The Ascendance of Laparoscopic Splenectomy

R. MATTHEW WALSH, M.D.,* B. TODD HENIFORD, M.D., FREDRICK BRODY, M.D.,* JEFFREY PONSKY, M.D.*

From the *Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio and Department of Surgery, Medical Center of the Carolinas, Charlotte, North Carolina
The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/ mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50800). The mean morcellated weight of the entire group was 411 g (333300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (2933300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 15). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.

acceptance of laparoscopic choT lecystectomy has fostered an enthusiasm towards the modification of nearly all intra-abdominal operaHE SUCCESS AND

tions to laparoscopically assisted procedures with varying success. The goal of all laparoscopic procedures is to provide a safe and effective alternative that reduces patient discomfort and disability, utilization of resources, and costs.1 These requirements have clearly been achieved in the procedures of laparoscopic cholecystectomy, adrenalectomy, and antireflux surgery while being inconclusive for appendectomy, colectomy, and hernia repair. The role of laparoscopy for splenectomy also appears to fulfill these goals. Splenectomy may be required in the management of a variety of hematologic disorders and as a consequence of trauma. Depending on the nature of the disease removal of the spleen may be required for diagnosis, staging, or therapeutic reasons. Improvements in the diagnosis and treatment of hematologic

diseases have recently been complemented by the application of minimally invasive techniques to the performance of splenectomy. Several factors may combine to adversely impact the application of laparoscopy to splenectomy. These include the relative infrequency of the procedure, the advanced skills required, difficulty in directly manipulating the spleen, and attendant bleeding risks with the frequently concurrent cytopenias and dyscrasias. We sought to review our experience with laparoscopic splenectomy to determine its overall success and applicability.
Patient Characteristics

Address correspondence and reprint requests to R. Matthew Walsh, M.D., Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.

Laparoscopic splenectomy was introduced at the Cleveland Clinic in July 1995 and more recently at the Medical Center of the Carolinas in July 1998. Through September of 1999 a total of 150 elective laparoscopic splenectomies were attempted for nontraumatic, hematologic diseases as indicated in Table 1. Immune thrombocytopenic purpura (ITP) was clearly the most frequent indication in 75 patients, accounting for 50 per cent of the entire group. Other indications included lymphoma in 26 (17%); splenomegaly in 19 (12.6%); leukemia in 10 (6.6%); spherocytosis and hemolytic
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anemia in four each; splenic mass and thrombotic thrombocytopenic purpura (TTP) in three each; splenic abscess in two, and splenic cyst, torsion, and contained rupture in one each. There were 12 pediatric patients ranging in age from 4 to 17 years. The mean age of the remaining 138 adult patients was 54 years (range 1889), and there were 86 females and 64 males. Thirty-seven adults (27%) had splenomegaly as defined by a cranial-caudal length greater than 11 cm or a morcellated weight greater than 300 g. Additionally at the time of operation, 36 patients (24%) had a platelet count less than 50,000/mL, and 24 patients (16%) had a hemoglobin less than 10 mg per cent. The introduction of laparoscopic splenectomy did not replace open splenectomy, but it has largely supplanted its role. During the first 3 years after the introduction of laparoscopic splenectomy at the Cleveland Clinic a total of 115 splenectomies (open and laparoscopic) were performed, 23, 32, and 60 per year, respectively. During this period the proportion of laparoscopic splenectomies performed per year increased from 17 to 38 to 75 per cent, respectively. Over a short span of time laparoscopic splenectomy has largely replaced traditional splenectomy regardless of operative indication and has also resulted in an overall increase in the number of splenectomies performed.
Operative Technique

The right lateral decubitus position is our preferred approach for laparoscopic splenectomy and is particularly well suited for patients with splenomegaly. Enlargement of the spleen can result in unusual and rounded configurations that in addition to sheer size and weight make the spleen difficult to manipulate. There also may be areas of autoinfarction that lead to inflammatory adhesions to the diaphragm and omentum. Lateral positioning facilitates manipulation of the spleen by taking advantage of gravity to expose the
TABLE 1. Patient Characteristics: Indications for Laparoscopic Splenectomy No. of Patients ITP Lymphoma Splenomegaly Leukemia Hemolytic anemia Hereditary spherocytosis TTP Splenic mass Splenic abscess Splenic cyst Torsion Contained rupture Splenic artery aneurysm Total 75 26 19 10 4 4 3 3 2 1 1 1 1 150

