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Laparoscopic splenectomy in childhood
Laparoscopic
Splenectomy
in Childhood
By Baird M. Smith, Kurt P. Schropp, Thorn E Lobe, David A. Rogers, Gerald J. Presbury, Judith A. Wilimas, and Winfred C. Wong Memphis, 0 The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patient is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGlA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complications in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis. Copyright o 1994 by W.B. Saunders Company INDEX WORDS:
Splenectomy,
laparoscopic,
pediatric.
T
HE DEVELOPMENT of tissue morcellation techniques permits the removal of large solid organs such as the spleen. Laparoscopic splenectomy has been used in adults.1-5 We report our initial experience with laparoscopic splenectomy in childhood. MATERIALS AND METHODS Seven consecutively treated pediatric patients for whom medical therapy failed to control their hematologic disease were selected for laparoscopic splenectomy. Those with a hemoglobinopathy underwent gallbladder ultrasound examination for diagnosis of simultaneous biliary tract disease. Concomitant cholecystectomy was planned if cholelithiasis or “sludge” was found. The patients were immunized with polyvalent vaccine against streptococcal pneumococcus and Haemophilus influenzae if not previously administered. The children were fasted the night before surgery, and an oral osmotic bowel preparation was given if gaseous abdominal distension was present. Prophylactic antibiotics were given intravenously, on call to the operating room, and steroids were administered if warranted by the patient’s history. The patients were prepared and draped in the supine position, under general anesthesia. A Foley catheter and nasogastric tube were inserted to empty the bladder and stomach. A l-cm incision was made in the infraumbilical fold through which a Veress needle was inserted to establish pneumoperitoneum of 12 mm Hg. If the spleen was large, the open technique of port insertion was preferentially used to avoid injuring the spleen. A IO-mm Surgiport (USSC, Norwalk, CT) was placed, and the lo-mm Hydrolaparoscope (CirconiACMI, Stamford, CT) was inserted. A 5-mm Surgiport was inserted in the epigastrium, the left upper quadrant, and the left lower quadrant; these were used to hold the stomach, short gastric vessels, and depress the colon, respectively. A 12-mm Surgiport was inserted beneath the left costal margin in the
Journalof
Pediatric Surgery,
Vol29,
No
8 (August), 1994: pp 975-977
Tennessee midclavicular line; it was used for clip application, scissors, and the EndoGIA stapling device (Fig 1). The smaller the child, the further from the costal margin the 12-mm cannula should be placed. If cholecystectomy is to be performed concomitantly, a sixth port is placed. in the right upper quadrant directly above the gallbladder. The patient was rotated into the steep reverse Trendelenburg position with the left side elevated. An atraumatic grasping instrument was applied beside the greater curvature of the stomach on the gastrosplenic ligament, which is retracted to the right. A second atraumatic instrument is used to retract the splenic side of the gastrosplenic ligament to the left, tenting the ligament to improve visibility and dissection. The lesser sac was entered between the instruments, and division of the short gastric vessels was performed in a superior direction. Each vessel was stapled four times and divided between the middle staples with bipolar electrosurgical cautery or shears. If easy, the most superior (shortest) branches were divided at this time, but usually it was more efficient to defer their division until the spleen is further mobilized. The patient was rotated into the right lateral decubitus position, and the splenic flexure of the colon was taken down from its attachment to the splenic hilum. The splenocolic and lienorenal ligaments were divided with the bipolar electrosurgical device. The splenic hilum was exposed, permitting visualization and removal of any accessory spleens. Care was taken to avoid the pancreas, and the EndoGIA was applied across the splenic hilar vessels and fired (Fig 2). The vessels were inspected for bleeding, and the remaining short gastric vessels or ligamentous structures were clipped and divided. Via the 12-mm port site, an 8- x S-in Lap Sac (Cook Urological, Spencer, IN) was then introduced. This step involved rolling the bag tightly, removing the port, and placing the bag tip directly into the abdomen where it was grabbed by a .5-mm grasping instrument and pulled and/or pushed into the abdominal cavity. There? it was unfolded and placed on the inferior edge of the right hepatic lobe. The spleen was then moved up onto the right lobe of the liver, and the neck of the bag was opened with three instruments. The spleen was grasped at its hilum with the fourth instrument and was “dunked” into the bag. The neck of the bag was exteriorized through the 12-mm port site, and tissue was morcellated automatically (preferably) or manually (using sponge forceps and suction) until the entire sac could be removed. The automatic tissue morcellator (Cook Urological) obviates the tedious manual morcellation with a suction cannula and sponge forceps.6 The 12-mm trocar and cannula were reinserted into the abdomen
