Laparoscopic surgery has transformed the way complex abdominal operations are performed, and splenectomy is no exception. In his comprehensive lecture on Laparoscopic Splenectomy, Dr. R. K. Mishra, a world-renowned laparoscopic surgeon and academician, provides a detailed overview of the principles, indications, techniques, and challenges of this advanced minimally invasive procedure. His lecture is both educational and practical, designed for surgeons, gynecologists, and postgraduate trainees seeking mastery in minimal access surgery.

Introduction to Laparoscopic Splenectomy

The spleen plays a central role in hematological and immunological functions, but in several disorders, removal becomes necessary for therapeutic or diagnostic purposes. Traditionally performed through an open approach, splenectomy was associated with significant morbidity due to the spleen’s location in the left hypochondrium and its proximity to vital structures. Dr. Mishra emphasizes that with the advent of laparoscopic techniques, splenectomy has become safer, less painful, and associated with faster recovery, while maintaining the same therapeutic effectiveness as open surgery.

Indications for Laparoscopic Splenectomy

Dr. Mishra begins the lecture by outlining the common indications where laparoscopic splenectomy is considered the gold standard:

Hematological disorders such as idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, and autoimmune hemolytic anemia.

Hypersplenism causing cytopenias.

Benign or malignant splenic tumors and cysts.

Splenic abscess or trauma, in selected stable patients.

Staging for lymphoma and other hematological malignancies.

He stresses the importance of preoperative immunization, especially against encapsulated organisms like pneumococcus, meningococcus, and Haemophilus influenzae, to reduce the risk of overwhelming post-splenectomy infection (OPSI).

Patient Selection and Preparation

Not all patients are ideal candidates for laparoscopic splenectomy. Dr. Mishra highlights critical selection criteria:

Spleen size: Laparoscopic splenectomy is most suitable for normal-sized or moderately enlarged spleens. Extremely large spleens (>20 cm) may require hand-assisted or open approaches.

Patient stability: Hemodynamically unstable patients, especially after trauma, are not suitable for laparoscopic procedures.

Surgeon’s expertise: Proper training in advanced laparoscopy is essential due to the spleen’s fragility and vascularity.

Preoperative preparation includes routine investigations, cross-matching of blood, and vaccination at least two weeks before surgery.

Positioning and Port Placement

According to Dr. Mishra, proper positioning is critical for success. The patient is placed in the right lateral decubitus position with the left side elevated, which allows gravity to retract the stomach and colon away from the operative field.

Typical port placement involves:

A 10 mm camera port at the umbilicus or epigastrium.

Working ports (5 mm or 10 mm) in the left subcostal and midclavicular lines.

An accessory port may be placed for retraction of the spleen or stomach.

This strategic placement ensures ergonomic access for dissection and vascular control.

Surgical Technique

Dr. Mishra explains the stepwise approach in detail:

Diagnostic laparoscopy is performed to assess the anatomy.

Mobilization of the spleen begins with division of the splenocolic ligament, allowing the spleen to be lifted upward.

Dissection of the splenorenal and splenophrenic ligaments follows, exposing the hilum.

Control of the splenic hilum is the most critical step. Modern energy devices or laparoscopic staplers are used to secure the splenic vessels safely. Dr. Mishra warns that careless handling can lead to torrential bleeding.

Short gastric vessels are divided carefully to prevent gastric ischemia or bleeding.

Once completely mobilized, the spleen is placed in a specimen retrieval bag, morcellated if necessary, and removed through the enlarged port site.

Challenges and Complications

Dr. Mishra dedicates part of his lecture to the potential challenges surgeons may face:

Massive splenomegaly makes laparoscopic handling more difficult due to limited working space.

Bleeding from splenic hilum remains the most dreaded complication, often requiring conversion to open surgery.

Injury to pancreas tail during hilar dissection can lead to postoperative pancreatic fistula.

Subphrenic collections or abscesses may occur if meticulous hemostasis is not achieved.

He emphasizes that timely conversion to open surgery should never be viewed as a failure but as a wise surgical judgment to ensure patient safety.

Advantages of Laparoscopic Splenectomy

The lecture highlights the multiple advantages of this minimally invasive approach:

Reduced postoperative pain and need for analgesics.

Shorter hospital stay and faster return to normal activities.

Better cosmetic outcomes due to small incisions.

Lower incidence of wound-related complications like infection or hernia.

Dr. Mishra points out that with experience, operative time decreases and outcomes improve, making laparoscopic splenectomy the preferred option for most elective indications.

Postoperative Care and Follow-Up

Postoperative management includes early ambulation, pain control, and gradual resumption of oral intake. Antibiotic prophylaxis is essential in the immediate period, while long-term preventive care includes lifelong vigilance for infections. Dr. Mishra stresses the need for patient education regarding OPSI and the importance of prompt medical attention for febrile illnesses.

Conclusion

In his lecture, Dr. R. K. Mishra underscores that laparoscopic splenectomy represents the standard of care for many splenic disorders. Through clear explanations and surgical insights, he emphasizes the importance of careful patient selection, meticulous technique, and readiness to convert when necessary. His lecture serves as an invaluable resource for budding laparoscopic surgeons, providing both theoretical knowledge and practical wisdom gained through years of surgical expertise.