retroperitoneal attachments and allow a safe dissection even in the presence of dense diaphragmatic adhesions. Fewer trocars are typically required and splenic retraction can be accomplished with less risk of capsular disruption. At least one week before operation patients receive a polyvalent pneumococcal, meningococcal, and polysaccharide Haemophilus-B conjugate vaccine. Prophylactic antibiotics are given immediately before surgery. Proper patient positioning and padding are important to achieve maximal operative exposure and avoid neurovascular traction and pressure injuries. Patients undergo endotracheal intubation in the supine position, a urinary catheter is placed, and any additional invasive monitoring that may be required is performed before rolling to a right-lateral decubitus position. The extended arms are secured by a double-arm board. Rolled blankets are placed at the umbilicus, between the legs, and in the right axilla. The operating-room table is flexed at the level of the umbilicus to lengthen the distance between the iliac crest and the costal margin. Laparoscopic splenectomy is typically a two-person operation with both persons facing the patients abdomen. The surgeon and assistant direct their attention to a single video monitor over the patients left shoulder for in-line operating. Reverse Trendelenburg position allows for blood and irrigation fluid to collect in the pelvis away from the operative field. Typically three 10-mm ports are required. Port sites are tentatively marked so that after insufflation the optimal positions will be 4 cm below the inferior tip of the spleen but within reach of the diaphragm. Substantial inferior and lateral placement of the trocars may be necessary with massive splenomegaly. Occasionally better access to the diaphragm is needed and can be accomplished with a fourth or fifth trocar positioned further posterior to the usual three trocars. The typical position of the lateral port is at the level of the 11th rib tip, the medial port is close to the midline, and the middle port is halfway between. An open insertion at the middle port is performed followed by all additional ports placed under laparoscopic guidance. A 5/10-mm 30 or 45 laparoscope is a requirement. Mobilization of the splenic flexure of the colon is performed when necessary. Proceeding in an inferior-to-superior direction the peritoneal attachments are sharply divided approximately one cm from the spleen. The dissection continues lateral to medial with retraction toward the midline by a blunt grasper until the pancreas and hilar vessels are visualized. Mobilizations of the inferior pole including branches from the epiploic vessels are divided between clips or with a harmonic scalpel. The operation proceeds best when the laparoscope is exchanged between the medial and lateral trocars and the

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surgeon operates with both hands. Care should be taken when mobilizing the superior pole to identify the greater curvature of the stomach and short gastric vessels. The remaining hilar pedicle is divided with a vascular gastrointestinal anastomosis stapler. Several firings of the stapler are usually required and may also be used to divide the short gastric vessels. If preferred a 10-mm right-angled clamp can individually dissect the hilar and short gastric vessels before placing clips. The spleen is then placed into an appropriately sized impermeable retrieval bag. This bag should be strong yet flexible so that it is easy to manipulate but will not rupture during extraction. Often the most challenging aspect of the operation is placing an enlarged spleen in the retrieval bag. This is facilitated by placing the closed end of the bag at the diaphragm and widely opening the bag toward the lateral trocar while holding the posterior lip of the bag with a left-handed instrument. The hilum is grasped with a right-handed instrument and the spleen is slid into the bag while the patient is placed in the Trendelenburg position. Occasionally placement of a massively enlarged spleen into the bag is expeditiously accomplished by using a hand-assisted technique. Typically the trocar site nearest the nondominant hand is enlarged to just allow insertion of the hand. The opening of the bag is delivered through the largest port site and excised in chunks with a ringed forceps. The abdomen is reinsufflated, the operative site is irrigated, and hemostasis is assured. A drain is placed if a pancreatic injury is suspected. The patients have the orogastric tube and typically the urinary catheter removed in the operating room. A liquid diet is started the evening after surgery and regular diet the first postoperative day. Patients are encouraged to ambulate beginning the day of surgery. Serum amylase and hemoglobin levels are obtained the morning after surgery.
Results

group was 411 g. The mean operative time was 161 minutes (range 69389). The average blood loss was 138 cm3 (range <50800), and only one patient, who had been converted, received a transfusion for operative bleeding. The mean length of stay after a successful laparoscopic splenectomy was 2.4 days (range 15). At a mean follow-up of 19 months there were nine patients with persistent recurrent ITP (12%); none were found to have a remaining accessory spleen by nuclear imaging. The types of complications related to laparoscopic splenectomy are similar to those of open splenectomy. There were two operative mortalities (1.3%) occurring within 2 weeks of surgery. Both had malignant hematologic disease, splenomegaly and cytopenias, and died from rapidly developing post-splenectomy sepsis, one with documented preoperative fungemia. An additional 14 patients (9%) developed complications requiring a prolonged hospital stay or readmission. The most common morbidity was pancreatic injury in seven (5%) which was manifested by clinical pancreatitis or an amylase-rich postoperative fluid collection. Additional complications included atelectasis in two, and in one patient each abscess, portal vein thrombosis, wound infection, pulmonary embolus, and repeat laparoscopy for suspected (but not found) bleeding.
Discussion