From The Universityof Tennessee, MemphisiLeBonheur Children s Medical Center, St Jude Children’s Research Hospital, Memphis, TN. Presented at the 1993 Annual Meeting of the Section on Surgery of theAmetican Academy of Pediatrics, Washington, DC, October 29-31, 1993. Address reprint requests to Thorn E Lobe, MD, 777 Washington Ave, Suite P21 OA, Memphis, TN 38105. Copyright 8 1994 by W.B. Saunders Company 0022-3468/94129Og-0004$03.00/0
975
976
SMITH ET AL
-4
RESULTS
2
,
, -\4
4y‘..,,
5mm
12mm
#
_Smm
Fig 1.
The diseases in the seven patients were idiopathic thrombocytopenic purpura (5) hereditary spherocytosis (l), and sequestration crisis for sickle cell disease (1). The age range was 15 months to 13 years (mean, 5.7 years). The patient with hereditary spherocytosis required concomitant cholecystectomy for cholelithiasis. The hospital course of one patient with idiopathic thrombocytopenic purpura was complicated by preoperative hemoperitoneum, caused by a hemorrhagic ovarian cyst and a low platelet count. The platelet count increased during the postoperative period in all patients with idiopathic thrombocytopenic purpura. One patient had a 24-hour period of ileus, which prolonged her stay by an extra day. The operation in the patient with the preoperative hemoperitoneum was converted to an open procedure for better hemostasis and visualization. In other respects, the cases were straightforward and without complications. The average operating time for the seven patients was 3.5 hours (range, 2.5 to 4 hours).
Trocar site for laparoscopic splenectomy.
DISCUSSION to establish pneumoperitoneum if concomitant cholecystectomy was required. The splenic bed and pancreas were reinspected for hemostasis, and all trocars were removed. Wounds were closed in the standard fashion for pediatric laparoscopic procedures. Afterward, the Foley catheter and nasogastric tube was removed. The patients were offered fluids on the evening of their surgery and usually had solids the following day. Intramuscular metoclopramide or a scopolamine patch were administered for nausea. Most patients were discharged on the second postoperative day, with a prescription for penicillin and analgesics.
Fig 2. The vascular load of an EndoGlA stapler is placed across the splenic hilum to transect the tissue en masse.
Traditional splenectomy, performed through an upper abdominal incision, is associated with a number of complications, including hemorrhage, atelectasis, pneumonia, ileus, subdiaphragmatic abscess, and incisional hernias. These may prolong the hospital stay and convalescence. The laparoscopic approach eliminates many of these problems. Exposure is easily obtained by sliding the laparoscope up beneath the costal margin, to within centimeters of the operative field. Its magnification and optics permit accurate dissection and meticulous hemostasis. Because the small incisions of laparoscopic surgery are less painful than upper abdominal incisions, patients use fewer narcotics, have fewer respiratory complications, and have improved return of pulmonary function.’ The duration of postoperative ileus is shortened, and the small incisions are unlikely to herniate.8 In our series, all but one child (whose procedure was converted to open) went home on the second postoperative day and returned to unrestricted activities within one week of discharge. It appeared that the patients found the small scars cosmetically preferable to a large subcostal or midline scar. The laparoscopic approach may prove at least as safe as the open approach. The spleens removed from children are often of normal size, which facilitates the endoscopic proce-
LAPAROSCOPIC
SPLENECTOMY
977
dure. The disadvantage of this approach appears to be the increased operative time, but this should diminish with experience. We believe that the advantages of laparoscopic splenectomy over the open
technique include improved exposure, decreased pain, improved pulmonary function postoperatively, shortened hospitalization, rapid return to unrestricted activities, and improved cosmetic appearance.
