- Email: [email protected]
Laparoscopic Assisted Splenectomy for Treatment of Presumed Immune Thrombocytopenic Purpura: Initial Results
mayo Laparoscopic Assisted Splenectomy for Treatment of Presumed Immune Thrombocytopenic Purpura: Initial Results RICHARD T. SCHLINKERT, M.D.,
AND THEODORE A. BRAICH,
• Objective: To present the initial results of performance of laparoscopic splenectomy in two patients at Mayo Clinic Scottsdale. • Design: We describe two 18-year-old patients with idiopathic immune thrombocytopenic purpura and the technique of laparoscopic splenectomy used for treatment. • Material and Methods: For adequate visualization of the spleen and exposure of the upper midline area should urgent laparotomy become necessary, we position the patient supine with a sandbag under the left lower costal margin. Insertion of five 10-mm trocars facilitates placement of instruments. Dissection of the spleen is begun inferiorly. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips, as are the short gastric vessels. Cautery is used for dividing the splenophrenic ligaImmune thrombocytopenic purpura (ITP) is characterized by peripheral thrombocytopenia in conjunction with adequate marrow megakaryocytes and the absence of other causes of peripheral destruction of platelets.' The pathophysiologic features of ITP involve antibodies or immune complexes (or both) that either have an affinity for or bind in an "innocent bystander" fashion to platelets or megakaryocytes. The affected platelets are then subjected to sequestration and destruction by the reticuloendothelial system. Megakaryocyte binding can lead to decreased production of platelets by inhibition of production or intramedullary destruction of platelets.2 Therapeutic options for chronic ITP include corticosteroids, splenectomy, intravenously administered γ-globulin, immunosuppressive drugs, danazol, vinca alkaloids, and immunoadsorption. Therapy must be tailored to the severity From the Division of General Surgery (R.T.S.) and Division of Hematology/Oncology and Internal Medicine (T.A.B.), Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. R. T. Schlinkert, Division of General Surgery, Mayo Clinic Scottsdale, 13400 East Shea Boulevard, Scottsdale, AZ 85259. Mayo Clin Proc 1994;69:422-424
M.D.
ment. The spleen is placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision, after which the spleen is morcellated and then removed. Considerable care must be exercised to ensure that the plastic bag is not punctured and that no ectopic splenic tissue is present. * Results: Both laparoscopic splenectomies were successful, and no intraoperative or postoperative complications occurred. After dismissal on postoperative day 3, the patients quickly resumed all activities. The platelet counts returned to normal. • Conclusion: These encouraging results support the use of laparoscopic splenectomy for immune thrombocytopenic purpura and suggest that this procedure may have a role in patients with other conditions of the spleen. (Mayo Clin Proc 1994; 69:422-424) ITP = immune thrombocytopenic purpura
of the problem. In addition, major comorbidities should be considered in planning treatment. Splenectomy has an important role in the management of ITP. This procedure removes a major site of production of antibodies and also the predominant site of sequestration of platelets for most patients. Who will respond to splenectomy, however, cannot be predicted with certainty. Approximately 80% of patients will have a response, and in 65% of patients, the response will be complete and durable.3 In an effort to decrease postoperative discomfort, laparoscopic techniques have been used to perform splenectomy in selected patients.47 Herein we report our initial results with this procedure at Mayo Clinic Scottsdale. MATERIAL AND METHODS Patients.—Two patients with chronic thrombocytopenia without palpable splenomegaly underwent laparoscopic splenectomy. A preoperative diagnosis of idiopathic chronic immune thrombocytopenia was based on peripheral thrombocytopenia and normal findings on a bone marrow biopsy specimen with adequate megakaryocytes, no history of exposure to drugs, and negative results of antinuclear
422
© / 994 Mayo Foundation for Medical Education and Research
Mayo Clin Proc, May 1994, Vol 69
LAPAROSCOPIC SPLENECTOMY
423