Laparoscopic splenectomy was able to be completed in all but two patients (98.6%). The reasons for conversion in these two patients with splenomegaly were a suspected gastrotomy in one and bleeding from a capsular tear in a previously irradiated spleen with extensive perisplenic adhesions in the other. Thus even in the setting of splenomegaly 94.6 per cent of procedures were successfully completed laparoscopically. The average cranial-caudal length in patients with splenomegaly was 17.3 cm (range 1225) with a mean weight of 735 g (range 2933300). In three patients a laparoscopic hand-assist device was required for manipulation or extraction of an enlarged spleen. The average morcellated splenic weight of the entire

Similar to other laparoscopic intra-abdominal procedures laparoscopic splenectomy has great appeal for patients requiring splenectomy. Introduced in 19912 laparoscopic splenectomy has offered an equivalent alternative to traditional splenectomy without protracted discomfort and disability and fewer wound and pulmonary complications. Rapid acceptance of the procedure has been noted in our experience by the current high proportion of laparoscopic splenectomies that occurred over a 3-year period despite the lack of prospective comparative trials. The transcendence of the procedure has corresponded with a simultaneous evolution in the operative technique. Not unexpectedly the initial laparoscopic attempts used an anterior approach to the spleen that closely resembled the traditional approach to splenectomy. This patient positioning requires more trocars yet results in frequent splenic rupture and conversions due to the need but the inability to directly manipulate the organ. The adaptability and creativity that has been fostered by laparoscopic surgery led to the modification of the procedure to a lateral approach.35 With the patient turned gravity acts as a retractor that greatly facilitates manipulation of the spleen and allows for blood to collect away from the operative field. This significant alteration in the procedure has been associated with successful comple-

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tion of the operation in 80 to 100 per cent of patients.3, 57 The addition of laparoscopic techniques has not altered the indications for any operation, including splenectomy (Table 2). Our early experience has shown a rapid rise in the total number of splenectomies performed and likely reflects broad patient and physician acceptance of laparoscopy and an increase in appropriate referrals. ITP is well suited for laparoscopic splenectomy and is the most frequent indication for operation. In our experience it accounted for half of all operations. The earliest attempts at laparoscopic splenectomy were performed for ITP owing to its overall frequency and normal splenic size.8, 9 Medical therapy is initially indicated for the treatment of ITP with splenectomy reserved for an inability to achieve or sustain remission or for complications developing during medical therapy. Durable responses to splenectomy are expected in 70 to 90 per cent of patients regardless of the operative approach.6, 1012 Concern has been raised as to the ability to identify accessory spleens that may be present in 10 to 30 per cent of patients and can result in recurrence of disease.1317 This problem may be of particular concern for patients operated in the lateral position, and one series has reported a 50 per cent persistence of splenic tissue by nuclear imaging, although few had clinically recurrent disease.18 Our results of a 12 per cent recurrence of ITP correspond favorably with other series as does the lack of missed accessory spleens by nuclear imaging.19 A diliTABLE 2. Indications for Splenectomy Hematologic disorders Hemolytic anemias Hereditary spherocytosis Thalassemia major Sickle cell disease Autoimmune hemolytic anemia Pyruvate kinase deficiency Thrombocytopenias ITP TTP Myeloproliferative disorders Myelofibrosis Neoplasia Hairy cell leukemia Hodgkins disease Non-Hodgkins lymphoma Chronic lymphocyte leukemia Miscellaneous disease Felty syndrome Gauchers disease Sarcoidosis Splenic cysts Splenic vein thrombosis Acquired immunodeficiency syndrome Splenic artery aneurysm Splenic abscess Trauma

gent search should routinely be made to identify accessory spleens during elective splenectomy in the splenic hilum, vascular pedicle, pancreatic tail, omentum, and splenic ligaments.15 Should a missed accessory spleen be ultimately discovered to account for recurrent disease then repeat laparoscopic excision may be accomplished.20 Splenectomy may be required for benign or malignant hematologic disease associated with splenomegaly. An enlarged spleen makes the performance more challenging because of the reduced functional operating space, limited retraction of the spleen, enlarged hilar vessels, and difficulty in placing the spleen in the retrieval bag. This is not an infrequent problem as 27 per cent of our laparoscopic patients had associated splenomegaly. Nearly all of these were completed laparoscopically and are typically associated with longer operative times, less blood loss, and shorter hospital stay as compared with traditional surgery.21 Our experience has shown that laparoscopic splenectomy is particularly difficult for spleens greater than 20 cm in length or after radiation to the spleen and splenomegaly. We recommend a hand-assist technique for spleens >23 cm in length or >19 cm in diameter. Two of the most common causes of splenomegaly in our experience were chronic lymphocytic leukemia and non-Hodgkins lymphoma. Splenectomy is warranted for these types of hematologic malignancies for diagnosis, treatment of intractable pain, respiratory compromise, and amelioration of hypersplenism and immune-mediated cytopenias.5, 22 The suspicion of malignant disease is not a contraindication for laparoscopic splenectomy, but additional care should be taken to avoid splenic disruption. Laparoscopic splenectomy may also be successfully applied to staging in Hodgkins disease when the status of abdominal disease will alter management.23, 24 There is reason to be optimistic that the acceptance of laparoscopic splenectomy will result in earlier diagnosis and effective palliation of hematologic malignancies. Perioperative complications are well known after splenectomy and are not eliminated by the adaptation to laparoscopy. The dreaded and often lethal complication is that of overwhelming post-splenectomy infection. Fortunately rare, fulminant sepsis accounts for an operative mortality in 2 to 4 per cent of patients after splenectomy and is usually related to the underlying malignant hematologic disease.2527 The incidence of post-splenectomy sepsis has not been higher in those having laparoscopic splenectomy, nor have the other postoperative complications. The overall morbidity of laparoscopic splenectomy should not exceed 10 per cent and is usually attributable to hemorrhage or pancreatitis. In our experience pancreatic injury is the most frequent complication and typically

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Complications (%)

LS

8 10 14 7 0 0 23

resolves without intervention. The injury occurs at the pancreatic tail as the splenic hilum is divided and may well occur as often with open splenectomy. Intervention when necessary is directed toward symptomatic fluid collections that can be accessed by percutaneous drainage. Hemorrhage during routine laparoscopic splenectomy is minimal in our experience with a large number of patients having an operative blood loss less than 50 mL. In general laparoscopic splenectomy compares favorably with open splenectomy (Table 3). The two approaches are similar in amount of blood loss, complication rate, and efficacy in treatment of hematologic disease. Laparoscopic splenectomy appears superior to open splenectomy in amount of postoperative pain, parenteral analgesic use, length of hospital stay, and return to normal activity. The experience to date indicates that laparoscopic splenectomy is indicated for all elective splenectomies.
REFERENCES

Hospital Days

Blood Loss (mL)

