Open splenectomy is performed in most cases through a high left subcostal or midline incision. In cases of traumatic rupture, the spleen is grasped medially and the splenorenal ligament is divided. After dissection of diaphragmatic peritoneal attachments, the spleen is delivered in the direction of the incision. The short gastric vessels are ligated and divided. The hilum is exposed after dividing attachments to the colon. The tail of the pancreas should be gently separated from the spleen. The splenic vessels are individually ligated and divided. Accessory spleen(s) should be removed, if present.
In patients with traumatic injury, splenectomy should be avoided if possible. Suturing of the splenic laceration or partial splenectomy is preferred. In cases of partial splenectomy, ligation of the lower splenic segmental artery and vein may be indicated. The cut edge of the spleen is sutured with interrupted absorbable sutures, which may be placed over pledgets. The cut surface may be covered with omentum or a synthetic mesh.
The number of the ports used depends on the surgeon’s preference and range from 3 to 5 1,2,3,7. Ligation of the short gastric vessels is easily performed while the lateral attachments are still intact. A retractor or other instrument may be used to push the spleen medially to enable cutting the lateral peritoneal attachments and the splenocolic ligaments with cauterizing scissors or the harmonic scalpel. An instrument is passed posterior to the spleen to retract the hilum anteriorly, and the connective tissue is dissected until the splenic vessels are freed adequately for application of clips, suture, or endovascular staples. The pancreas, the mesentery, and omentum should be inspected for accessory splenic tissue. The spleen is placed into a sac which is introduced via the umbilical or anterior axillary port.
In cases where it is difficult to place the spleen into the endoscopic bag, filling the sac partially with irrigation fluids, tying an umbilical tape loosely around the middle portion of the spleen, or placing the spleen in the pelvis and the sac in the splenic bed, may help to retrieve the organ13. The umbilical incision can be enlarged slightly to enable removal of the spleen. Once inside the bag, the spleen can be divided into pieces by digital fracture with ring forceps, or by using an automatic tissue morcellator.
Surgical Therapy of Splenic Cysts
Nonparasitic splenic cysts that are symptomatic or are over 5 cm in diameter should be removed either by partial splenectomy or near-total cystectomy with decapsulation.5 These procedures can be performed laparoscopically. 4 Three or 4 canullas are used. For decapsulation, electrocautery scissors4 or ultrasonic shears may be used. It remains unclear whether fulgurization of the remaining cyst wall and omentopexy prevent recurrences.
The optimal treatment of hydatic splenic cysts is still debatable. Most authors recommend splenectomy following medical treatment 8, but successful conservative management by percutanous puncture under sonographic guidance and instillation of alcoholic or hypobaric solutions is reported.9 Partial cystectomy has been recommended for selected cases using laparoscopic techniques.10
Children with hemolytic disorders may suffer from concomitant gallstone disease. Laparoscopic cholecystectomy has been advocated as the procedure of choice for these patients and can often be performed at the time of the splenectomy.
Complications and Adverse Effects
The risk of postsplenectomy infections depends on the etiology of the disease. The majority of infections occur within 2 years after splenectomy and are fatal in almost 50% of cases. The incidence is low in patients with spherocytosis, ITP and splenic trauma and higher in Hodgkin’s disease (8%).
Splenoportal thrombosis following splenectomy is a rare complication.12, 14 The true rate of thrombotic complications after splenectomy is not defined, but early diagnosis and prompt initiation of anticoagulant therapy is mandatory. Port site splenosis has been reported after laparoscopic splenectomy13 and has to be considered in the differential diagnosis of port site pain and a palpable nodule. Leaks along the pancreatic tail can also rarely occur after splenectomy.
Tulman S, Holcomb GW, Karamanoukian HL, et al: Pediatr Laparoscopic Splenectomy. J Pediatr Surg 28:689-692, 1993
Bax NMA, Van Der Zee D: Laparoscopic Splenectomy: Is This the Way to Do It? Pediatr Endosurg & Innov Tech 5:281-286, 2001
Rescorla FJ, Engum SA, West KW, Tres Scherer LR 3rd, Rouse TM, Grosfeld JL: Laparoscopic splenectomy has become the gold standard in children. Am Surg 68:297-301, 2002
Van Der Zee DC, Kramer WL, Ure BM, Mokhaberi B, Bax NM: Laparoscopic management of a large posttraumatic splenic cyst in a child. Surg Endosc 13:1241-2, 1999
Morgenstern L: Nonparasitic splenic cysts: pathogenesis, classification, and treatment. J Am Coll Surg 194:306-14, 2002
Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002 Mar;37(3):453-6.
Reddy VS, Phan HH, O’Neill JA, Neblett WW, Pietsch JB, Morgan WM, Cywes R, Holcomb GWIII: Laparoscopic versus open splenectomy in the pediatric population: a contemporary single-center experience. Am Surg 67:859-63, 2001
Durgun V, Kapan S, Kapan M, Karabicak I, Aydogan F, Goksoy E: Primary splenic hydatidosis. Dig Surg 20:38-41, 2003
Ormeci N, Soykan I, Palabiyikoglu M, Idelman R, Erdem H, Bektas A, Sarioglu M: A new therapeutic approach for treatment of hydatid cysts of the spleen. Dig Dis Sci 47:2037-44, 2002
Bickel A, Loberant N, Singer-Jordan J, Goldfeld M, Daud G, Eitan A: The laparoscopic approach to abdominal hydatid cysts: a prospective nonselective study using the isolated hypobaric technique. ArchSurg 136:789-95, 2001
Ure BM, Eypasch EP, Troidl H: Long-term results after laparoscopic cholecystotomy in a child with symptomatic gallstone disease. Surg Endosc 11:671-72, 1997
Brink JS, Brown AK, Palmer BA, Moir C, Rodeberg DR: Portal vein thrombosis after laparoscopy-assisted splenectomy and cholecystectomy. J Pediatr Surg 38:644-7, 2003
Kumar RJ, Borzi PA: Splenosis in a port site after laparoscopic splenectomy. Surg Endosc 15:413-4, 2001
Rattner DW, Ellman L, Warsaw AL: Portal vein thrombosis after elective splenectomy. Arch Surg 128:565-570, 1993 and Skarsgard E, Doski J, et al: Thrombosis of the portal venous system after splenectomy for pediatric hematologic disease. J Pediatr Surg 28: 1109-1112, 1993.
This guideline was prepared by the IPEG Guidelines Committee and was reviewed and approved by the Executive Committee of the International Pediatric Endosurgery Group (IPEG) July, 2004.
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