ligament
Once the anterior margin of the spleen has been exposed, a grasping forceps is introduced through the axillary trocar to retract the spleen toward the left to visualize the gastrosplenic ligament.
10. Dissection
• Principles
After the anterior surface of the splenic hilum is exposed, the lesser sac is opened. This is relatively easy to do with the ultrasonic scissors, which coagulate and divide the gastro-omental and short gastric vessels. This opening is limited to the inferior part of the lesser sac for an exeresis of the inferior pole of the spleen. It involves the division of the short gastric vessels for an exeresis of the superior pole.
• Gastro-omental vessels
1. Gastro-omental vessels
The division of the gastro-omental vessels, caudad to cephalad, permits opening of the inferior recess of the lesser sac.
• Short gastric vessels
1. Inferior short gastric vessels
2. Anterior surface of the tail of the pancreas
Ascending division of the inferior short gastric vessels further opens the lesser sac and permits the retraction of the stomach toward the right, exposing the anterior surface of the tail of the pancreas.
11. Ligation
• Recommendations
Control of the vascular supply is the most delicate step of the procedure. The surgeon must:
- proceed cautiously and calmly, taking the time needed;
- perfectly visualize each maneuver;
- carefully prepare the pedicle and its various branches before ligation or stapling.
If bleeding occurs during this step, control of the vessels becomes very difficult. A conversion and a transfusion may be required.
• Splenic branches
• Identification
1. Splenic artery
2. Splenic vein
Dissection of the hilar area enables the surgeon to identify 2 or 3 splenic branches, each of which comprises an artery anteriorly and a vein posteriorly. The choice of the area to be excised is made at this point, according to the location of the tumor or following the hematologist’s opinion in the case of a hematologic indication.
If the pancreas is embedded in the hilum, a posterior approach may be used for this dissection, after the posterior peritoneum is opened and the phrenicosplenic ligament is divided.
• Dissection
1. Splenic artery
2. Splenic vein
This dissection is carried out to free the splenic branches from their remaining attachments. A dissector is used. The freeing must be performed with care, especially during the separation between the artery and the vein, due to the small diameter and fragility of these vessels.
• Ligation
• Branch of splenic artery
The branch of the splenic artery is stapled, using 2 clips proximally and 1 clip distally. It is then divided.
• Branch of splenic vein
The branch of the splenic vein is stapled or ligated distally. It is then coagulated and divided proximally using ultrasonic dissectors or a bipolar grasper. Stapling is rarely possible, due to the lack of space between the vascular structures.
12. Transection of parenchyma
1. Biological glue
2. Omentum
Immediately after the arterial ligation, a line of demarcation appears between the devascularized portion of the spleen and the normal spleen. Using the active jaw of the ultrasonic dissectors, the surgeon scores a transection line on the surface of the parenchyma, 1 cm from the line of demarcation on the devascularized side of the spleen. This landmark will be used to find the dissection plane at the end of the transection of the parenchyma.
The parenchyma is cauterized and divided with the ultrasonic dissector in its slow mode, to prevent oozing that could obstruct the visual field. A clean transection will avoid the potential loss of fragments in the abdominal cavity and the risk of splenosis.
Perfect hemostasis of the cut section makes it unnecessary to use hemostatic sponges or drainage. The omentum can be placed in contact with the cut section with biological glue to reduce the risk of postoperative adhesions.
13. End of procedure
Retrieval precautions
Extraction of the operative specimen is less difficult than during a total splenectomy, because of the more moderate volume. It is important to avoid rupturing the spleen, which would cause contamination of the abdominal cavity by the splenic pulp.
The retrieval bag must be sturdy enough to not tear during the extraction, and large enough to contain the whole specimen.

Extraction site
The retrieval bag is used when the operative specimen is small or decreased in size by puncture of a cyst, or when the pathologist agrees to analyze the fragmented operative specimen after fracture of the spleen. In these cases, the bag is extracted through the 12 mm operating trocar.
Otherwise, the operative specimen can be extracted through a Pfannenstiel incision, which gives better cosmetic results than an enlargement of the subcostal incision.

Lavage and closure
Lavage of the peritoneal space is performed after bagging the operative specimen, but before its extraction, which induces an exsufflation.
The trocar wounds and incision are closed.

Postoperative management
For hypersplenisms, antibiotic therapy (penicillin) is administered for 3 months, and stopped once the platelet count is normalized.
14. Conclusion
Partial splenectomy in children is feasible via laparoscopy. It requires an exacting operative technique and a surgical team skilled in laparoscopic splenectomy. As in all minimally invasive techniques, its advantages include improved cosmetic results, decreased postoperative discomfort, and minimal wound morbidity (Ho, 2002; Idowu and Hayes-Jordan, 1998; Seshadri et al., 2000).
15. Reference
Behrman RE, Jenson HB, Kliegman R, editors. Nelson Textbook of Pediatrics, 16th ed., Philadelphia:
W. B. Saunders Company; 2000.
Diebold J, Audoin J, Le Tourneau A, Caulet S. Pathologie splénique : les lésions pseudo-tumorales.
Revue française des laboratoires 1987;166:157-64.
Ho CM. Splenic cysts: a new approach to partial splenectomy. Surg Endosc. 2002;16:717.
Idowu O, Hayes-Jordan A. Partial splenectomy in children under 4 years of age with
hemoglobinopathy. J Pediatr Surg 1998;33:1251-3.
Liu DL, Xia S, Xu W, Ye Q, Gao Y, Qian J. Anatomy of vasculature of 850 spleen specimens and its
application in partial splenectomy. Surgery 1996;119:27-33.
Poulin EC, Thibault C. The anatomical basis for laparoscopic splenectomy. Can J Surg 1993;36:484-8.
Reinberg O. Splénectomies partielles par laparoscopie chez l’enfant. Le journal de coelio-chirugie
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Seshadri PA, Poulin EC, Mamazza J, Schlachta M. Technique for laparoscopic partial splenectomy.
Surg Laparosc Percutan Tech 2000:10;106-9.
Sfez M. Anesthésie pour coeliochirurgie en pédiatrie. Ann Fr Anesth Reanim 1994;13:221-32.
Sfez M, Veyckemans F, Lejus C, Ricard C, Raux O, Hayem C et al. Facteurs favorisant les incidents
lors de la coeliochirurgie en pédiatrie. Cah Anesthesiol 1996;44:101-2.