laparoscopicsplenectomy
TRANSCRIPT
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Splenectomy
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Historical background
• “An organ of mystery” (Galen)• “Unnecessary” (Aristotle)• “An organ that hinders the speed of runners”
(Pliny)• “An organ that produce laughter and mirth”
(Babylonian Talmud)
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Open splenic surgery
• 1st splenectomy: 1549, Adrian Zacarelli• 1st partial splenectomy: 1590, Franciscus
Rosetti• 1st splenectomy in the USA: 1816, O’Brien• 1st repair of lacerated spleen: 1895, Zikoff
(Russian)
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Laparoscopic splenectomy
• In 1992, several reports of laparoscopic splenectomies started emerging in small series.
• Laparoscopic splenectomy has become a useful alternative to open splenectomy.
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Spleen Anatomy
• Most common relationship of artery and vein is artery anterior
• Other positions occur• Main artery divides
into hilar branches over the pancreatic tail
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Spleen Anatomy
• Major Ligaments– Gastrosplenic
• Short gastrics
– Splenorenal (lienorenal)
– Splenocoloic
• Minor Ligament– Splenophrenic
– Pancreaticosplenic
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Anatomy
Blood SupplyBlood Supply• Splenic arterySplenic artery (pattern of terminal branches)
– Distributed type: (70%)– Short trunk w/ many long branches over ¾ of the
medial surface of the spleen.
– Magistral type: (30%)– Long main trunk dividing near the hilum into short
terminal branches.
• Short gastric arteryShort gastric artery
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Anatomy
• The most common anomaly of splenic embryology is the accessory spleen..
• 80% in the splenic hilum and vascular pedicle
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Spleen Anatomy
Locations of Accessory SpleensA Splenic hilum
B Along splenic vessels
C Splenocolic ligament
D Perirenal omentum
E Small bowel mesentery
F Presacral area
G Uterine adnexa
H Peritesticular region
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Splenic Function
• Immune function– Filtering function– Opsonin production– Clearance of
encapsulated organisms– Clearance of metastatic
cells
• Erythrocyte maintenance
• Platelet reservoir• Storage organ for factor
VIII
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Indications for Splenectomy
• Most common indication is trauma totrauma to spleenspleen, whether iatrogenic or otherwise
• Most common elective splenectomy is ITP– followed by • hereditary spherocytosis• autoimmune hemolytic anemia• thrombotic thrombocytopenic purpura.
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Indications for splenectomy
• Hematologic disorder– Hereditary spherocytosis– Autoimmune anemia– Thalassemia– Hereditary Hemolytic anemia– Sickle cell disease– ITP– TTP– Sickle cell
• Malignancy– Lymphoma (Hodgkin’s and non
Hodgkin’s disease)– Lymphoproliferative disorders– Hairy cell leukemia
• Splenic Mass– Cysts and tumors– Abscesses
• Ruptured spleen– Trauma– Incidental
• Other– Felty’s syndrome– Gaucher’s disease– Splenic vein thrombosis– AIDS
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Change of Indications
Decrease Increase
• Decline of staging laparotomy for Hodgkin’s disease
• Increase of splenectomies for hereditary spherocytosis and myeloproliferative disorders
• Significant Increase indication for ITP
• New indication: Hairy cell leukemia, Felty’s syndrome, AIDS
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Preoperative Considerations
• Splenic artery embolization:– Recommended for:• Massive splenomegaly• Previous pancreatitis, gastric or pancreatic surgery• Portal hypertension, varices • Uncorrectable thrombocytopenia
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Preoperative Considerations• Splenic artery embolizations:– Advantages:• Reduced operative blood loss from devascularized
spleen• Reduces spleen size for easier dissection and removal.
– Disadvantages:• Acute left sided pain (limited duration)
– This is mitigated by general anesthesia ---> OR
• pancreatitis
• Currently no consensus
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Preoperative Considerations
• Pneumovax, haemophilus, meningococcus vaccinations 2 weeks pre-op
• Corticosteroids• Availability of blood and platelet products• Preoperative IgG administration to patients
with ITP and critically low platelet counts• Perioperative antibiotics• Pre-operative embolization- controversial
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Preoperative Considerations
• Vaccination::– Splenectomy imparts <1 to 5% fulminant infection
(overwhelming post-splenectomy infections)
– Vaccination against encapsulated bacteria 2 wks before surgery.
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Preoperative Considerations• Vaccination:– Common bacteria:• Streptococcus pneumoniaeStreptococcus pneumoniae• Hemophilus influenzae type BHemophilus influenzae type B• MeningococcusMeningococcus• Grp A streptococcus• Capnocytophaga canimorsus (related to dog bites)• Grp B streptococcus• Enterococcus sp.• Bacteroides sp.• Salmonella sp.• Bartonella sp.
