Laparoscopic Splenectomy

What is Laparoscopic Splenectomy?

Laparoscopic Splenectomy is a minimally invasive surgical procedure that is done to remove either a part or whole of the spleen. It has the advantage of less postoperative pain, lesser recovery time, shorter hospital stay, and early resumption of normal activities.

Is the Laparoscopic Splenectomy procedure an elective or an emergency procedure?

Laparoscopic Splenectomy is generally done as an elective procedure.

Types of procedure

Laparoscopic Splenectomy may be of the following types:

• Lateral approach Laparoscopic Splenectomy
• Anterior approach Laparoscopic Splenectomy
• Hand-assisted Laparoscopic Splenectomy (HALS)

Indications

Some indications for which Laparoscopic Splenectomy is done include:

• Benign Hematologic Disease:
  • Immune thrombocytopenic purpura: The platelets carry autoantibodies resulting in their destruction and removal by the spleen
  • Hereditary spherocytosis: A genetic condition in which there are defects in the red blood cell membranes leading to their destruction and removal by the spleen
  • Major thalassemia with secondary hypersplenism or anemia: A severe form of the condition thalassemia in which there is a defect in the formation of hemoglobin and subsequent enlargement of the spleen.
  • Intermediate thalassemia with secondary hypersplenism or anemia: There is a defect in the formation of hemoglobin and subsequent enlargement of the spleen
  • Sickle cell disease: A genetic disorder in which there is a presence of abnormal hemoglobin in the red blood cells
  • Refractory autoimmune hemolytic anemia: It is increased and abnormal destruction of the red blood cells
• Malignant Disease:
  • Myeloproliferative diseases: There is an abnormal production of the blood cells within the bone marrow
  • Lymphoproliferative diseases: There is an abnormal production of the white blood cells within the bone marrow
  • Hairy cell leukemia: It is a type of chronic leukemia in which there are an abnormal production and proliferation of b cell within the bone marrow
  • Hodgkin’s lymphoma: cancer affecting the white blood cells
  • Non-Hodgkin's lymphoma: cancer affecting the white blood cells
  • Malignant vascular tumors
  • Malignant lymphoma
  • Lymphangiosarcoma
• Other Conditions:
  • Splenic abscess
  • Spontaneous rupture
  • Spread of gastric cancer to the spleen

Contraindications and Risk factors

Some contraindications and risk factors for Laparoscopic Splenectomy include:

• Inability to tolerate general anesthesia
• Severe cardiopulmonary dysfunction
• Coagulopathies
• Uncontrolled diabetes
• Cirrhosis
• Portal hypertension
• Conditions which might require a laparotomy
• Splenectomy secondary to trauma

Investigations before the procedure

Some investigations that may be done before Laparoscopic Splenectomy include:

• Laboratory tests:
  • CBP and ESR
  • Coagulation profile and blood typing
  • Liver and renal function tests
  • Complete metabolic panel
  • Blood glucose/HbA1c
  • Complete urine examination
• Imaging tests:
  • Chest X-ray
  • Abdominal ultrasound
  • CT scan
  • Echocardiography
• Electrocardiography

Preoperative advice

Before performing a Laparoscopic Splenectomy, the following may be done:

• Risks and benefits of the procedure are explained
• Anticoagulant medications are stopped a few days before the procedure
• Nothing by mouth after midnight on the night before surgery
• Antibiotic prophylaxis may be started a few days before the surgery

Intraoperative details

Duration: Laparoscopic Splenectomy may last between 1-3 hours.

Anesthesia: Laparoscopic Splenectomy is done under general anesthesia.

Description of the procedure

Depending on the type of Laparoscopic Splenectomy that is being done the individual may be lying on his/her back, or right lateral decubitus position, after the anesthetic has taken effect, multiple incisions are made in the abdomen and insufflation is done, a fiber-optic scope and other surgical instruments are introduced into the abdomen through these incisions, and a diagnostic laparoscopy is done to look for the presence of any accessories spleens. The attachments of the spleen namely, the splenocolic ligament, gastrosplenic ligament, and the phreno-splenic ligament are dissected and the blood vessels supplying the spleen are ligated. The endoscopic stapling of the hilum of the spleen is done. The stoppage of bleeding is usually done with ultrasonic coagulation. The spleen is then removed, the abdomen is insufflated again, another diagnostic laparoscopy is done once it is confirmed that that is no bleeding and there are no accessories spleens the instruments are removed and all the incisions are closed with absorbable sutures. In the anterior approach Laparoscopic Splenectomy, the liver and the stomach need to be retracted before splenectomy is done. The hand-assisted lap splenectomy provides the advantage of both open and laparoscopic procedures and is useful in the removal of very large spleens that may otherwise be impossible to remove through lap splenectomy.

Postoperative details

After lap splenectomy, the following are done:

• The individual is moved to a recovery room and an ICU and monitored until awake and stable
• Cardiac and pulmonary functions are monitored
• Intravenous fluids may be given

Common post-procedure occurrences:

• Pain at the site of surgery
• Bruising at the site of surgery
• Nausea
• Lightheadedness and fatigue

Discharge: Usually on the third or fifth postoperative day.

Medications: Pain relievers and antibiotics may be prescribed.

Review: Usually one week after discharge.

Resumption of normal activities: Usually one week after the procedure.

Role of diet/ Exercise/ Lifestyle changes

Some measures that may be taken after lap splenectomy include:

• Avoid bathing up to 2-3 days after the procedure
• Avoid strenuous activities for a week after the procedure
• Maintain good hand and respiratory hygiene
• Stay away from people who are sick
• Watch out for signs of complications such as fever, extreme pain

Complications

Some complications that may be seen after lap splenectomy include:

• Bleeding
• Infections
• Pneumonia
• Post-splenectomy sepsis/Overwhelming Infection
• Injury to adjacent organs such as colon, stomach, or the pancreatic tail
• Missed accessory spleens
• Portal vein thrombosis

Prognosis

The prognosis for lap splenectomy depends on the underlying condition that is being treated and the general health of the individual.

Indications for hospitalization if required

Hospitalization will be required for lap splenectomy.

Suggested clinical specialist/ Departments to consult for the procedure

Lap splenectomy will be done by specialists from the Department of Interventional Endoscopic Surgery and Surgical Gastroenterology.