REFERENCES 1. Cuschieri A, Shimi S, Banting S, et al: Technical aspects of laparoscopic splenectomy: Hilar segmental devascularization and instrumentation. J R Co11Surg Edinb 37:414-416,1992 2. Carroll BJ, Phillips EH, Semell CJ, et al: Laparoscopic splenectomy. Surg Endosc 6:183-185,1992 3. Hashizume M, Sugimachi K, Ueno K: Laparoscopic splenectomy with an ultrasonic dissector. N Engl J Med 326:438,1992 4. Delaitre B, Maignien B: Splenectomy by the coelioscopic approach. Report of a case. Presse Med 20:2263,1991 (letter) 5. Bruni R, Santoro M, Caratozzolo M, et al: Laparosplenectomy in Hodgkin’s disease. G Ital Oncol8:127-129. 1988
6. Lobe TE, Schropp KP, Joyner R. et al: The suitability of automatic tissue morcellation for the endoscopic removal of large specimens in pediatric surgery. J Pediatr Surg 29:1-3, 1994 7. Schauer PR, Luna JR, Abraham A, et al: Pulmonary function after laparoscopic cholecystectomy. Presented to the Society of University Surgeons at the 54th Annual Meeting, February 1993 8. Schippers E, Oettinger AP, Anurov M, et al: Intestinale Motilitaet nach laparoskopischer vs. konventioneller Cholezystektomie. Langenbecks Arch Chir 377:14-l& 1992
Splenectomy
in Childhood
By Baird M. Smith, Kurt P. Schropp, Thorn E Lobe, David A. Rogers, Gerald J. Presbury, Judith A. Wilimas, and Winfred C. Wong Memphis, 0 The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patient is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGlA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complications in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis. Copyright o 1994 by W.B. Saunders Company INDEX WORDS:
Splenectomy,
laparoscopic,
pediatric.
T
HE DEVELOPMENT of tissue morcellation techniques permits the removal of large solid organs such as the spleen. Laparoscopic splenectomy has been used in adults.1-5 We report our initial experience with laparoscopic splenectomy in childhood. MATERIALS AND METHODS Seven consecutively treated pediatric patients for whom medical therapy failed to control their hematologic disease were selected for laparoscopic splenectomy. Those with a hemoglobinopathy underwent gallbladder ultrasound examination for diagnosis of simultaneous biliary tract disease. Concomitant cholecystectomy was planned if cholelithiasis or “sludge” was found. The patients were immunized with polyvalent vaccine against streptococcal pneumococcus and Haemophilus influenzae if not previously administered. The children were fasted the night before surgery, and an oral osmotic bowel preparation was given if gaseous abdominal distension was present. Prophylactic antibiotics were given intravenously, on call to the operating room, and steroids were administered if warranted by the patient’s history. The patients were prepared and draped in the supine position, under general anesthesia. A Foley catheter and nasogastric tube were inserted to empty the bladder and stomach. A l-cm incision was made in the infraumbilical fold through which a Veress needle was inserted to establish pneumoperitoneum of 12 mm Hg. If the spleen was large, the open technique of port insertion was preferentially used to avoid injuring the spleen. A IO-mm Surgiport (USSC, Norwalk, CT) was placed, and the lo-mm Hydrolaparoscope (CirconiACMI, Stamford, CT) was inserted. A 5-mm Surgiport was inserted in the epigastrium, the left upper quadrant, and the left lower quadrant; these were used to hold the stomach, short gastric vessels, and depress the colon, respectively. A 12-mm Surgiport was inserted beneath the left costal margin in the
Journalof
Pediatric Surgery,
Vol29,
No
8 (August), 1994: pp 975-977
