Hamda Al Zarooni, MD, Ajda Altinoz, MD, Shadi Al Bahri, Guido Mannaerts, MD, PhD. Tawam Hospital Johns Hopkins International
Introduction: Massive splenomegaly is defined as a palpable spleen more than 8 cm below the costal margin, > 20 cm in diameter , or weighs > 1000 gm. We present a case of massive splenomegaly who underwent splenic artery embolization to facilitate laparoscopic splenectomy.
Case Presentation: A 22 year old male with a history of beta thalassemia major undergoing regular blood transfusions presented with generalized weakness and abdominal distension. On examination, his spleen was palpable to the left lower abdomen. Workup showed pancytopenia, CT abdomen revealed a splenic diameter of 27cm, splenic and portal vein dilation up to 18mm. Distal splenic artery embolization was performed by interventional radiology using Gelfoam. Day 3 post-embolization, patient underwent Laparoscopic splenectomy. He was positioned supine. Ports placed according to splenic borders. A 12mm right hypochondrial camera port, 5mm epigastric, 12mm infraumbilical and a 5mm left paraumbilical port. Spleen was retracted through the left paraumbilical port using a fan retractor. An electrothermal bipolar sealing device introduced through the infraumbilical port was used for dissection of the splenic ligaments and hilum. Splenic artery control was stapled using a white (2.8mm) cartridge. Specimen was retrieved through a pfannenstiel incision in three portions. . No remnants left in the abdomen. Spleen measured 27 cm in size. Drain was placed in the splenic bed. Intraoperative blood loss was 100ml. The patient was discharged on postoperative day 3 without complications. Drain was negative for amylase. Post-splenectomy vaccination was administered.
Discussion: Splenectomy for massive splenomegaly was conventionally done via midline laparotomy; however with the emergence of minimally invasive surgery and interventional radiologic techniques, laparoscopic splenectomy in massive splenomegaly is now feasible. Supine position as opposed to the conventional right lateral decubitus allowed for easier port placement and ergonomics, as the spleen was occupying the left side of the abdomen. Removal of the specimen via pfannenstiel incision saves time, carries low morbidity, is cosmetically acceptable and provides adequate histology. According to our literature review, expected benefits from splenic artery embolization included decreased intraoperative bleeding and reduction in splenic size. Despite the spleen not decreasing in size in our case, potential intraoperative hemorrhage was significantly reduced.
Conclusion: Combining laparoscopic splenectomy with preoperative splenic artery embolization in massive splenomegaly may reduce intraoperative blood loss, morbidity, conversion rates and hospital stay. Further studies are required to study the best interval between embolization and surgery to maximize potential benefits.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94308
Program Number: P516
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster