Overview
Definition:
Laparoscopic splenectomy is a minimally invasive surgical procedure to remove the spleen using laparoscopic techniques
It involves small incisions, a laparoscope, and specialized instruments to perform the dissection and ligation of blood vessels and tissues surrounding the spleen.
Epidemiology:
While open splenectomy was historically the standard, laparoscopic splenectomy is now the preferred approach for elective splenectomy in adults and children, with conversion rates to open surgery decreasing as surgeon experience grows
Indications vary based on geographic location and prevalent diseases.
Clinical Significance:
Splenectomy is indicated for various hematological disorders, splenic rupture, hypersplenism, and certain infiltrative diseases
Laparoscopic splenectomy offers significant advantages over open surgery, including reduced postoperative pain, shorter hospital stays, quicker return to normal activities, and improved cosmesis, making it crucial for surgical trainees to master.
Indications
Hematological Disorders:
Immune thrombocytopenic purpura (ITP), hereditary spherocytosis, thalassemia, autoimmune hemolytic anemia (AIHA), lymphomas, and other myeloproliferative neoplasms
Indicated when medical management fails or for specific complications.
Splenic Trauma:
Hemodynamic stability with splenic injury where non-operative management is not feasible or has failed
Laparoscopic approach is preferred for elective repair or resection of contained hematomas.
Splenic Masses And Cysts:
Benign or malignant splenic tumors, large splenic cysts, or abscesses requiring removal
Diagnostic uncertainty or symptomatic lesions are key drivers.
Hypersplenism:
Enlarged spleen causing pancytopenia due to sequestration of blood cells
Often associated with liver cirrhosis and portal hypertension, though splenectomy is a palliative measure in such cases.
Splenic Infarction And Abscess:
Splenic infarcts that are symptomatic or progressing, and splenic abscesses that are not responsive to antibiotic therapy, may necessitate splenectomy.
Preoperative Preparation
Hematological Assessment:
Complete blood count (CBC) with differential, peripheral smear for morphology, coagulation profile (PT, INR, aPTT), and platelet count are essential
Vaccination against encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis) is crucial 2 weeks prior to surgery.
Imaging Studies:
Abdominal ultrasound, CT scan of the abdomen with intravenous contrast, and MRI are used to delineate splenic size, shape, location, assess for associated pathology (masses, cysts, thrombosis), and evaluate surrounding structures.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is typically required
Careful attention to fluid management, potential for blood loss, and monitoring for coagulopathy are paramount.
Patient Counseling:
Discussing the procedure, potential risks (bleeding, infection, injury to adjacent organs), benefits of minimally invasive approach, and the lifelong risk of infection post-splenectomy (Overwhelming Post-splenectomy Infection - OPSI)
Patients should be educated on symptoms of OPSI and when to seek immediate medical attention.
Procedure Steps
Patient Positioning And Trocar Placement:
Patient is usually placed in a supine position with slight left tilt
Four ports are typically used: a camera port (umbilicus), and three operating ports in the left upper quadrant
Variations exist based on spleen size and surgeon preference.
Mobilization Of The Spleen:
The spleen is mobilized by dissecting the short gastric vessels, the gastrocolic ligament, and the splenophrenic ligaments
Careful dissection near the pancreas and stomach is essential to avoid injury.
Ligation Of Splenic Vessels:
The splenic artery and vein are meticulously identified, isolated, and ligated using staplers, clips, or energy devices
Ligation of the main vascular pedicle is typically the last step before spleen removal.
Spleen Retrieval:
The resected spleen is placed into a specimen retrieval bag and removed through one of the larger port sites, often the umbilical or epigastric incision, after morcellation if necessary for large spleens
Careful inspection of the specimen bag for intactness is vital.
Hemostasis And Closure:
Thorough inspection for hemostasis is performed, especially around the pancreatic bed
Drains are rarely used
The port sites are closed with sutures or adhesive strips.
Postoperative Care
Pain Management:
Adequate analgesia, often multimodal, including IV or oral opioids and NSAIDs, is crucial for early mobilization and comfort.
Monitoring For Complications:
Close monitoring for bleeding (hemorrhage), intra-abdominal fluid collections (seroma, abscess), pancreatitis, and injury to adjacent organs (stomach, colon, diaphragm)
Vital signs, urine output, and abdominal examination are critical.
Dietary Advancements:
Early return to a clear liquid diet, advanced as tolerated to a regular diet, is encouraged to promote gastrointestinal function.
Early Ambulation:
Encouraging patients to ambulate as soon as possible helps prevent deep vein thrombosis (DVT), pulmonary embolism (PE), and promotes lung expansion, reducing the risk of pneumonia.
Antibiotic Prophylaxis:
While routine prophylactic antibiotics are not typically used post-splenectomy, empiric antibiotics may be considered if infection is suspected
Long-term antibiotic prophylaxis is generally not recommended for immunocompetent individuals post-elective splenectomy, but patient education on OPSI risk is paramount.
Complications
Early Complications:
Bleeding (intra-abdominal hematoma, hemoperitoneum), intra-abdominal infection (abscess), pancreatic injury (pancreatitis, pancreatic fistula), injury to surrounding organs (stomach, colon, diaphragm, left kidney), pneumothorax
Subphrenic abscess is a significant concern.
Late Complications:
Overwhelming Post-splenectomy Infection (OPSI) - a life-threatening sepsis, venous thromboembolism (DVT/PE), portal vein thrombosis, incisional hernia at port sites
Recurrence of the underlying hematological disorder if splenectomy was performed for such conditions.
Prevention Strategies:
Meticulous surgical technique, careful dissection, adequate hemostasis, appropriate use of retrieval bags, thorough intraoperative inspection, and patient education regarding OPSI risk and prompt medical attention for febrile illness
Post-splenectomy vaccination and antibiotic prophylaxis in specific high-risk scenarios are key.
Prognosis
Factors Affecting Prognosis:
The underlying disease for which splenectomy is performed is the most significant prognostic factor
For trauma or benign conditions, prognosis is generally excellent
Factors like surgeon experience, presence of comorbidities, and development of complications influence outcomes.
Outcomes:
Laparoscopic splenectomy is associated with excellent short-term outcomes and reduced morbidity compared to open surgery
Long-term survival is largely determined by the primary diagnosis
The risk of OPSI, though low, is a critical consideration.
Follow Up:
Regular follow-up with hematologist and surgeon is recommended
Patients should be educated about the lifelong risk of OPSI and advised to carry a medical alert card
Prompt treatment of fevers and signs of infection is critical
Annual influenza vaccination and booster doses for pneumococcal and meningococcal vaccines are advised.
Key Points
Exam Focus:
DNB/NEET SS exams frequently test indications for splenectomy, differences between open and laparoscopic approaches, key anatomical structures at risk, methods of vascular control, and management of post-splenectomy complications, especially OPSI.
Clinical Pearls:
Always vaccinate against encapsulated organisms before elective splenectomy
Be meticulous with hemostasis, especially around the pancreas
Use a retrieval bag for spleen extraction to prevent contamination
Counsel patients extensively on OPSI risks and symptoms.
Common Mistakes:
Inadequate pre-operative vaccination, failure to identify and ligate all short gastric vessels, injury to the pancreas, inadequate hemostasis, and not adequately counseling patients on post-splenectomy infection risks
Converting to open surgery unnecessarily due to lack of experience.