| |  IntroductionThe spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight against certain bacteria. It is also known to function as a site for the development of new red blood cells from their hematopoietic stem cell precursors, and particularly in situations in which the bone marrow, the normal site for this process, has been compromised by a disorder such as leukemia. The spleen is enlarged in a variety of conditions such as malaria, mononucleosis and most commonly in "cancers" of the lymphatics, such as lymphomas or leukemia. It is removed under the following circumstances: 1. When it becomes very large such that it becomes destructive to platelets/red cells
2. For diagnosing certain lymphomas
3. Certain cases of wandering spleen
4. When platelets are destroyed in the spleen as a result of an auto-immune process (see also idiopathic thrombocytopenic purpura)
5. When the spleen bleeds following physical trauma
6. Following spontaneous rupture
7. For long-term treatment of congenital erythropoietic porphyria (CEP) if severe hemolytic anemia develops
8. The spread of gastric cancer to splenic tissue
9. When using the splenic artery for kidney revascularisation in renovascular hypertension. The spleen, originally called the "organum plenum mysterii" by Galen, has long been an important organ for surgeons. Traditionally, surgical removal of the spleen was done by an open approach using either an upper midline or left subcostal incision. With the advent of minimally invasive techniques, laparoscopic splenectomy has become a standard procedure for elective removal of the spleen for most indications. However, several technical challenges remain related to removing this fragile, well-vascularized organ that lie close to the stomach, colon, pancreas, and kidney.
Indications
Indications for laparoscopic splenectomy are the same for open splenectomy except when emergent splenectomy and exploratory laparotomy for traumatic injuries are needed. Laparoscopic splenectomy is indicated for various benign hematologic diseases, malignant hematologic diseases, secondary hypersplenism, and other anatomical disorders of the spleen. - Laparoscopic splenectomy for malignant diseases of the spleen can be used for diagnostic or therapeutic reasons. Indications include myeloproliferative disorders, lymphoproliferative diseases, hairy cell leukemia, Hodgkin and non-Hodgkin lymphoma, malignant vascular tumors, malignant lymphomas, and lymphangiosarcomas.
- The most common benign hematologic disease treated with laparoscopic splenectomy is immune thrombocytopenia purpura, and it is recommended when medical therapy, including steroids and intravenous gammaglobulin, fail or long-term steroids are needed. Laparoscopic splenectomy can also be warranted in other benign conditions, including other types of thrombotic purpura, hereditary spherocytosis, major and intermediate thalassemia with secondary hypersplenism or severe anemia, sickle cell disease, and refractory autoimmune hemolytic anemia.
- Although the use of laparoscopic splenectomy in trauma has been reported, its role is limited because most hemodynamically stable patients with splenic injuries are successfully treated non-operatively, and unstable patients require emergent laparotomy for control of hemorrhage and to evaluate possible associated traumatic injuries.
Contraindications to laparoscopic splenectomy are similar to contraindications for all laparoscopic surgeries. - Although reports on the safety of laparoscopic splenectomy in patients with cirrhosis and portal hypertension have been published, many consider this an absolute contraindication to laparoscopic splenectomy.
- Contraindications include the inability to tolerate general anesthesia, uncontrollable coagulopathy, and the need for laparotomy for associated procedures.
- Massive splenomegaly is a relative contraindication; however, the hand-assist technique may facilitate removal of large spleens in a minimally invasive fashion.
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