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Laparoscopic Splenectomy for Children With Hematological Disorders: Our Initial Experience With 45 Cases

Abdulla Alwabari*, Lalit Parida*, Ahmed H. Al-Salem**

*Department of Surgery, Division of Pediatric Surgery, King Fahad Specialist Hospital

**Department of Pediatric Surgery, Maternity and Children Hospital,

Dammam, Saudi Arabia

 

Correspondence:

Ahmed H. Al-Salem,

P. O. BOX 61015

QATIF 31911; SAUDI ARABIA

FAX: 966 3 8630009; e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: In 1991, Delaitre reported the first laparoscopic splenectomy. Since than laparoscopic splenectomy has become the procedure of choice to treat hematological diseases requiring splenectomy. The Eastern Province of Saudi Arabia is known to have a high incidence of hemoglobinopathies which necessitate splenectomy. This report describes our initial experience with laparoscopic splenectomy for children with various hematological disorders.

Material and Methods: The medical records of all children who had laparoscopic splenectomy at our hospital were retrospectively reviewed for age, sex, indication for splenectomy, operative time, hospital stay and postoperative complications. The results were compared to a similar group of children who had open splenectomy with or without cholecystectomy.

Results: Over a period of 3.5 years between January 2005 and June 2008, a total of 45 children had laparoscopic splenectomy with or without cholecystectomy. Their age ranged from 2 years - 12 years (mean 7 years). There were 23 males and 22 females. The indications for splenectomy were: sickle cell disease (30), B-thalassemia major (5), thalassemia intermediate (4) ITP (5) and autoimmune hemolytic anemia (1). Thirty-seven children had laparoscopic splenectomy only and 8 had laparoscopic splenectomy and cholecystectomy. The operative time ranged from 1.5 hours – 9 hours (mean 2.75 hours). Their hospital stay ranged from 3 days – 10 days (mean 4.5 days). There was no mortality. Three patients (6.7%) required conversion to open splenectomy. In one because of a very large size spleen and severe adhesions, and in the other two because of intra-operative bleeding. The results in term of operative time, hospital stay and postoperative complications were compared to a similar group of 45 children who had open splenectomy (37) with or without cholecystectomy (8).

Conclusions: Laparoscopic splenectomy is feasible and safe in children with hematological disorders in general and sickle cell disease in particular and can be done concomitantly with cholecystectomy. Currently, it requires more operative time than the open approach. This is specially so for children with sickle cell disease who are known to have large spleens with severe adhesions. It is however superior to open splenectomy with regard to duration of hospital stay, cosmetic appearance and post-operative complications.

Key words: laparoscopic splenectomy, cholecystectomy, hemoglobinopathies

  

Introduction

Traditional open surgery is still regarded as the standard approach for splenectomy in children and adults. Recently, minimal invasive surgery has gained acceptance as an alternative approach for a variety of surgical conditions in children including splenectomy [1]. Splenectomy is a common surgical procedure in the Eastern Province of Saudi Arabia, where sickle cell disease (SCD) and other hemoglobinopathies are common [2, 3, 4, 5, 6]. To determine the safety and efficacy of laparoscopic splenectomy in children, a retrospective review of our preliminary experience was compared to a similar group of children who previously underwent open splenectomy.

