Pediatric Laparoscopic Splenectomy

First submitted by:
Danielle Walsh
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Anatomy:

The gross anatomy of the spleen is best understood by its anatomic relations and attachments.  Understanding of these relationships is critical to safely performing a splenectomy.  Located in the left upper quadrant of the abdomen, the spleen resides between the diaphragm and the stomach.  It is composed of a convex diaphragmatic surface that is oriented superiorly and laterally and a visceral surface oriented inferiorly and medially.  The visceral surface has four impressions correlating with the stomach, colon, pancreas, and left kidney.  The gastric impression is the largest, facing anteromedially, and formed by the posterior aspect of the fundus, body, and greater curvature of the stomach.  The gastric impression is anterior to the other three impressions and demarcated posteriorly by the hilar vessels.  The colic impression is over the inferior pole of the spleen.  The pancreatic impression is small and often not present but occurs between the colic impression and the most lateral aspect of the hilum.  The renal impression faces inferomedially and associates with the superior and lateral aspect of the anterior surface of the left kidney.1-3

The spleen has three key attachments both to the body wall and other viscera, making it highly susceptible to capsular tear during deceleration injury: the splenorenal ligament, splenicocolic ligament, and gastrosplenic ligament.  The splenorenal ligament is composed of two layers between which the splenic vessels are found.  The posterior layer originates from the parietal peritoneum along the inferior portion of the diaphragm.  The anterior layer originates as the posterior wall of the lesser sac.  The two layers sandwich between them the splenic vessels and the tail of the pancreas as they course laterally to the hilum.  As they reach the hilum, the splenorenal ligament merges with the gastrosplenic ligament.  The gastrosplenic ligament is also composed of two layers between which the short gastric arteries and portions of the left gastroepiploic artery course.  The layers are formed by the visceral peritoneum on the anterior and posterior surfaces of the stomach.  The splenicocolic ligament runs between the inferior aspect of the hilum along the inferior pole of the spleen down to the splenic flexure of the colon and is contiguous medially with the gastrocolic ligament.  Unlike the other two, this attachment is relatively avascular.1-3

Indications for splenectomy:

The workup and evaluation of patients with splenic pathology is not the focus of this article and are not discussed at length here, however, the common indications are listed below.  The main indications for splenectomy in the pediatric population include traumatic splenic rupture, hereditary spherocytosis, hereditary elliptocytosis, sickle cell anemia, chronic immune thrombocytopenic purpura (ITP) with failure to respond to medical management, splenic vein thrombosis, Echinococcal cyst, splenic abscess and select leukemias and lymphomas.4  The epidemiology is often based on the condition that necessitates splenectomy each of which necessitates their own workup.  Splenic trauma is the most common indication for splenectomy as the spleen is the most common intra-abdominal injured organ (45%).  In the case of sickle cell anemia, younger African-American children are more likely to need a splenectomy for splenic sequestration.  Most normal erythrocytes will pass through the spleen easily, but sickled, spherocytic or otherwise abnormally shaped cells will remain in the spleen to be ingested by macrophages and cause splenic enlargement, known as sequestration.  Repeated episodes of sequestration can result not only in splenomegaly, but also critical anemia, significant abdominal pain, and splenic infarctions.  Children with acute splenic sequestration may present emergently with weakness, dyspnea, marked splenomegaly, abdominal pain and hypovolemic shock.  In these patients, judicious hydration, oxygenation, and transfusion will improve hemodynamics.5  Both in sickle cell disease as well as hereditary spherocytosis, partial splenectomy has been described.6,7  In the instance of sickle cell disease, it has reportedly decreased the episodes of splenic sequestion and decreased the need for transfusion while maintaining some level of immune protection.  In the instance of hereditary spherocytosis it has reportedly decreased the severity of anemia while also maintaining immune function.  This however is not yet the gold standard in management and is thus not the focus of this article.