Tennessee midclavicular line; it was used for clip application, scissors, and the EndoGIA stapling device (Fig 1). The smaller the child, the further from the costal margin the 12-mm cannula should be placed. If cholecystectomy is to be performed concomitantly, a sixth port is placed. in the right upper quadrant directly above the gallbladder. The patient was rotated into the steep reverse Trendelenburg position with the left side elevated. An atraumatic grasping instrument was applied beside the greater curvature of the stomach on the gastrosplenic ligament, which is retracted to the right. A second atraumatic instrument is used to retract the splenic side of the gastrosplenic ligament to the left, tenting the ligament to improve visibility and dissection. The lesser sac was entered between the instruments, and division of the short gastric vessels was performed in a superior direction. Each vessel was stapled four times and divided between the middle staples with bipolar electrosurgical cautery or shears. If easy, the most superior (shortest) branches were divided at this time, but usually it was more efficient to defer their division until the spleen is further mobilized. The patient was rotated into the right lateral decubitus position, and the splenic flexure of the colon was taken down from its attachment to the splenic hilum. The splenocolic and lienorenal ligaments were divided with the bipolar electrosurgical device. The splenic hilum was exposed, permitting visualization and removal of any accessory spleens. Care was taken to avoid the pancreas, and the EndoGIA was applied across the splenic hilar vessels and fired (Fig 2). The vessels were inspected for bleeding, and the remaining short gastric vessels or ligamentous structures were clipped and divided. Via the 12-mm port site, an 8- x S-in Lap Sac (Cook Urological, Spencer, IN) was then introduced. This step involved rolling the bag tightly, removing the port, and placing the bag tip directly into the abdomen where it was grabbed by a .5-mm grasping instrument and pulled and/or pushed into the abdominal cavity. There? it was unfolded and placed on the inferior edge of the right hepatic lobe. The spleen was then moved up onto the right lobe of the liver, and the neck of the bag was opened with three instruments. The spleen was grasped at its hilum with the fourth instrument and was “dunked” into the bag. The neck of the bag was exteriorized through the 12-mm port site, and tissue was morcellated automatically (preferably) or manually (using sponge forceps and suction) until the entire sac could be removed. The automatic tissue morcellator (Cook Urological) obviates the tedious manual morcellation with a suction cannula and sponge forceps.6 The 12-mm trocar and cannula were reinserted into the abdomen
From The Universityof Tennessee, MemphisiLeBonheur Children s Medical Center, St Jude Children’s Research Hospital, Memphis, TN. Presented at the 1993 Annual Meeting of the Section on Surgery of theAmetican Academy of Pediatrics, Washington, DC, October 29-31, 1993. Address reprint requests to Thorn E Lobe, MD, 777 Washington Ave, Suite P21 OA, Memphis, TN 38105. Copyright 8 1994 by W.B. Saunders Company 0022-3468/94129Og-0004$03.00/0
975
976
SMITH ET AL
-4
RESULTS
2
,
, -\4
4y‘..,,
5mm
12mm
#
_Smm
Fig 1.
The diseases in the seven patients were idiopathic thrombocytopenic purpura (5) hereditary spherocytosis (l), and sequestration crisis for sickle cell disease (1). The age range was 15 months to 13 years (mean, 5.7 years). The patient with hereditary spherocytosis required concomitant cholecystectomy for cholelithiasis. The hospital course of one patient with idiopathic thrombocytopenic purpura was complicated by preoperative hemoperitoneum, caused by a hemorrhagic ovarian cyst and a low platelet count. The platelet count increased during the postoperative period in all patients with idiopathic thrombocytopenic purpura. One patient had a 24-hour period of ileus, which prolonged her stay by an extra day. The operation in the patient with the preoperative hemoperitoneum was converted to an open procedure for better hemostasis and visualization. In other respects, the cases were straightforward and without complications. The average operating time for the seven patients was 3.5 hours (range, 2.5 to 4 hours).
