الفهرس 
AANNAATTOOMY OOFF TTHE SSPLLEEEENNOnly 14 pages are availabe for public view
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Abstract
Since Quittenbaum performed the first successful splenectomy in 1826, the operation had been performed for a variety of hematological conditions among other indications. However, few changes in the operative technique of splenectomy occurred until 1991, when Delaitre and Maignien described their initial success with LS. Since then, LS has become the preferable option for treatment of various hematological disorders especially in patients with normal-sized spleens. (Tan et al, 2003) & (Cordera et al, 2003).
The indications of splenectomy can categorized as A- non traumatic indications as 1- malignant hematological diseases (e.g. Lymphoma, Leukemia, Myelodysplastic and Myeloproliferative Disorders); 2- benign hematological diseases (e.g. Hereditary Spherocytosis, Autoimmune hemolytic anemia, Sickle cell disease, thalassemia, ITP, TTP and Gaucher’s disease) 3- mass lesions of the spleen (e.g. Abscesses, Cysts and Tumors) 4- Vascular disorders of the spleen and 5- Miscellaneous disorders(e.g. portal hypertension and Felty’s syndrome); and B- traumatic indications: in cases of penetrating trauma, blunt trauma and operative trauma (Godinez et al, 2009). The indications for performing LS are the same as those for OS, with few exceptions as traumatic indications. The most common indications are ITP and heriditary spherocytosis (Park et al, 2000).
LS plays a limited role in traumatic splenic injuries due to technical limitations in controlling hemorrhage with this approach. Massive splenomegaly (long axis length >25 cm) is a relative contraindication due to difficulties in establishing pneumoperitoneum and adequate working space. Other relative contraindications are splenic artery aneurysm, splenic abscess, portal hypertension, and ascites (Uyen et al, 2001).
LS can be performed by a variety of techniques, the first described was the anterior approach with patient in supine position, then the anterolateral and posterolateral approaches with patient in lateral or semilateral position was introduces and became the most widely adopted technique due to the many advantages it offers compared to the previous technique. Recently LS reached the era of robotic surgery and NOTES (Dalvi, 2007).
LS may cause different intraoperative and post operative complications. Intraoperative complications include hemorrhage (the commonest) and injury to adjacent organs. Postoperative complications after splenectomy include pulmonary complications, subphrenic abscess, hemorrhage, pancreatitis, wound infections, and deep vein thrombosis. (Uyen et al, 2001).
Still, the potential advantages associated with the development of a minimally invasive form of splenectomy are considerable. The main advantages are better operative outcomes with shortened period of ileus, hospital stay and decreased analgesic use and the reduction in the rate of major complications. This will help patients to resume their normal activities in a shorter time than open surgery patients (Flowers et al, 1996).
Despite the increasing acceptance for performing LS, several factors dissuade the inexperienced laparoscopic surgeon from performing the procedure. The large and potentially complex blood supply of the spleen creates the potential for rapid, severe hemorrhage, especially when combined with splenomegaly and thrombocytopenia often seen in patients with hematologic diseases. The operative dissection also is made difficult by the remote location of the spleen in the recesses of the left upper quadrant, as well as the intimate relationships with surrounding organs such as the colon, stomach, and pancreas. Technical operative skills and equipment requirements for LS are significantly greater than for other laparoscopic procedures such as cholecystectomy and appendectomy (Flowers et al, 1996).
Moreover, with the presence of splenomegaly, particularly massive splenomegaly, the laparoscopic approach can pose significant technical challenges and often requires an accessory incision for extraction or hand assistance. Compared to LS for normal-sized spleens, conversion rates tend to be higher, and some series but not all, report an increased risk of complications with increasing splenic weight. Accordingly, the benefits of a laparoscopic approach are less clear for these patients (Feldman et al, 2008).
However, as laparoscopic techniques, surgical skills, and instrumentation have improved, so have the safety and efficacy of this procedure even in the presence of splenomegaly and other contraindications. LS is now replacing OS as a therapeutic option in many centers (Smith et al, 2004).
The aim of our work was to study LS as an established procedure for managing patients with different indications of splenectomy, focusing on patient selection, technique used to conduct the operation, benefits, limitations and complications specific to the laparoscopic approach.