Pre-operative Evaluation and Planning:

All patients should undergo a thorough history and physical examination and often times imaging to define the anatomy.  On physical examination, the normal spleen is soft, non-tender, and often not palpable, though it can extend up to 1-2 cm below the left costal margin.  Light pressure should be used to palpate the spleen in young children because it can be pushed away with the fingers.  An enlarged spleen is firm and more easily palpable at least two centimeters below the costal margin and extending as far down as the hemipelvis.8

A CBC, CMP and reticulocyte count are often part of the primary evaluation of patients with splenic pathology but also help with what products if any may be needed before or during the operation.  Patients with severe anemia may require blood transfusion with the exception of patients with congenital hemolytic icterus to avoid hemolytic crisis.  Blood products should be ready for the operating room.  Additionally, the more massive the splenomegaly, the more accessible circulating blood volume will be removed with the splenectomy if the artery and vein are transected simultaneously.9  Thrombocytopenic patients may require platelet transfusion on the morning of, or during the operation given their short half-life.  If the patient was on long term steroids, as is often the case in ITP, they should be continued peri-operatively to avoid adrenal insufficiency.10  As most laparoscopic splenectomies are planned, this allows for preoperative immunization to avoid overwhelming post splenectomy infection.  All patients should receive polysaccharide pneumococcal, conjugate Haemophilus influenza type b, and polysaccharide meningococcal vaccinations two weeks prior to surgery.  If the procedure is performed emergently, the patient should receive the vaccinations prior to discharge.

Whether operating on adults or children, imaging is often useful in preoperative planning to define the orientation of the anatomy in splenomegaly.  In massive splenomegaly, the surrounding anatomy can be vastly altered due to displacement by the spleen.  The size of the spleen alone can be prohibitive of a laparoscopic approach.  In adults, the upper limit of feasibility is considered thirty centimeters but is less of an issue in children.11  Typically, the larger the spleen, the more caudal port placement should be so the hilar structures can be accessed.  In the setting of trauma, imaging is critical to establish the extent of splenic disease.  In this instance, a CT abdomen and pelvis with IV contrast remains the gold standard for diagnosis of splenic trauma.

Laparoscopic versus open splenectomy:

Since its description in 1991, laparoscopic splenectomy has been rigorously investigated to determine how it compares with the open procedure.12-17  Uniformly, the laparoscopic approach has been shown to increase operative time and thus operative costs.12-17  However, the amount of narcotic utilized for pain and overall length of stay is less with the laparoscopic approach.12,15-17  Although the operative costs are larger, with less narcotic utilized and less time in the hospital, select studies suggest the total cost of admission is less than that for open splenectomy.15-17  This however is not consistent as some studies have shown it to be overall more expensive.14,18

Laparoscopic approach and technique:

Laparoscopic splenectomy has been described from both an anterior and lateral approach.  Although originally described as an anterior approach, the lateral approach was soon shown to be advantageous. 11,19-21  The advantages of the lateral approach arise from the improved exposure gained due to gravity.  Having the patient in the right lateral decubitus position allows the viscera fall away, placing the peritoneal attachments to the spleen on tension and making the dissection easier.  This enhances visualization of the vasculature and decreases the number of ports needed as fewer instruments are needed solely for retraction.  Being able to better visualize the vasculature allows for a safer dissection with less blood loss and thus a decreased conversion rate to an open procedure as shown by Povedin et al.21  The anterior approach however is necessary in the instance of concomitant procedures.  As is often the case in patients with sickle cell anemia or hereditary spherocytosis, the increased hemolysis has resulted in significant gallstone burden and thus a cholecystectomy would be indicated.  In this instance, both procedures may be performed through an anterior approach.  Otherwise, the lateral approach has largely been adopted as the preferred approach for laparoscopic splenectomy.11

To perform the lateral approach, the patient is placed in the right lateral decubitus position.  The shoulders are placed in flexion over the front of the chest with padding between the arms.  The right leg is straight while the left leg is placed in slight flexion for stability.  The legs are padded accordingly.  A small bump is placed under the right flank to allow the left flank to open up by separating the inferior costal margin from the iliac crest.  The abdomen and flank are then prepped and draped from the xiphoid down to the pubis.

Insufflation can be achieved by the operator’s preferred method.  Port placement is variable depending on the degree of the splenomegaly and operative plan.  Typically anywhere from three to five ports are utilized.  An umbilical port is placed and should be able to accommodate an endovascular stapler and the endosurgical catch bag (10-15mm).  Typically one or two 5mm ports are placed in the left upper quadrant two finger breadths from the costal margin and act as ports for additional traction and dissection.  A 5mm port is placed in the left lower quadrant and is the primary working port through which the ultrasonic or radiofrequency dissection device will be used.  A 30-degree telescope is utilized and can be utilized through the left lower quadrant and umbilical ports.

