Laparoscopic Partial Splenectomy

First submitted by:
Shawn Tsuda
(see History tab for revisions)
Category

The primary immunologic function of the spleen is to clear pathogens and antigens. However, there has been a presumed lack of essential function of the spleen that has led to the spleen being removed completely when indicated. The risk of lifetime post-splenectomy overwhelming sepsis is around 4.25%, with a mortality approaching 60%.

Indications

The indications for partial splenectomy include diagnostic partial splenectomy for idiopathic splenomegaly, splenic cysts, benign tumors, metastases, splenic infarct, iatrogenic injury to the spleen, and the hematologic disorder hereditary spherocytosis. Hereditary spherocytosis, an autosomal dominant inherited hemolytic disorder may be particularly relevant with children who are less than 4 years old, who may be at risk for overwhelming postsplenectomy infection (OPSI), but for whom partial splenectomy may reduce hemolytic complications such as anemia, gallstones, and exercise intolerance while preserving splenic function. Children may also be at additional risk of pulmonary hypertension after splenectomy and fulminant sepsis from cat or dog bites. This may not be the case with other hemoglobinopathies for which splenectomy is a treatment.

Technique

Animal studies have shown that 25% splenic preservation may be adequate to preserve splenic function. Splenic regrowth does not necessarily occur; but when it does, completion splenectomy may be indicated. Open partial splenectomy and splenic embolization have been described. However, laparoscopic splenectomy may hold advantages over an open approach for the decrease in postoperative pain and recovery time. Splenic embolization has been hampered by complications of splenic abscess, pain, nausea, and fever.

Operative techniques described include ligating the main splenic vessels and the short gastric vessels, but preserving the pedicle arising from the left gastroepiploic vessels. Alternatively the main splenic vessles can be ligated and the short gastric vessels preserved. In both cases, about 10-30% of splenic parenchyma are preserved and a rim of devascularized tissue is left behind to reduce splenic bleeding.

References

Laparoscopic Partial Splenectomy: Indications and results of a multicenter retrospective study. Géraldine Héry, François Becmeur, Laure Méfat, David Kalfa and Patrick Lutz, et al.
2008, Volume 22, Number 1, Pages 45-49

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). B. Habermalz, S. Sauerland, G. Decker, B. Delaitre and J.-F. Gigot, et al.
2008, Volume 22, Number 4, Pages 821-848

Partial laparoscopic decapsulation of congenital splenic cysts: a medium-term evaluation proves the efficiency in children. H. Till and K. Schaarschmidt
2004, Volume 18, Number 4, Pages 626-628

Laparoscopic subtotal splenectomy in hereditary spherocytosis.
C. Vasilescu, O. Stanciulea and C. Arion
2007, Volume 21, Number 9, Page 1678

Laparoscopic splenectomy for blunt trauma: a safe operation following embolization. Kenneth J. Ransom and Michael S. Kavic
2009, Volume 23, Number 2, Pages 352-355