Pédiatrie Endosurgery & Innovative Techniques

Volume 2, Number 3, 1998

Mary Ann Lieben, Inc.

How I Do It

A New Technique for Laparoscopic Splenectomy

in Children with Massive Splenomegaly

ANDRÉ HEBRA, M.D., EDWARD P. TAGGE, M.D., JOHN T. JOHNSON, M.D.,

ELISE HARDEE, R.N., and H. BIEMANN OTHERSEN, Jr., M.D.

ABSTRACT

Splenectomy is indicated in several hématologie disorders, and it can be particularly chal-

lenging in children with sickle cell disease (SSD), splenomegaly, and recurrent sequestra-
tion. The authors report a new technique for laparoscopic splenectomy in children with hy-
persplenism and splenomegaly using an intracorpórea! morcellator. With this technique,
splenectomy is accomplished by sequential coring of splenic tissue, which allows for safe and
complete laparoscopic removal of very large spleens, even in small children. It provides ex-
pedient recovery and minimal postoperative pain and scarring. This new approach should
enable surgeons to perform laparoscopic splenectomy even in patients with massive
splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the
creation of additional incisions to remove the spleen.

INTRODUCTION

is emerging as an acceptable method for extracting the relatively inaccessible, vascular,

Laparoscopyfragile spleen
and often found in several hematological disorders.1,2 Laparoscopic splenectomy has
been described in adults and in children with various modifications, including the use of accessory bags
and additional incisions for removal of this organ.3,4 A particular challenge, however, remains in the pédi-
atrie population with sickle cell disease (SSD), splenic sequestration, and resultant splenomegaly.5 These
patients are often at high risk for postoperative complications as a consequence of the surgical stress and
insult that result from the large surgical incisions currently required to extract the enlarged spleen follow-
ing laparoscopic assisted mobilization or conventional open splenectomy. To our knowledge, this report is
the first to describe a new procedure for successful laparoscopic splenectomy using an intracorporeal splenic
fragmentation technique.

Division of Pédiatrie Surgery, Medical University of South Carolina, Charleston, South Carolina.

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MATERIALS AND METHODS

Before surgery, it is helpful to obtain ultrasonographic evaluation of the degree of splenomegaly, because
evaluation of splenic size by percussion or palpation is notoriously inaccurate. This can be easily accom-
plished by ultrasonographic measurement of the greatest longitudinal diameter of the spleen: from the dome
to the tip, measured at the hilum in the coronal plane. Using tables that correlate the normal measurement
in centimeters with age, one can objectively determine the degree of splenomegaly. Significant splenomegaly
is present when this measurement exceeds three times the expected measurement for age.

Technique
After induction of general endotracheal anesthesia, the patient is placed in the lateral decubitus position
with the left side up and the abdomen slightly hyperextended (which is accomplished by flexing the mid-
portion of the operating room table).6 Figure 1 illustrates the positioning of the patient. An orogastric tube
is placed, and then removed at the completion of the procedure. Urinary catheters are not necessary. By use
of the Hasson (open) technique, a 10-mm trocar is placed in the left upper quadrant in the midclavicular
line, lateral to the umbilicus. Through this port, a 10-mm 30° angled laparoscope is introduced. If a 5-mm
30° angled laparoscope is available, a 5-mm trocar can be used instead of the 10-mm camera port. Under
direct visualization, three additional ports are placed: two 5-mm and one 12-mm, as illustrated in Fig. 2.
The lateral position allows the use of gravity to keep the colon, stomach, and left lobe of the liver away
from the operative field. A single 5-mm splenic retractor (also known as a liver retractor) is used to lift the
spleen and expose its attachments. Once the splenocolic ligament is divided, careful dissection exposes the
hilum until the splenic artery and vein are identified. The splenic vessels are divided with either an endo-
scopie linear stapler or large hemoclips. The harmonic scalpel can be used to divide short gastric vessels
and the splenorenal and spleno-phrenic ligaments. Once the spleen is totally mobilized and devascularized,
it is placed in the left upper quadrant of the abdomen. Again, by use of the Trendelenburg position and lat-
eral rotation of the operating room table, gravity will keep the spleen in the ideal location, against the di-
aphragm and the lateral abdominal wall. The Steiner electromechanical morcellator (Karl Storz, Tuttlingen,
Germany) is then used to systematically core the spleen, pieces being extracted through the 12-mm port
until the entire spleen is removed (Fig. 3). The left upper quadrant is then irrigated, and the entire peri-

FIG. 1. Patient placement in the lateral decubitus position (left side up) with the table flexed and the kidney rest el-
evated to provide maximal exposure of the left upper quadrant of the abdomen.

