Carl Westcott, MD. Wake Forest Medical Center , Winston-Salem, NC.
and Steve Eubanks, MD. Duke Medical Center, Durham, N.C.
Illustrations by Rob Flewell,CMI
A. Thrombocytopenia
1.Idiopathic Thrombocytopenic Purpura
a. Adults: if a trial of glucocorticoid therapy fails to produce a persistent improvement in platlet count.
b. Children : if there are important consequences of abnormal bleeding (ie. Intracranial hemorrhage)
2.Thrombotic Thrombocytopenic Purpura
The role for splenectomy in TTP is currently unclear. It may have a role in those resistant to plasmapheresis
B. Anemias
1.Erythrocyte Structural abnormalities
a.Hereditary Spherocytosis- splenectomy at 6 to 8 yrs of age.
b.Hereditary Eliptocytosis- if have symptoms of severe anemia.
c.Hereditary Pyropoikilocytosis- if severe, usually required as a child.
C. Hypersplenism
(Most of these patients will have splenomegaly, and will not be candidates for laparoscopic splenectomy. Although no size guidelines exist, we have had limited success with spleens over 18 to 20 cm in the long axis, and recommend open splenectomy in these patients.)
1. Primary Hypersplenism
2. Secondary Hypersplenism
a.Splenic Vein Thrombosis
b.Gaucher Disease
c.Felty Syndrome
d.SLE
D. Malignancy
Malignancy often confers splenomegaly, which increases the need for an open procedure. Although no real guidelines exist, laparoscopic splenectomy is not recommended for moderate and large sized spleens, as discussed for hypersplenism.
1.Hairy Cell Leukemia
2.Chronic Myelogenous Leukemia
a. Justified for compressive symptoms, or sequestration of cellular elements.
3. Chronic Lymphocytic Leukemia
a. For splenomegaly
A. Spleen Size
Although there is no real consensus on exactly what is too large, large spleens decrease the likelihood of successful laparoscopic removal. Routinely adding this risk and expense of laparoscopy to cases that are likely to be converted to open, is not an ideal appropriation of resources. Again, we tend to use the open technique for spleens that exceed 20cm in the long axis by CT scan. Borderline sized spleens can be attempted, if the dissection is successful, often placement in the removal bag can be difficult. If this occurs a small incision is made to avoid intra-abdominal fracture.
B. Physiologic Limitations
The surgeon stands on the patients left side of the table. The assistant stands across the table from the surgeon, but slightly cranial with respect to the patient. The camera operator stands either to the left of the surgeon, or to the right of the assistant
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1.)Fragmentation. If the spleen becomes lacerated or shows signs of fragmentation at any phase of bagging, a 6 to 8 cm incision is made at the mid axillary trocar site through which the spleen is removed manually. The risk of splenosis after fragmentation does not justify further attempts to place the spleen into the retrieval bag. If a laceration is made prior to devascularization the case is converted to open, using a left upper quadrant incision.
2.) Pancreatic injury. The abdominal side wall limits the ability to distract the spleen from the pancreatic tail in the laparoscopic approach. In some cases the tail of the pancreas will abut the splenic hilum, and a safe plane is not apparent. If this is the case the open approach is advocated, as the traction is greater through a midline incision. Pancreatic injury should be avoided at the cost of conversion to an open procedure if necessary.
Park A, Gagner M, Pomp A. The lateral approach to laparoscopic splenectomy. Am J Surg. 173(2):126-30, 1997 Feb.
Katkhouda N, Waldrep D, Feinstein D, et. al. Unresolved issues in laparoscopic splenectomy. Am J Surg. 172(5):585-9, 1996 Nov.
Gigot J,de Ville de Goyet J, Van Beers, B et.al. Laparoscopic splenectomy in adults and children: experience with 31 patients. Surgery. 199(4):384-9,1996 Apr.
Watson D, Coventry B, Chin T, et. al. Laparoscopic versus open splenectomy for immune thrombocytopenic purpura. Surgery. 121(1) : 18-22, 1997 Jan.
Rhodes M, Rudd M, O'Rourke N et.al. Laparoscopic splenectomy and lymph node biopsy for hematologic disorders. Ann Surg. 222(1):43-6, 1995, July.
Friedman R, Fallas M, Carroll B et.al. Laparoscopic splenectomy for ITP. The gold standard. Surg Endosc. 10(10):991-5,1996 Oct.