Laparoscopy for Splenic Conditions George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO.

Laparoscopy for Splenic Conditions

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital

Kansas City, MO

Splenic Conditions

• ITP

• Spherocytosis

• Splenic cysts

• Wandering spleen

J Pediatr Surg 28:689-692, 1993J Pediatr Surg 28:689-692, 1993

Pre-Operative Preparation• Ultrasound

• Often done by pediatrician, hematologist• Rarely needed for splenectomy, except may be useful for

extremely large spleen

• CT Scan – Useful in planning splenic cystectomy

• WinRho• Bone marrow stimulant• Usually used to platelet count• Useful pre-operatively to platelet count in ITP pt.

• Immunizations –Pneumococcus (Prevnar, Pneumovax)

Patient Positioning

Patient Positioning

Personnel Positions

Laparoscopic Splenectomy

• ITP, spherocytosis

• Port placement• (2) cannulas (5, 12)• (2) stab (3 mm) incisions

• Instruments• Harmonic scalpel (5 mm)• Articulating stapler (12 mm)

Laparoscopic Splenectomy

Operative Steps• Divide spleno-colic

ligament, then short gastrics

• Clip artery• Autotransfuse pt• Protects stapler malfxn

Laparoscopic Splenectomy

Operative Steps

• Divide spleno-renal lig.

• Articulating stapler across hilum

• Bag specimen, morcellate extracorporally

Issues

• How large is too large?

• Measurement (LeClair)

• Earlier splenic artery ligation helpful

• Can divide spleen (spherocytosis) with harmonic, if necessary

Issues

• Postoperative platelet ct. > 500,000

• Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic)

• Baby aspirin ( 81 mg) QD for 6 mos

• Re-check at 3 months & 6 months

Splenic Cysts

• Primary

• epithelial lining

• Pseudocysts (secondary)

• no epithelial lining

• often develop after trauma

Splenic Cystectomy

• First step is decompression of cyst

Splenic Cystectomy

• Excise cyst as close as possible to splenic parenchyma with harmonic scalpel

• Coagulate lining with Argon beam coagulator

• ? Place omentum adjacent to exposed cyst lining

European Experience

• 3 European centers (Mainz, Mannheim, Hannover)

• 1995 - 2005

• 14 pts (median 8.5 yr)

• 10 recurrences (71%)

APSA 2006APSA 2006

CMH Experience1990 - 2006

• 8 pts (6 – 18 yrs)

• 4 open, 4 laparoscopic

• ALOS: 2.75 days (open)1.75 days (laparoscopic)

• No recurrences ( 6 CT scans)

Laparoscopic Cystectomy

Wandering Spleen

Wandering Spleen

? ? ?