Trocar site for laparoscopic splenectomy.
DISCUSSION to establish pneumoperitoneum if concomitant cholecystectomy was required. The splenic bed and pancreas were reinspected for hemostasis, and all trocars were removed. Wounds were closed in the standard fashion for pediatric laparoscopic procedures. Afterward, the Foley catheter and nasogastric tube was removed. The patients were offered fluids on the evening of their surgery and usually had solids the following day. Intramuscular metoclopramide or a scopolamine patch were administered for nausea. Most patients were discharged on the second postoperative day, with a prescription for penicillin and analgesics.
Fig 2. The vascular load of an EndoGlA stapler is placed across the splenic hilum to transect the tissue en masse.
Traditional splenectomy, performed through an upper abdominal incision, is associated with a number of complications, including hemorrhage, atelectasis, pneumonia, ileus, subdiaphragmatic abscess, and incisional hernias. These may prolong the hospital stay and convalescence. The laparoscopic approach eliminates many of these problems. Exposure is easily obtained by sliding the laparoscope up beneath the costal margin, to within centimeters of the operative field. Its magnification and optics permit accurate dissection and meticulous hemostasis. Because the small incisions of laparoscopic surgery are less painful than upper abdominal incisions, patients use fewer narcotics, have fewer respiratory complications, and have improved return of pulmonary function.’ The duration of postoperative ileus is shortened, and the small incisions are unlikely to herniate.8 In our series, all but one child (whose procedure was converted to open) went home on the second postoperative day and returned to unrestricted activities within one week of discharge. It appeared that the patients found the small scars cosmetically preferable to a large subcostal or midline scar. The laparoscopic approach may prove at least as safe as the open approach. The spleens removed from children are often of normal size, which facilitates the endoscopic proce-
LAPAROSCOPIC
SPLENECTOMY
977
dure. The disadvantage of this approach appears to be the increased operative time, but this should diminish with experience. We believe that the advantages of laparoscopic splenectomy over the open
technique include improved exposure, decreased pain, improved pulmonary function postoperatively, shortened hospitalization, rapid return to unrestricted activities, and improved cosmetic appearance.
REFERENCES 1. Cuschieri A, Shimi S, Banting S, et al: Technical aspects of laparoscopic splenectomy: Hilar segmental devascularization and instrumentation. J R Co11Surg Edinb 37:414-416,1992 2. Carroll BJ, Phillips EH, Semell CJ, et al: Laparoscopic splenectomy. Surg Endosc 6:183-185,1992 3. Hashizume M, Sugimachi K, Ueno K: Laparoscopic splenectomy with an ultrasonic dissector. N Engl J Med 326:438,1992 4. Delaitre B, Maignien B: Splenectomy by the coelioscopic approach. Report of a case. Presse Med 20:2263,1991 (letter) 5. Bruni R, Santoro M, Caratozzolo M, et al: Laparosplenectomy in Hodgkin’s disease. G Ital Oncol8:127-129. 1988
6. Lobe TE, Schropp KP, Joyner R. et al: The suitability of automatic tissue morcellation for the endoscopic removal of large specimens in pediatric surgery. J Pediatr Surg 29:1-3, 1994 7. Schauer PR, Luna JR, Abraham A, et al: Pulmonary function after laparoscopic cholecystectomy. Presented to the Society of University Surgeons at the 54th Annual Meeting, February 1993 8. Schippers E, Oettinger AP, Anurov M, et al: Intestinale Motilitaet nach laparoskopischer vs. konventioneller Cholezystektomie. Langenbecks Arch Chir 377:14-l& 1992