Patients and Methods

The medical records for all children less than 15 years of age who underwent laparoscopic splenectomy at our hospital were retrospectively reviewed. Over a period of 3.5 years from January 2005 to June 2008, a total of 45 children had laparoscopic splenectomy, 30 of them had SCD. Thirty-seven had laparoscopic splenectomy only and 8 had laparoscopic splenectomy and cholecystectomy. They were compared to a similar group of children who had open splenectomy in term of operative time, hospital stay and postoperative complications and the statistical analysis was performed using Student’s t-test. The data extracted from the medical records included age at operation, sex, hematological parameters, diagnostic methods, operative procedures, duration of operation, hospital stay and post operative complications. The diagnosis of SCD was based on a positive sickling test and hemoglobin electrophoresis using Helena laboratories super Z electrophoresis. All our patients with SCD underwent a standardized perioperative management. Each patient with an admission Hb less than 10 g/dl underwent preoperative simple blood transfusion to increase the Hb level to 10-12 g/dl and the hematocrit to 30% - 40%. They were transfused with packed RBC (3 ml / Kg X (Hb desired - Hb on admission). All patients also received intravenous fluid hydration starting the night before operation using either D5 ¼ normal saline or D5 ½ normal saline depending on the age of the patient and at a rate of one and a half their maintenance requirement. Intraoperatively, all were monitored with pulse oximeter to check the O2 saturation and attention was paid to avoid hypoxemia, hypothermia, acidosis, hypercarbia and hypocarbia. Post operatively, all patients received analgesia in the form of pethedine (1mg/kg) every 6 hours for the first 24 hours and then as required. Chest physiotherapy and mobilization were encouraged early. The intravenous fluids were continued post operatively till the patient took adequate oral intake. Prophylactic antibiotics for 3 doses (ampicillin and gentamycin or a cephalosporin) were given to all the patients. All our patients received Pneumococcal, Haemophilus influenzae and Meningococcal immunization 10 days to 2 weeks prior to surgery and on discharge were given long acting intramuscular penicillin every 3 weeks or two times per day oral penicillin for 2-3 years postoperatively depending on the patient’s age.

Laparoscopic splenectomy was performed with the patient in the lateral position and using four ports. A 10 mm trocar was inserted below the umbilicus for the camera. A 5 mm trocar was inserted about 2 cm below the xiphoid process for a grasper. A 10 mm trocar was inserted in the anterior axillary line about midway between the umbilicus and xiphoid process. This was used for the ligasure, harmonic scalpel or endo GIA. The retractor was inserted through a 5 mm trocar placed in the mid axillary line just below the left costal margin. The adhesions and short gastric vessels were divided using the 5 mm ligasure or harmonic scalpel. The splenic hilum was divided using the ligasure in 28 patients, harmonic scalpel in 8 and both in 5. Endo GIA was used in 4 patients. The spleen was inserted in a 15 mm endo catch and retrieved via the infraumbilical port after breaking it into small pieces.

Table 1. Comparasion between laparoscopic and open splenectomy

Variable  OPEN SPLENECTOMY LAPAROSCOPIC SPLENECTOMY
No total of patients 45 45
Mean age in years (range) 7.6 (1.8 – 13) 7 (2-12)
Sex (M:F) 24:21 23:22
MEAN HOSPITAL STAY (RANGE) ** 6.5 DAYS (5 -12) 4.5 DAYS (3 -10)
COMPLICATIONS 7 (15.6%) 2 (4.4%)

** P value < 0.0001 (significant)

*** P value < 0.0001 (significant)

Results

A total of 45 children had laparoscopic splenectomy. The indications for splenectomy were: sickle cell disease (30), B-thalassemia major (5), B-thalassemia intermediate (4) idiopathic thrombocytopenic purpura (5) and autoimmune hemolytic anemia (1). There were 23 males and 22 females. Their age ranged from 2-12 years (mean 7 years). Thirty (16 males and 14 females) had sickle cell disease. Their mean Hb S was 76.3% (range 71-87.44), their mean Hb F was 18.9% (range 8.8 -27) and their mean Hb A2 was 2.9% (range 1.8-3.9). Thirty-eight had laparoscopic splenectomy only and 7 had laparoscopic splenectomy and cholecystectomy. The results regarding the operative time, hospital stay, and postoperative complications were compared to a similar group of 45 children (37 had open splenectomy only and 8 had open splenectomy and cholecystectomy) as shown in table 1. The indications for splenectomy in the control group were: sickle cell disease (28), sickle-beta-thalassemia (5), beta-thalassemia major (8), ITP (2), thalassemia intermediate (1) and autoimmune hemolytic anemia (1). Three (6.7 %) of the laparoscopic splenectomy group were converted to open splenectomy. In one, because of a very large size spleen and severe adhesions, and in the other two because of intraoperative bleeding. Two patients (4.4%) in the laparoscopic group developed complications. One had mild acute chest syndrome while the other had postoperative fever that settled conservatively. On the other hand, 7 (15.6%) of the open splenectomy group developed complications. These included mild acute chest syndrome in 2, left pleural effusion in 1, bleeding at the splenic bed in 1, adhesive intestinal obstruction in 1, and postoperative fever in 3.