The first maneuver is to divide the splenocolic ligament.  This is a relatively avascular attachment and allows the splenic flexure of the colon to fall away from the inferior pole of the spleen.  The dissection continues with the division of the gastrosplenic ligament.  This attachment contains the short gastric vessels and thus care should be taken with the ultrasonic device to be completely across the vessels with each bite as a partial transection of these vessels can result in bleeding that is difficult to control.  During this portion of the dissection, the stomach may be very closely approximated to the spleen and the dissection should ride the splenic surface to avoid incidental injury to the greater curvature of the stomach.  The stomach should fall further away from the operative field at this point, exposing the anterior surface of the splenorenal ligament and the splenic vessels.  The spleen is then rolled medially, exposing the posterior surface of the splenorenal ligament.  This layer is divided all the way up to the upper pole of the spleen taking care not to damage either the tail of the pancreas or the splenic vessels.  This removes extraneous tissue to accommodate the endovascular stapler when dividing splenic vessels.  If the tail of the pancreas extends to the hilum, this should be carefully dissected away from the vessels.  With the spleen mobilized and now only attached by the hilar vessels, an endovascular stapler is passed through the umbilical port and the vessels divided.  Occasionally the hilar vessels can be very short with the tail of the pancreas in close proximity, necessitating the individual vessels with clips or energy devices.  The endosurgical catch bag is then placed through the umbilical port into which the spleen is placed.  The opening of the bag is then brought out through the umbilical incision.  Using finger fracture or ring forceps, the spleen is then morselated and delivered from the abdomen.  If the spleen proves too large to fit in any of the currently available devices, a lower pelvic or pfannenstiel incision can be utilized for delivery of the spleen while maintaining cosmesis.

In the instance of blood dyscrasias such as hereditary spherocytosis and ITP, careful inspection searching for accessory spleen is necessary.  Failure to remove such accessory spleens will result in recurrence.  The most common location for accessory spleen to occur is in the splenorenal ligament, followed by the greater omentum, the retroperitoneal bed around the tail of the pancreas, the splenocolic ligament, and finally the mesentery of the large and small intestines.  After all accessory spleen has been removed and hemostasis has been achieved, the ports are removed and the fascia at the umbilical site closed.9,11

In the increasing effort to capitalize on the benefits afforded by minimally invasive surgical techniques, there have been increasing efforts to perform single port laparoscopic splenectomy.22-25  This is often performed through a single umbilical incision using a multiport device.  This however remains a relatively new technique and although described, has limited data on whether it is truly beneficial over standard laparoscopic splenectomy.25

Complications:

The list of possible complications with laparoscopic splenectomy is extensive and includes hemorrhage, pancreatitis, subphrenic abscess, wound infection, perforation of a hollow viscus, thrombocytosis, pleural effusion, pneumonia, pneumothorax in the instance of diaphragmatic injury, DVT and portal vein thrombosis.  The more common complications include bleeding and wound infection.  These complications are not specific to the laparoscopic approach and meta-analysis has shown that the complication rate for the laparascopic approach is approximately 15% compared to 26% for the open approach.26  The rate of pulmonary, wound, and infectious complications were all less for the laparoscopic approach.  The rate of bleeding complications was higher in the laparoscopic approach and is the primary reason for conversion to an open procedure.  Other common reasons for conversion to open include splenomegaly impeding the operator’s ability to safely perform the procedure laparoscopically as well as injury to a hollow viscus.  The rate of conversion to open is as high as 5% and increases as the degree of splenomegaly increases.11,27

Overwhelming Post-Splenectomy Infection (OPSI)

One of the primary risks of splenectomy is no longer having protection against encapsulated bacterial infection.  These encapsulated bacteria include Streptococcus pneumonia, Haemophilus influenza, and Neisseria meningitidis.  The absence of IgM antibody to these organisms can lead into the development of overwhelming post-splenectomy infection (OPSI).  The younger the patient undergoing splenectomy the higher the risk of developing OPSI, with OPSI being most common in children less than 5 years of age.  The risk of these infections can be decreased by postponing splenectomy until the patient is 5 years of age or older and making sure the patient receives appropriate vaccination against encapsulated organisms at least ten days before the procedure.  These vaccinations include polysaccharide pneumococcal (PCV-7 and PPV23), conjugate Haemophilus influenza type b, and polysaccharide meningococcal.  PPV23 should be given starting at age 2 and PCV-7 should be given based on a normal vaccination schedule.  In addition to immunization, children post-splenectomy are started on prophylactic antibiotics to avoid OPSI.  Penicillin 125 mg twice a day until age 3 and then Penicillin 250 mg twice a day for two years minimum is an appropriate regimen.

 

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Submitted by: Barrett Cromeens, D.O., Ph.D., Shiva Zargham, M.D., Amirreza Motameni, M.D., Danielle Walsh, M.D.