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Preoperative Considerations
• Vaccination::– in emergency splenectomy, trauma, give vaccine
3rd day– booster injections every 5 – 6 yrs regardless of the
reason for splenectomy for pneumococcal– annual influenza immunization
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Preoperative Considerations• Deep venous Thrombosis Prophylaxis:– Specially in splenectomy for myeloproliferative
disorders (MPD).– 40% risk for PVT (portal vein thrombosis)
– Anorexia– Abdominal pain– Leukocytosis & thrombocytosis
● Early diagnosis w/ contrast-enhanced CT scan● Anticoagulation Prophylaxis
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SPLENECTOMY• Open Splenectomy:– Indication:• traumatic rupture of the spleen (most
common)• massive splenomegaly• ascites• portal hypertension• multiple prior operations• extensive splenic radiations• possible splenic abscess
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Partial Splenectomy• Indicated:– children (risk of splenectomy sepsis)– Lipid storage disorders (Gaucher’s disease)– Some blunt & penetrating splenic injuries
• Open or laparoscopic• Bleeding from cut surface of the spleen is
controlled by:– cauterization– argon coagulation– application of hemostatic agents (cellulose gauze /
fibrin glue)
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Relative Contraindications to Laparoscopic Approach
• Active hemorrhage with hemodynamic instability
• Non-platelet coagulopathy• Contraindications to pneumoperitoneum• Splenomegaly• Pregnancy• Extensive previous upper abdominal surgery
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Laparoscopic versus open splenectomy
• Earlier discharge• Less pain• Earlier resumption of oral intake• Fewer blood transfusions• Similar operative time with increased
experience
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Three Areas of Controversy
• Massive splenomegaly • Splenic rupture• Higher recurrence?
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Massive splenomegaly
• Technical challenge– Difficulty to manipulate the spleen– Difficulty in the extraction of the spleen
• Options– Totally laparoscopic splenectomy– Hand port assisted
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Laparoscopic Splenectomy for Ruptured Spleen
• Indications– Incidental splenectomy– Trauma
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Laparoscopic Splenectomy for Ruptured Spleen
• The patient has to be hemodynamically stable (on going bleeding requiring large blood transfusion)
• Use of 10mm suction/irrigation device• Early control of splenic hilum• Hand port could be helpful
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Prevention of Residual Function
• Extreme care to avoid parenchymal rupture and cell spillage
• Systematic and careful exploration of the abdominal cavity for accessory spleens
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SPLENECTOMY
• Open Splenectomy:–Position:
• Supine:–midline incision for rupture or massive
splenomegaly or for staging Hodgkin’s.–Left subcostal incision
• for elective splenectomies
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Date of download: 9/18/2014 Copyright © 2014 McGraw-Hill Education. All rights reserved.
Splenocolic ligament is divided at the beginning of open splenectomy.
Legend:
From: Part II. Specific ConsiderationsSchwartz's Principles of Surgery, 9e, 2010
From: Part II. Specific ConsiderationsSchwartz's Principles of Surgery, 9e, 2010
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Technique
• Patient Positioning– supine– lithotomy– right lateral decubitus
• Trocar placement– 3 vs. 4
• Angled scope
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1) Splenic mobilization
2) Splenic hilum
3) Extraction after finger morcellation
Technique
(depends on the anatomy)
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Technique
• Division of the lowermost short gastric vessels
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Technique
• Inferior and lateral mobilization of the spleen– previously performed
last– now performed early
to gain better access to the hilum
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Technique
• Division of the hilar vessels with the vascular stapler
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Technique
• Division of the uppermost short gastric vessels
• Can be approached from the medial or lateral aspect
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Technique
• Placement in a retrieval bag
• Extraction in piecemeal fashion
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Post-op Considerations
• Removal of NGT and foley prior to extubation• Up in chair for a few hours the night of
surgery• Liquid diet begun on the first post-op day• Ambulate in the hall on the first post-op day• Discharge on the first or second post-op day
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Accessory spleens (AS)
• Long term follow up is essential because a small accessory spleen can hypertrophy after splenectomy and be detected via CT scan or scintigraphy
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Changes in blood after splenectomies
1. Appearance of Howell-Jolly bodies & siderocytes
2. Leukocytosis
3. Increased platelet counts
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Complications of Splenectomies
• Pulmonary complications:– Left lower lobe atelectasis (most common) – Pleural effusion– Pneumonia
• Hemorrhage– subphrenic hematoma
• Infectious complication:– Subphrenic abscess
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Complications of Splenectomies
• Pancreatic complications: due to intra-op trauma to tail of pancreas– Pancreatitis– Pseudocyts– Pancreatic fistula
• Thromboembolic phenomena (5-10%)– For pt. w/ hemolytic anemia / myeloproliferative
disorders and splenomegaly• Subcutaneous heparin & low-dose anticoagulantion
therapy postop
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Complications of Splenectomies• Overwhelming Postsplenectomy Infection
(OPS):− lifetime risk of severe infection (1-5%)− incidence similar among children & adult but
mortality is higher in children.− mortality is highest in hematologic conditions:• Thalassemia major• Sickle cell
− lowered due to pneumococcal vaccine
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Complications of Splenectomies• Overwhelming Postsplenectomy Infection
(OPS):− Loss the ability to filter and phagocytize bacteria
and parasitized blood cells− infection to encapsulated bacteria or parasites
− Loss a significant source of antibody production:• Streptococcus pneumoniae (most common infection
50-90%)• Haemophilus influenzae type B• Meningococcus• Grp A streptococcus
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Complications of Splenectomies• Overwhelming Postsplenectomy Infection
(OPS):– Risk Factors:• Splenectomies for hematologic indications• Compromised immune system:
− Hodgkin’s.− taking chemotherapy / radiation therapy
• Children usually develops w/in 2 yrs postsplenectomy
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Complications of Splenectomies
• Overwhelming Postsplenectomy Infection (OPS):− Immunoprophylaxis:• Pneumococcal vaccine – booster injection every 5-6yrs• Annual influenza immunization
− Antibiotic prophylaxis usually single daily dose of penicillin or amoxillin for children for 1st − asplenic children receive daily prophylaxis with oral
penicillin VK or amoxicillin until at least age five and for at least one year following splenectomy
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• http://youtu.be/y6YtmRgvHrU