The study had taken place in Ain Shams University hospitals during the period from June 2008 to June 2010. The study was a prospective interventional study involving 20 patient in whom splenectomy was indicated. The indication for splenectomy in the study group was: treatment of thrombocytopenia not responding to medical treatment in ITP patients, for symptomatic refractory pancytopenia in patients with secondary hypersplenism and for treatment of anemia in patients of hereditary spherocytosis.
The selected patients were subjected to thorough history taking; complete physical examination with calculation of the patient’s BMI, full laboratory workup, pelviabdominal ultrasound and other complementary preoperative investigations. The patients were given H. influenzae type B vaccine and pneumococcal polysaccharide vaccine 2 weeks prior to the operation and any abnormality in the blood picture (anemia or thrombocytopenia) was corrected before the operation. Informed consent was obtained from all patients.
All of the patients included in the study had a benign hematological indication for splenectomy with ITP patients representing the majority of study population (65%) followed by Spherocytosis patients (25%) with only a minority of cases were hypersplenism secondary to chronic liver disease.
All patients had an attempt for LS using the anterolateral approach with patient in semilateral decubitus with change of position to full lateral decubitus when needed as this combination of semilateral and lateral position helped us to achieve the advantages of both. We used a combination of the LigaSure and the Harmonic ace for dissection and for control the splenic vessels we used endoscopic linear stapler with vascular cartridges. Different operative parameters and outcomes were documented.
Patients were observed for period of ileus, time needed to resume full oral intake, hospital stay period, the need for analgesia, postoperative complications and early hematological response, and they had a follow up visit one week after discharge.
The mean operative time in our study was slightly better than that reported in earlier studies but longer than more recent studies, and longer than that reported for OS.
The mean estimated intraoperative blood loss in our study was comparable to that reported in other studies in the literature and less than that reported for OS.
We had no intraoperative complications other than bleeding, with an intraoperative transfusion rate similar to that published by other authors.
The conversion rate in our study was within the rates published in other studies but more in line with earlier studies which reported higher conversion rates. Multivariate analysis of preoperative parameters in our study revealed that the splenic size (maximum interpolar length) was the independent predictor for conversion with 16 cm as cut-off value.
The rate for occurrence of significant bleeding in our study was higher than those reported in the literature. In most of the cases of significant intraoperative bleeding the source was from the spleen itself or small vessels in splenic ligaments, with only one case where bleeding was due to injury of hilar vessels. Multivariate analysis of preoperative parameters in our study revealed that the splenic size (maximum interpolar length) and BMI were the independent predictors for occurrence of significant bleeding.
The mean period needed to resume full oral intake was slightly longer than what is reported in most studies and the hospital stay period was comparable to most other studies; with both being better than figures reported in OS.
The period of administration of oral and parental analgesia in our study was better than those reported for OS but couldn’t be directly compared to other studies difference in postoperative pain management protocols.
The postoperative complication rate in our study was similar to that reported in the literature and except for one patient that needed reexploration for bleeding the reported complications were minor ones (prolonged ileus and wound infection). Multivariate analysis of preoperative parameters in our study revealed that the splenic size (maximum interpolar length) was the independent predictor for conversion with 16 cm as cut-off value.
Analysis of different preoperative parameters and their relation to operative outcomes revealed that the increase in splenic size and BMI tend to increase the operative time, estimated intraoperative blood loss, period of ileus, period needed to resume full oral intake, hospital stay and period of analgesia.
Analysis of operative parameters and their effect on postoperative outcomes revealed that the occurrence of significant intraoperative bleeding and occurrence of conversion had significantly affected most of the postoperative outcomes (manifested by prolonged period of ileus, time to full oral intake, hospital stay, period of analgesia and increased complication rates). Also the study showed a trend of increasing postoperative outcomes (increased period of ileus, time needed to resume full oral intake, duration of hospital stay and period of parenteral analgesia) with the increase in operative times.
All our patients started to show the desired hematological response detected by postoperative and follow up CBC results but the period of follow up was not long enough to establish the definite clinical effects of the operation.
Cost analysis was not done due to the lack of data about the total hospital costs, and societal costs but It was obvious that the operating room costs higher than OS.