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Mini-Laparotomy for Splenectomy in Children: An Excellent Mini-Invasive Alternative to Laparoscopic Approach

Esposito C., Alicchio F., Ascione G., Sammarco G., and Settimi A.

Chair of Pediatric Surgery, “Federico II” University, Naples, Italy

Chair of Pediatric Surgery, Magna Graecia University, Catanzaro, Italy

 

Correspondence 

Ciro Esposito
Chair of Pediatric Surgery, “Federico II” University, Naples, Italy
Via Bernini 58; 80129 Naples, Italy
Tel: + 39.081. 746 33 77; Fax.+ 39.081.746 33 61;
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: Laparoscopic splenectomy is frequently performed to treat various haematological and autoimmune disorders in children. This study underlines the efficacy and safety of minimal sub-costal incision to perform splenectomy in children with haematological disorders.

Materials and methods: We analyzed the data of 31 consecutive children who underwent splenectomy for haematological disorders in our Unit between January 2000 and January 2006. The patients were 19 girls and 12 boys whose ages ranged between 4 and 14 years (median, 7.5 years). Their weight ranged from 15 to 49 kg (median 23 kg). The indications for splenectomy were hereditary spherocytosis (11 cases), b-thalassemia (10 cases), idiopathic thrombocytopenic purpura (7 cases), and sickle cell disease ( 3 cases). All children had been vaccinated against pneumococcal and meningococcal infections 1 month before surgery. Eight children presented with an associated cholelitiasis and were cholecystectomized via laparoscopy during the same anaesthesia.

Results: The size of the spleen at preoperative US was on average 14 ± 2.0 cm, (16 ± 2.5 cm along its longitudinal axis) and weighed 550±55.1 gr. Operating time was 35±10 minutes for splenectomy alone ± 20-25 min. in patients who also underwent an associated cholecystectomy. No complications were recorded. In 3 children there was a breakage of the splenic capsula after extraction of the spleen. Post-operative analgesia was necessary for 24-48 hours in all patients; hospital stay was 3.0 ± 1 days.

Conclusion: Based on our large experience, we believe that the open approach via a minimal sub-costal incision is a safe and effective mini-invasive procedure to perform splenectomy in children. In case of coexisting cholelytiasis, the cholecystectomy can be performed laparoscopically during the same anaesthesia.

 

Key words: spleen, laparoscopic splenectomy, minimally invasive surgery.

 

 

INTRODUCTION

Children who present with hematological disorders requiring splenectomy can be treated using the open or laparoscopic approach [3,7]. Laparoscopic splenectomy is considered by some authors a safe procedure to perform in children; nevertheless, this advanced procedure requires laparoscopic expertise [2,14]. Analyzing the international literature, it appears that the majority of surgeons prefer to isolate the spleen in laparoscopy, and then extract it through a mini-laparotomy in the inguinal region [9, 11,20]. Following a large experience with laparoscopic splenectomy, our group attempted a different approach consisting in performing splenectomy through a mini-laparotomy in the left subcostal region.

 

MATERIALS AND METHODS

Thirty-one consecutive children underwent splenectomy for haematological disorders in our Unit between January 2000 and January 2006.

The patients were 19 girls and 12 boys whose ages ranged between 4 and 14 years (median, 7.5 years). Their weight ranged from 15 to 49 kg (median 23 kg). The indications for splenectomy were hereditary spherocytosis (11 cases), b-thalassemia (10 cases), idiopathic thrombocytopenic purpura (7 cases), and sickle cell disease ( 3 cases). All the children had been vaccinated against pneumococcal and meningococcal infections 1 month before the intervention. Eight of the 31 children presented an associated cholelitiasis and thus were cholecystectomized via laparoscopy during the same anaesthesia.

The size of the spleen was determined preoperatively by ultrasound (US) and measured both on average and along its longitudinal axis. Operative management consisted in the insertion of a nasogastric tube to void the stomach; in the 8 patients with an associated cholelithiasis, we performed a laparoscopic cholecistectomy using 4 trocars, according to the standard procedure, before performing the splenectomy. The incision of the trocar located in left subcostal region was enlarged laterally to perform the splenectomy.

As for the patients who underwent the splenectomy alone, a minimal sub-costal incision (mean 7 cm; min 6 - max 9 cm), was performed. The inferior polar vessels were sectioned; the spleen was then detached from its posterior adhesions and gently extracted through the mini-laparotomy. The short gastric vessels were coagulated with mono- or bipolar forceps, and the arterial and secondary the vein were ligated, preserving blood splenic sequestration.

The patients who underwent splenectomy alone did not require any drainage; on the contrary in those with associated cholecystectomy a drainage on the right side was left in place for 24 hours.

Local wound anaesthesia and postoperative systemic analgesia were administered in all children. Feeding was restarted on first postoperative day.

 

RESULTS

No major complications were recorded. In all children the size of the spleen was measured preoperatively using US; on average it was 14 ± 2.0 cm and 16 ± 2.5 cm along its longitudinal axis; weight was 550 ± 55.1gr. Operating time was 35 ± 10 minutes for splenectomy alone; in the 8 children requiring cholecystectomy as well, an additional 20-25 minutes were recorded.