antibody assay, Coombs' test, and human immunodeficiency virus antibody test (in one patient). Technique.—Preoperatively, patients are given pneumococcal vaccine. For the procedure, the patient is placed in a supine position with a sandbag under the left lower costal margin. This maneuver allows good visualization of the spleen and also keeps the upper midline exposed should urgent entry into the abdominal cavity become necessary. With use of carbon dioxide pneumoperitoneum, 10-mm trocars are placed as shown in Figure 1. These trocars allow increased flexibility of instrument placement and camera location. Dissection of the spleen is begun at its inferior aspect. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips. The short gastric vessels are likewise divided. The splenophrenic ligament is divided by using cautery. The spleen is then placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision. The spleen is morcellated and removed. Considerable care must be taken to ensure that the plastic bag is not punctured during splenic removal to avoid splenosis. The surgeon should search for accessory spleens. RESULTS Two 18-year-old patients have undergone laparoscopic splenectomy at our institution. In both patients, the estimated blood loss was less than 150 mL, and the operative time was approximately 3 hours. The spleens were removed through the umbilical trocar site, which was enlarged to approximately 3 cm in one patient. Both splenectomies were successful, and the patients had no intraoperative or postoperative complications. The platelet counts responded rapidly in each patient and were normal at 1 -month follow-up. Both patients were dismissed on postoperative day 3 and promptly resumed full activity. DISCUSSION The range of laparoscopic assisted surgical procedures is expanding. As each new procedure is performed with use of this technique, the results must be assessed to determine the safety and efficacy of the laparoscopic approach. Splenectomy is traditionally performed through an upper midline or left subcostal incision. These incisions are similar to those used for open cholecystectomy; thus, laparoscopic splenectomy should offer many of the same advantages as laparoscopic cholecystectomy. Laparoscopic splenectomy, however, is a more complex operation in which larger vessels must be controlled and splenic rupture must be avoided. Therefore, we initiated this procedure in patients with a preoperative diagnosis of ITP because, with this condition,
Fig. 1. Diagram showing placement of trocars for laparoscopic splenectomy. See text for details of technique. the spleen is not dramatically enlarged and is technically easy to remove. Positioning of the patient is critical to allow adequate visualization yet leave a clear route for urgent laparotomy should bleeding occur. The position we described herein fulfills both criteria. Individual vessels have been controlled by clips or ligatures. Large clip appliances, which should facilitate vascular control, have now been developed. A search for ectopic splenic tissue is important because this is one cause of failure of splenectomy for ITP.8 In our two patients, we cannot determine with certainty the adequacy of the search for accessory splenic tissue; however, both patients had appropriate increases in platelet counts after splenectomy. Clearly, larger numbers of patients will need to be studied to substantiate the safety and efficacy of this procedure. Nonetheless, these initial results are encouraging. The application of laparoscopic splenectomy to other disease processes will need to be determined. Success will depend on the ability to control the vascular pedicle and on the acceptability of a morcellated pathologic specimen for the pathologist. Currently, we are expanding our indications for this
424
LAPAROSCOPIC SPLENECTOMY
procedure to diseases that generally are associated with somewhat larger spleens. Although the operative time was 3 hours in our initial two patients, the time is likely to decrease as experience is gained with the procedure. This trend has been noted with laparoscopic cholecystectomy. CONCLUSION At our institution, two patients underwent laparoscopic splenectomy for presumed idiopathic ITP. No intraoperative or perioperative complications occurred, and both patients had appropriate increases in platelet counts postoperatively. Further studies in which laparoscopic splenectomy is undertaken for this condition are warranted. Laparoscopic splenectomy may have a role in the treatment of other disease processes of the spleen as well. REFERENCES 1. McMillan R. Chronic idiopathic thrombocytopenic purpura. N EnglJMed 1981;304:1135-1147
Mayo Clin Proc, May 1994, Vol 69
Ballem PJ, Segal GM, Stratton JR, Gemsheimer T, Adamson JW, Slichter SJ. Mechanisms of thrombocytopenia in chronic autoimmune thrombocytopenic purpura: evidence of both impaired platelet production and increased platelet clearance. J Clin Invest 1987; 80:33-40 Pizzuto J, Ambriz R. Therapeutic experience on 934 adults with idiopathic thrombocytopenic purpura: multicentric trial of the Cooperative Latin American Group on Hemostasis and Thrombosis. Blood 1984;64:1179-1183 Thibault C, Mamazza J, Létourneau R, Poulin E. Laparoscopic splenectomy: operative technique and preliminary report. Surg Laparosc Endosc 1992; 2:248-253 Cuschieri A, Shimi S, Banting S, Vander Velpen G. Technical aspects of laparoscopic splenectomy: hilar segmental devascularization and instrumentation. J R Coll Surg Edinb 1992; 37:414-416 Delaitre B, Maignien B. Laparoscopic splenectomy—technical aspects. Surg Endosc 1992;6:305-308 Delaitre B, Maignien B, Icard P. Laparoscopic splenectomy. BrJSurg 1992; 79:1334 Façon T, Caulier MT, Fenaux P, Plantier I, Marchandise X, Ribet M, et al. Accessory spleen in recurrent chronic immune thrombocytopenic purpura. Am J Hematol 1992; 41:184189