274 437 359 NA NA 376

OS

138 320 259 385 NA NA 222

LS

6.7 6.7 8.8 10 5.8 5.8

OS

2.3 4.8 3.5 2.3 2 3.0 2.5

LS

1. Glasgow RE, Yee LF, Mulvihill SJ. Laparoscopic splenectomy: The emerging standard. Surg Endosc 1997;11:10812. 2. Delaitre B, Maignien B, Icard P. Laparoscopic splenectomy. Br J Surg 1992;79:1334. 3. Park A, Gagner M, Pomp A. The lateral approach to laparoscopic splenectomy. Am J Surg 1997;173:12630. 4. Smith CD, Meyer TA, Goretsky MJ, et al. Laparoscopic splenectomy by the lateral approach: A safe and effective alternative to open splenectomy for hematologic diseases. Surgery 1996; 120:78994. 5. Walsh RM, Heniford BT. Laparoscopic splenectomy for non-Hodgkins lymphoma. J Surg Oncol 1999;70:11621. 6. Tsiotos G, Schlinkert RT. Laparoscopic splenectomy for immune thrombocytopenic purpura. Arch Surg 1997;132:6426. 7. Rhodes M, Rudd M, ORourke N, et al. Laparoscopic splenectomy and lymph node biopsy for hematologic disorders. Ann Surg 1995;222:436. 8. Carroll BJ, Phillips EH, Semel CJ, et al. Laparoscopic splenectomy. Surg Endosc 1992;6:1835. 9. Lefor AT, Melvin WS, Bailey RW, Flowers JL. Laparoscopic splenectomy in the management of immune thrombocytopenia purpura. Surgery 1993;114:6138. 10. Akwari OE, Itani KM, Coleman RE, Rosse WF. Splenectomy for primary and recurrent immune thrombocytopenic purpura (ITP). Ann Surg 1987;206:52941. 11. Gigot JF, Lengele B, Gianello P, et al. Present status of laparoscopic splenectomy for hematologic diseases: Certitudes and unresolved issues. Semin Laparosc Surg 1998;5:14767. 12. Schlinkert FT, Mann D. Laparoscopic splenectomy offers advantages in selected patients with immune thrombocytopenic purpura. Am J Surg 1995;170:6246. 13. Olsen WR, Beaudoin DE. Increased incidence of accessory spleens in hematologic disease. Arch Surg 1969;98:7623. 14. Davis PW, Williams DA, Shamberger RC. Immune thrombocytopenia: Surgical therapy and predictors of response. J Pediatr Surg 1991;26:40712. 15. Rudowski WJ. Accessory spleens: Clinical significance

OS LS

Operative Time (min)

161 196 153 196 89 261 202 Cleveland Clinic (present study) Glasgow et al.1 (1997) Friedman et al.19 (1997) Diaz et al.28 (1997) Watson et al.29 (1997) Smith et al.4 (1996) Brunt et al.30 (1996) 28 74 15 47 10 20 150 52 63 15 13 10 26 156 121 116 84 131 134

14 34 13 19 20 30 OS open splenectomy; LS laparoscopic splenectomy; NA not applicable.

TABLE 3. Comparison of Open and Laparoscopic Splenectomy

No. of Patients

Study

OS

LS

OS

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with particular reference to the recurrence of idiopathic thrombocytopenic purpura. World J Surg 1985;9:42230. 16. Wallace D, Fromm D, Thomas D. Accessory splenectomy for idiopathic thrombocytopenic purpura. Surgery 1982;91:1346. 17. Glasgow RE, Mulvihill SJ. Laparoscopic splenectomy. World J Surg 1999;23:3848. 18. Gigot JF, Jamar F, Ferrant A, et al. Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. Surg Endosc 1998;12:1016. 19. Friedman RL, Hiatt JR, Korman JL, et al. Laparoscopic or open splenectomy for hematologic disease: Which approach is superior? J Am Coll Surg 1997;185:4954. 20. Morris KT, Horvath KD, Jobe BA, Swanstrom LL. Laparoscopic management of accessory spleens in immune thrombocytopenic purpura. Surg Endosc 1999;13:5202. 21. Terrosu G, Conini A, Baccarani U, et al. Laparoscopic versus open splenectomy in the management of splenomegaly: Our preliminary experience. Surgery 1998;124:83943. 22. Cusack JC, Seymour JF, Lerner S, et al. Role of splenectomy in chronic lymphocytic leukemia. J Am Coll Surg 1997;185: 23743.

23. Walsh RW, Heniford BT. Role of laparoscopy for Hodgkins and non-Hodgkins lymphoma. Semin Surg Oncol 1999;16: 28492. 24. Lefor AT, Flowers JL, Heyman MR. Laparoscopic staging of Hodgkins disease. Surg Oncol 1993;2:21720. 25. Flowers JL, Lefor AT, Steers J, et al. Laparoscopic splenectomy in patients with hematologic diseases. Ann Surg 1996; 224:1928. 26. Ellison EC, Fabri PJ. Complications of splenectomy: Etiology, prevention, and management. Surg Clin North Am 1983;63: 131330. 27. Shaw JH, Print CG. Postsplenectomy sepsis. Br J Surg 1989;76:107481. 28. Diaz J, Eisenstat M, Chung R. A case-controlled study of laparoscopic splenectomy. Am J Surg 1997;173:34850. 29. Watson DI, Coventry BJ, Chin T, et al. Laparoscopic versus open splenectomy for immune thrombocytopenic purpura. Surgery 1997;121:1822. 30. Brunt LM, Langer JC, Quasebarth MA, Whitman ED. Comparative analysis of laparoscopic versus open splenectomy. Am J Surg 1996;172:5969.