Three of the 31 children (9.7%) experienced minor complications; in particular , there was a breakage of the splenic capsula during extraction of the spleen. In one case (Fig. 1) there was a lesion of the inferior splenic pole. Accessory spleens were found and removed in 3 patients (9.7%), one patient presents 2 accessories spleens (Fig.2). As for skin closure it was performed in 20 patient using intradermic suture or using glue in 11 patients.Post-operative analgesia was necessary for 48 hours in all patients and hospital stay was 3.0 ± 1 days. In none of the patients there was a need for a nasogastric tube; all resumed feeding on the 1st or 2nd post operative day.

eArt36 -1 

Figure 1. A large spleen extracted through a left subcostal mini-laparotomy, at the end of the procedure. The spleen presents a capsula breakage on the medial side. 

eArt36-2 

Figure 2. Medially to the spleen 2 little spleens are clearly visible in the epiploon

All the children were given postoperative antibiotic treatment. The longest follow-up period was 84 months; after this time, no patient experienced any problems or complications related to the operation. After the discharge from hospital the patients were followed by pediatric hematologists. The splenectomy was shown in all cases to improve the patient’s haematological profile. We would like to emphasize that for the treatment of these hematological disorders, a splenectomy is equally effective whether it is performed laparoscopically or laparotomically .

 

DISCUSSION

The laparoscopic splenectomy has proven to be a safe procedure in children with haematological disorders [1, 4,12]. As for the option between laparoscopic or open splenectomy, the choice much depends on the surgical team’s experience in laparoscopic splenectomy. In fact only teams that perform both approaches (laparoscopy and laparotomy) can choose freely which approach is preferable to perform [9]. As a matter of fact, since our team has a large experience in laparoscopic surgery, and in particular in laparoscopic splenectomy, we have designed a mini-invasive approach for splenectomy in children, performing a mini-laparotomy with a left subcostal incision [9]. On the basis of our laparoscopic experience, we strongly believe that a laparoscopic splenectomy should be performed only if special devices (as ultrasonic or plasmakynetic energy) are available, since this new source of energy allows an easy and rapid dissection of the spleen and a simple hemostasis of vessels smaller than 5-mm in diameter [5, 6, 17]. Nevertheless, the laparoscopic procedure remains rather lengthy; in fact several authors report a duration of operating time that varies between 145 to 240 minutes, if not longer [8, 15, 16].

Moreover, in some series the spleen is extracted with a souprapubic or inguinal incision sacrificing the advantages of the mini-invasive laparoscopic approach [9, 10, 13]. From a technical point of view the major problem during laparoscopic splenectomy may arise during the manipulation of the endo-bag and in positioning the spleen in its proper place during extraction [5,18]. The introduction of the organ into the bag can be the most difficult part of the procedure, and may be extremely difficult with massively enlarged organs. This translates into longer operating time and higher operating costs if compared with the traditional open approach [9, 19] . Moreover, it may be difficult to control haemostasis in case a lesion of the splenic vessels occurs during the dissection phase; this is a frequent cause of conversion to open surgery. The advantage of the laparoscopy, on the contrary, is the availability of image magnification that allows a safer and clearer image of the operation as well as a complete exploration of the abdominal cavity [9, 12].

Among the disadvantages, the main one is probably the higher operating costs as compared with the traditional open approach. In fact, in laparoscopic splenectomy, with the exception of the instruments and trocars, which are reusable, the clips, endo-bag, automatic stapler and other devices needed, such as the ultrasonic or tripolar energy, are all extremely expensive [16, 17]. In our opinion, the use of a 5-7 cm subcostal left sided mini-laparotomy allows the surgeon to keep the mini-invasiveness of the laparoscopy, all the while retaining the advantage of a shorter operative time and an easier control of the hilar vessels. By contrast, one of the shortcomings of open splenectomy is the limited view of the abdominal cavity,as a full view requires a large laparotomy. It has been reported that the chances of finding an accessory spleen during a laparoscopic splenectomy are 18-33%, although the routine use of preoperativre US helps identifing an accessory spleen before surgery, as was the case in 3 of our patients in this series [3, 4 18].

There were 3 capsule breakages in our series (as fig 1 shows). We believe that this complication, which was without consequence for the patients, occurs with highly lobulated spleens; in such cases, a solution could be to enlarge the incision by 1-2 cm to facilitate extraction of the capsule. Another clear advantage of the minilapartomy is the shorter duration of surgery compared to our experience in laparoscopy. This decreased the need for narcotics compared with the laparoscopic approach. Oral feeding was possible from the 2nd postoperative day, and hospital stay was 3.0 ± 1 days, exactly as with laparoscopy. In case of an associated cholelithiasis we think that the optimal procedure is to perform the cholecistectomy first, using the laparoscopy, and then perform the splenectomy via a mini-laparotomy. At the end of cholecystectomy, extraction of the spleen can be facilitated by detaching the spleen from its posterior adhesions using laparoscopic instruments. As for cosmesis, intradermic suture or glue gave to our patients an excellent skin aspects.

In our experience, a minimal subcostal incision seems to be a logical and safe approach in children with haematological disorders, although a prospective double blind randomized study comparing the outcome of open and laparoscopic splenectomy will be necessary to define the most suitable approach to adopt in children with these disorders.

 

 

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