Discussion

In 1991, Delaitre reported the first laparoscopic splenectomy [1]. Since than, it has become the procedure of choice to treat hematological diseases requiring splenectomy both in children and adults. The Eastern Province of Saudi Arabia is known to have the highest incidence and heterogeneity of hemoglobinopathies in the world. SCD is one of the commonest hemoglobinopathies in the Province with a sickle cell trait frequency of about 25 % in some areas [2, 3]. In the Eastern Province of Saudi Arabia, SCD is characterized by persistence of splenomegaly into an older age group and sometimes into adults necessitating splenectomy for a variety of reasons including splenic sequestration crisis, hypersplenism, massive splenic infarction and splenic abscess [4]. This was the case in our series, where SCD was the commonest indication for splenectomy both in the open and laparoscopy groups. With good perioperative management, open splenectomy in children with SCD has been shown not only to be safe, but also beneficial in reducing their transfusion requirements, eliminating the risks of acute splenic sequestration crisis, eliminating the discomfort and mechanical pressure of the enlarged spleen and treating splenic abscess and massive splenic infarction [4,5,6]. Laparoscopic splenectomy on the other hand has been described as a safe and feasible alternative to open splenectomy both in children and adults [7, 8, 9, 10, 11]. The presence of an excessively large spleen and multiple adhesions as in our patients with SCD, are considered relative contraindications to laparoscopic splenectomy. We however found laparoscopic splenectomy feasible and safe in children with hematological disorders in general and sickle cell disease patients in particular and can be done concomitantly with cholecystectomy. The number of patients with SCD who had concomitant laparoscopic splenectomy and cholecystectomy in our series is however small and more studies are required to substantiate this. Currently, laparoscopic splenectomy requires more operative time than the open approach. This is specially so for children with SCD who are known to have large spleens with severe adhesions [4]. It is however superior to the open splenectomy with regard to duration of hospital stay, cosmetic appearance, and postoperative complications.

 

 

REFERENCES

1. Delaitre B, Maignien B: Splenectomy by the laparoscopic approach. Report of a case. Press Med 1991, 20(44): 2263.

2. Perrine RP, Pembrey ME, John P, et al. Natural history of sickle cell anemia in Saudi Arabia. Ann Intern Med 1978, 88: 1-6.

3. Al-Awamy BH. Sickle cell anemia, its clinical manifestations and their management. Saudi Med. J.1987, 9:553-562.

4. Al-Salem AH: Indications and complications of splenectomy for children with sickle cell disease. J Pediatr Surg 2006, 41: 1909-1915.

5. Al-Salem AH, Mallapa KK, Qaisarruddin S, Al-Jam’a A, Elbashir A. Splenic Abscess in children with sickle cell disease. Pediatr Surg Int 1994, 9:489-491.

6. Al-Salem AH, Qaisarruddin S, Nasserallah Z, Al-Dabbous I, Abu-Srair H, Al-Jam’a A. Splenectomy and acute splenic sequestration crisis in ickle cell disease. Pediatr Surg Int 1995, 11:26-28.

7. Thibault C, Mamazza L, Letourneau R, et al: Laparoscopic splenectomy: operative technique and preliminary report. Surg Laparosc Endosc 1992, 2: 248-253.

8. Tulman S, Holcomb GW III, Karamanoukian HL, et al: Pediatric laparoscopic splenectomy. J Pediatr Surg 1993, 28: 689-692.

9. Pugliese R, Sansonna F, Scandroglio I, et al: Laparoscopic splenectomy: A retrospective review of 75 cases. Int Surg 2006, 91:82-86.

10. Moores DC, McKee MA, Wang H, Fischer JD, Smith JW, Andrews HG: Pediatric laparoscopic splenectomy. J Pediatr Surg 1995, 30(8):1201-1205.

11. Nilsen BH, Hauhstvedt T, Odland P, Viste A: Laparoscopic splenectomy in children: surgical technique. Eur J Surg 1995, 161(3):199-201.