AND THEODORE A. BRAICH,
• Objective: To present the initial results of performance of laparoscopic splenectomy in two patients at Mayo Clinic Scottsdale. • Design: We describe two 18-year-old patients with idiopathic immune thrombocytopenic purpura and the technique of laparoscopic splenectomy used for treatment. • Material and Methods: For adequate visualization of the spleen and exposure of the upper midline area should urgent laparotomy become necessary, we position the patient supine with a sandbag under the left lower costal margin. Insertion of five 10-mm trocars facilitates placement of instruments. Dissection of the spleen is begun inferiorly. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips, as are the short gastric vessels. Cautery is used for dividing the splenophrenic ligaImmune thrombocytopenic purpura (ITP) is characterized by peripheral thrombocytopenia in conjunction with adequate marrow megakaryocytes and the absence of other causes of peripheral destruction of platelets.' The pathophysiologic features of ITP involve antibodies or immune complexes (or both) that either have an affinity for or bind in an "innocent bystander" fashion to platelets or megakaryocytes. The affected platelets are then subjected to sequestration and destruction by the reticuloendothelial system. Megakaryocyte binding can lead to decreased production of platelets by inhibition of production or intramedullary destruction of platelets.2 Therapeutic options for chronic ITP include corticosteroids, splenectomy, intravenously administered γ-globulin, immunosuppressive drugs, danazol, vinca alkaloids, and immunoadsorption. Therapy must be tailored to the severity From the Division of General Surgery (R.T.S.) and Division of Hematology/Oncology and Internal Medicine (T.A.B.), Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. R. T. Schlinkert, Division of General Surgery, Mayo Clinic Scottsdale, 13400 East Shea Boulevard, Scottsdale, AZ 85259. Mayo Clin Proc 1994;69:422-424
M.D.
ment. The spleen is placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision, after which the spleen is morcellated and then removed. Considerable care must be exercised to ensure that the plastic bag is not punctured and that no ectopic splenic tissue is present. * Results: Both laparoscopic splenectomies were successful, and no intraoperative or postoperative complications occurred. After dismissal on postoperative day 3, the patients quickly resumed all activities. The platelet counts returned to normal. • Conclusion: These encouraging results support the use of laparoscopic splenectomy for immune thrombocytopenic purpura and suggest that this procedure may have a role in patients with other conditions of the spleen. (Mayo Clin Proc 1994; 69:422-424) ITP = immune thrombocytopenic purpura
of the problem. In addition, major comorbidities should be considered in planning treatment. Splenectomy has an important role in the management of ITP. This procedure removes a major site of production of antibodies and also the predominant site of sequestration of platelets for most patients. Who will respond to splenectomy, however, cannot be predicted with certainty. Approximately 80% of patients will have a response, and in 65% of patients, the response will be complete and durable.3 In an effort to decrease postoperative discomfort, laparoscopic techniques have been used to perform splenectomy in selected patients.47 Herein we report our initial results with this procedure at Mayo Clinic Scottsdale. MATERIAL AND METHODS Patients.—Two patients with chronic thrombocytopenia without palpable splenomegaly underwent laparoscopic splenectomy. A preoperative diagnosis of idiopathic chronic immune thrombocytopenia was based on peripheral thrombocytopenia and normal findings on a bone marrow biopsy specimen with adequate megakaryocytes, no history of exposure to drugs, and negative results of antinuclear
422
© / 994 Mayo Foundation for Medical Education and Research
Mayo Clin Proc, May 1994, Vol 69
LAPAROSCOPIC SPLENECTOMY
423
antibody assay, Coombs' test, and human immunodeficiency virus antibody test (in one patient). Technique.—Preoperatively, patients are given pneumococcal vaccine. For the procedure, the patient is placed in a supine position with a sandbag under the left lower costal margin. This maneuver allows good visualization of the spleen and also keeps the upper midline exposed should urgent entry into the abdominal cavity become necessary. With use of carbon dioxide pneumoperitoneum, 10-mm trocars are placed as shown in Figure 1. These trocars allow increased flexibility of instrument placement and camera location. Dissection of the spleen is begun at its inferior aspect. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips. The short gastric vessels are likewise divided. The splenophrenic ligament is divided by using cautery. The spleen is then placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision. The spleen is morcellated and removed. Considerable care must be taken to ensure that the plastic bag is not punctured during splenic removal to avoid splenosis. The surgeon should search for accessory spleens. RESULTS Two 18-year-old patients have undergone laparoscopic splenectomy at our institution. In both patients, the estimated blood loss was less than 150 mL, and the operative time was approximately 3 hours. The spleens were removed through the umbilical trocar site, which was enlarged to approximately 3 cm in one patient. Both splenectomies were successful, and the patients had no intraoperative or postoperative complications. The platelet counts responded rapidly in each patient and were normal at 1 -month follow-up. Both patients were dismissed on postoperative day 3 and promptly resumed full activity. DISCUSSION The range of laparoscopic assisted surgical procedures is expanding. As each new procedure is performed with use of this technique, the results must be assessed to determine the safety and efficacy of the laparoscopic approach. Splenectomy is traditionally performed through an upper midline or left subcostal incision. These incisions are similar to those used for open cholecystectomy; thus, laparoscopic splenectomy should offer many of the same advantages as laparoscopic cholecystectomy. Laparoscopic splenectomy, however, is a more complex operation in which larger vessels must be controlled and splenic rupture must be avoided. Therefore, we initiated this procedure in patients with a preoperative diagnosis of ITP because, with this condition,
Fig. 1. Diagram showing placement of trocars for laparoscopic splenectomy. See text for details of technique. the spleen is not dramatically enlarged and is technically easy to remove. Positioning of the patient is critical to allow adequate visualization yet leave a clear route for urgent laparotomy should bleeding occur. The position we described herein fulfills both criteria. Individual vessels have been controlled by clips or ligatures. Large clip appliances, which should facilitate vascular control, have now been developed. A search for ectopic splenic tissue is important because this is one cause of failure of splenectomy for ITP.8 In our two patients, we cannot determine with certainty the adequacy of the search for accessory splenic tissue; however, both patients had appropriate increases in platelet counts after splenectomy. Clearly, larger numbers of patients will need to be studied to substantiate the safety and efficacy of this procedure. Nonetheless, these initial results are encouraging. The application of laparoscopic splenectomy to other disease processes will need to be determined. Success will depend on the ability to control the vascular pedicle and on the acceptability of a morcellated pathologic specimen for the pathologist. Currently, we are expanding our indications for this
424
LAPAROSCOPIC SPLENECTOMY
procedure to diseases that generally are associated with somewhat larger spleens. Although the operative time was 3 hours in our initial two patients, the time is likely to decrease as experience is gained with the procedure. This trend has been noted with laparoscopic cholecystectomy. CONCLUSION At our institution, two patients underwent laparoscopic splenectomy for presumed idiopathic ITP. No intraoperative or perioperative complications occurred, and both patients had appropriate increases in platelet counts postoperatively. Further studies in which laparoscopic splenectomy is undertaken for this condition are warranted. Laparoscopic splenectomy may have a role in the treatment of other disease processes of the spleen as well. REFERENCES 1. McMillan R. Chronic idiopathic thrombocytopenic purpura. N EnglJMed 1981;304:1135-1147
Mayo Clin Proc, May 1994, Vol 69
Ballem PJ, Segal GM, Stratton JR, Gemsheimer T, Adamson JW, Slichter SJ. Mechanisms of thrombocytopenia in chronic autoimmune thrombocytopenic purpura: evidence of both impaired platelet production and increased platelet clearance. J Clin Invest 1987; 80:33-40 Pizzuto J, Ambriz R. Therapeutic experience on 934 adults with idiopathic thrombocytopenic purpura: multicentric trial of the Cooperative Latin American Group on Hemostasis and Thrombosis. Blood 1984;64:1179-1183 Thibault C, Mamazza J, Létourneau R, Poulin E. Laparoscopic splenectomy: operative technique and preliminary report. Surg Laparosc Endosc 1992; 2:248-253 Cuschieri A, Shimi S, Banting S, Vander Velpen G. Technical aspects of laparoscopic splenectomy: hilar segmental devascularization and instrumentation. J R Coll Surg Edinb 1992; 37:414-416 Delaitre B, Maignien B. Laparoscopic splenectomy—technical aspects. Surg Endosc 1992;6:305-308 Delaitre B, Maignien B, Icard P. Laparoscopic splenectomy. BrJSurg 1992; 79:1334 Façon T, Caulier MT, Fenaux P, Plantier I, Marchandise X, Ribet M, et al. Accessory spleen in recurrent chronic immune thrombocytopenic purpura. Am J Hematol 1992; 41:184189