Laparoscopic Splenectomy in Children
The preliminary results and the retrospective comparison help establish the safety and efficacy of laparoscopic splenectomy in children. Although the peritoneal cavities of the children are limited, there are no special risks in pediatric patients. As many splenectomies are now being performed for cytopenic/anemic disease in children, pediatric patients requiring splenectomy may benefit from this minimal access approach. Decreased postoperative pain and recovery time are anticipated in these patients, just as for thousands of patients undergoing laparoscopic splenectomy.
Absolute contraindications to laparoscopic splenectomy include contraindications to general anesthesia. Extensive inflammation and adhesions in the left upper quadrant may be a relative contraindication because of the increased possibility of hemorrhage. Significant splenomegaly may also be a relative contraindication caused by increased difficulty of dissection and the need for more complex extraction procedures. A large spleen compared to a small abdomen is a problem in pediatric laparoscopic splenectomy. Especially in patients with HS, the spleen size is usually large.
Bleeding tendency is a contraindication to laparoscopic procedures. Many patients requiring splenectomy are coagulopathic from thrombocytopenia or qualitative platelet dysfunction. Preoperative use of intravenous IgG should be considered for patients with ITP. The response to IgG is generally as efficacious as the response to steroids with the added advantage of fewer associated side effects.
The surgeon performing splenectomy must be cognizant of this fact and have a low threshold for conversion to an open procedure in the event of a hemorrhage that is not easily visualized or controlled through the operating ports. As LS is an advanced technique, we recommend that anyone attempting the procedure be fully experienced in laparoscopic surgical techniques and instrumentation. Understanding the limitations of minimal access surgery, in addition to possessing the ability to convert to the open procedure to assure safe splenectomy and patient safety, is also important. Laparoscopic splenectomy may prove at least as safe as the open approach if performed by experienced surgeons.
The disadvantage is increased operative time. However, this may diminish with experience and introduction of the Endocatch II. With more experience and advances in technology, laparoscopic splenectomy may become easier, and the surgeon may be able to reduce their operative time and anesthetic risks. Several other aspects of the operative technique developed in pediatric patients deserve emphasis. Early mobilization of the spleen significantly increases the difficulty of exposing the hilum. The splenic artery and vein are individually clipped and divided, and a linear stapler is not necessary for pediatric patients. As superior branches of the short gastric vessels are difficult to clip at the early phase of the procedure, those branches should be left and divided at the end. The accessory spleen should be searched in patients with a hematologic disease requiring splenectomy for hypersplenism. Although these may occur within the attaching ligaments of the spleen and in the mesentery and omentum, they most frequently occur in the hilum along the splenic vessels. Four accessory spleens were found in our series, and they were successfully removed under laparoscopic guidance. The magnified view afforded during laparoscopy can allow for easier identification of accessory spleens, especially in the hilar region. The inability to identify accessory spleens by palpation is one limitation of laparoscopic surgery.
A thorough evaluation of accessory splenic tissue is essential intraoperatively. Traditional splenectomy, performed through a midline or subcostal 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.
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. Patients treated laparoscopic splenectomy ambulated the same day, and a decrease in postoperative hospital stay was seen compared to those who underwent open surgery. Most of the patients returned to unrestricted activities within 1 week after being discharged.