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FIG. 2. Placement of the trocars for laparoscopic splenectomy.

FIG. 3. The spleen (1) is devascularized (2) and placed against the lateral abdominal wall (3). The Steiner morcella-
tor (5) and a gallbladder grasping instrument (6) are introduced through a 12-mm port (4). It is important to note that
slight traction must be applied with the gallbladder grasper to sequentially bring segments of spleen into the rotating
blade of the morcellator (7) as it is advanced into the spleen (8).

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 HEBRA ET AL.

FIG. 4. The Steiner electromechanical morcellator from Karl Storz.

tonealcavity is examined carefully in a search for any residual fragments or for an accessory spleen. Small
fragments may occasionally be found in the left upper abdomen and should be removed. All trocar sites are
closed with absorbable sutures on the fascia and on the skin.

DISCUSSION

Laparoscopic splenectomy has been successfully performed since 1991 in a relatively small number of
adult patients.7,8 All reports describe the use of intracorporeal bags for extraction of the splenic remnant or

FIG. 5. Appearance of the spleen after complete removal using the Steiner electromechanical morcellator (shown
disassembled in this picture).

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the creation of a counter-incision to remove this organ. 1^1,9~11 Furthermore, in cases of massive
large
splenomegaly, most surgeons are reluctant to perform laparoscopic splenectomy, because placement of the
spleen in an intracorporeal bag is quite challenging, and counter-incisions are often necessary for removal
of the spleen, obviating the advantages of laparoscopic surgery.
Few reports address the use of laparoscopic technique for splenectomy in pédiatrie patients,4,5 primarily
because of the few absolute indications for splenectomy in the early pédiatrie years and the limited num-
ber of surgeons who perform advanced laparoscopic procedures in children. The technique described in this
report offers an innovative method for laparascopic splenectomy in very small patients even if massive
splenomegaly is present. This technique is relatively easy to learn and perform, and it affords complete (to-
tal) splenectomy as confirmed by follow-up liver-spleen scans done in our population of patients. We have
used this technique for 2 years and have not seen any cases of splenosis.
The Steiner electromechanical morcellator (Fig. 4) has been used primarily by gynecologic surgeons to
remove uterine tissue and fibroids. To our knowledge, this device had never been used for the purpose of
removing cores of splenic tissue, and this application was first developed at our institution. An important
technical point when this device is used is that the morcellator and a gallbladder grasper are used in con-
junction to pull segments of the spleen into the rotating circular blade of the morcellator. The morcellator
must be driven into the splenic tissue as slight and constant traction is applied on the tissue grasper to bring
the spleen into the rotating blade (see Fig. 3). It is important to carefully follow and visualize the ad-
vancement of the morcellator in order to avoid accidental injury to the diaphragm or viscera. The blade is
sharp, and if not carefully used it may result in injury to adjacent structures. Sequential morcellation of the
spleen is performed until the entire organ has been removed in cylindrical fragments, as illustrated in Fig.
5. The specimen is then collected for analysis, and the pathologist is still able to obtain detailed histologie
information, because several intact fragments of splenic tissue are available.
Important points about the use of this technique must be emphasized. First, the lateral position provides
excellent visualization and easy mobilization of the spleen. Second, the intracorporeal coring of splenic tis-
sue allows for safe and complete removal of the spleen with fewer ports and without the use of cumber-
some bags or additional incisions. Third, the use of this technique will extend the advantages of laparo-
scopic surgery to many patients who are likely to benefit the most: children with significant comorbidities
related to their underlying hématologie disorder and splenomegaly.

REFERENCES

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10. Emmermann A, Zomig C, Peiper M, et al: Laparoscopic splenectomy: Technique and results in a series of 27 cases.
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Address reprint requests to:
André Hebra, M.D.
Department of Surgery
Medical University of South Carolina
900 MUSC Complex, Suite 612
Charleston, SC 29425

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