Key anatomic landmarks for laparoscopic splenectomy. From Kathouda N. Laparoscopic Splenectomy. In: The SAGES Manual Volume 2: Advanced Laparoscopy and Endoscopy, Third Edition. Nguyen NT, Scott-Conner CEH, eds. Springer Science+Business Media. 2012. Reprinted with permission.
Splenorenal ligament: this ligament contains the splenic vessels and the tail of the pancreas.
Gastrosplenic ligament: this ligament contains the short gastric vessels and the left gastroepiploic artery.
Splenocolic ligament: this ligament is avascular and attaches the spleen to the splenic flexure of the colon.
An accessory spleen can be found in 15–30 % of patients . A small amount of residual splenic tissue may grow and can preserve immunologic function in the case of traumatic splenectomy or sickle cell autoinfarction. However, a meticulous search for superfluous tissue is a key operative step when immune-mediated disorders are present, such as ITP, as any remaining splenic tissue will cause failure of the operative treatment. Although initially thought to be a limitation of the laparoscopic approach, meticulous search for accessory spleens may be increased with improved visualization of intra-abdominal organs and increased identification of accessory spleens in laparoscopy (28 %) versus open (11 %) approach .
Wandering spleens are an uncommon cause of abdominal pain in pediatric patients . In this situation, the spleen is not fixated with its normal ligamentous attachments, which may be lax or absent, and splenic torsion can occur with intermittent or permanent vascular occlusion. Patients may present with acute abdominal pain due to ischemia or a history of chronic, waxing, and waning abdominal pain.
A thorough history and physical exam should be performed in the office, with attention to splenic size and normal variants for age. Imaging is warranted in the setting of massive splenomegaly as surrounding anatomy may be severely distorted by the enlarged spleen . If the spleen reaches into the pelvis, a laparoscopic approach may not be possible due to the sheer size of the spleen and the inability to visualize and divide the splenic vessels in a safe fashion.
Immunization should ideally occur 2 weeks prior to the operation and must include vaccines for Haemophilus influenzae , Neisseria meningitidis , and Streptococcus pneumoniae [9–11, 13, 14]. In the case of emergency splenectomy, immunization should occur 2 weeks after surgery. Pediatricians and primary care physicians should be aware of asplenic state to ensure compliance with vaccination schedules and need for booster immunizations as needed. In addition, careful family education is paramount to ensure that patients receive appropriate medical attention for lifelong risk of bacteremia.
Blood products should be available in the operating room, and an updated complete blood count with attention to platelet count should be reviewed prior to surgery. Platelet transfusion may be required for severe thrombocytopenia due to ITP, and patients may require transfusion prior to operation or during the operation.
Absolute contraindications to laparoscopic approach include inability to tolerate general anesthesia, portal hypertension with underlying liver cirrhosis, and severe uncorrected coagulopathy. Massive splenomegaly reaching into the pelvis [15–17] is a relative contraindication, although many cases of successful laparoscopic approach have been reported . Dissection of the splenic hilum, whether through an anterior or lateral approach, is the most important step , and laparoscopic manipulation of a massively enlarged spleen may be difficult due to limited working space, increasing risk of injury to surrounding organs .
After the induction of anesthesia, a Foley catheter and a nasogastric tube are placed. The patient is then placed in right lateral decubitus position and a beanbag may be utilized (Fig. 44.2). The ideal position is a 45–75° elevation of the left side, with additional padding beneath the right flank or operative table break to allow maximization of the distance between the left flank and the left anterior superior iliac spine. The surgeon then gains access to the peritoneal cavity either with a spring-loaded (Veress) needle or by open technique (Hasson). The umbilical port should be typically 12–15 mm to accommodate a 12 mm endoscopic stapler and a 10 mm or 15 mm endoscopic retrieval bag. Additional working ports are then placed under direct visualization; we recommend two 5 mm working ports in the left upper quadrant to facilitate traction and dissection and one additional working port in the left lower quadrant which will serve as the principle working port through which the endoscopic dissection device will be used, either an ultrasonic scalpel (Harmonic) or vessel sealer (LigaSure) (Fig. 44.3).
Patient and surgeon positioning for laparoscopic splenectomy. From Kathouda N. Laparoscopic Splenectomy. In: The SAGES Manual Volume 2: Advanced Laparoscopy and Endoscopy, Third Edition. Nguyen NT, Scott-Conner CEH, eds. Springer Science+Business Media. 2012. Reprinted with permission.
Port placement for laparoscopic splenectomy. From Kathouda N. Laparoscopic Splenectomy. In: The SAGES Manual Volume 2: Advanced Laparoscopy and Endoscopy, Third Edition. Nguyen NT, Scott-Conner CEH, eds. Springer Science+Business Media. 2012. Reprinted with permission.
An initial search for accessory spleens, especially in the splenic hilum, is undertaken. The operative bed is then positioned to allow the left flank to be elevated, thus allowing the spleen to “hang” from its lateral attachments.
The splenocolic ligament is divided, followed by the gastrosplenic ligament (Fig. 44.4). Attention should be paid to adequate hemostasis of the short gastric vessels, which are in close proximity to the stomach. Medial traction is then placed on the spleen to allow division of the splenorenal ligament. The hilar splenic vessels can be divided using clips, vascular staplers or energy devices (LigaSure), or a combination of these. Many surgeons staple the splenic artery and the splenic vein separately to minimize the risk of an arteriovenous fistula between those vessels, although this may not be evidenced based (Figs. 44.5 and 44.6).
Lateral dissection . From Kathouda N. Laparoscopic Splenectomy. In: The SAGES Manual Volume 2: Advanced Laparoscopy and Endoscopy, Third Edition. Nguyen NT, Scott-Conner CEH, eds. Springer Science+Business Media. 2012. Reprinted with permission.
View of the vasculature of the splenic hilum during laparoscopic splenectomy. The splenic artery is clipped proximal to its bifurcation. The star marks the splenic vein bifurcation.
Dissection of the splenic artery just proximal to its bifurcation with the Maryland-shaped LigaSure device. The vein is then clipped proximally and divided with a vascular-load stapler. The two white arrows point to the staple lines of the already divided splenic artery.
The spleen is then placed in an endoscopic retrieval bag (Fig. 44.7). In the case of massive splenomegaly, removal of the spleen may be challenging. Large enforced retrieval bags, which can be placed through a 15 mm trocar, are available. Additional techniques for removal include careful finger fracturing or morcellation with a ringed forceps. Occasionally, a minilaparotomy or Pfannenstiel incision may be required. Care must be taken to avoid spillage of splenic fragments within the abdomen, which may lead to splenosis. The abdomen is inspected for hemostasis and an additional cautious search for accessory splenic tissue is completed. Port sites are closed in a standard fashion. The patient is awoken from anesthesia and admitted for observation.
After complete dissection of its attachments, the large spleen is then placed in an extra-large laparoscopic specimen bag introduced through the 15 mm umbilical port. Note the divided vasculature at the splenic hilum (arrow).
Benefits of the lateral approach to splenectomy include improved exposure due to dissection technique, thus less need to grasp and manipulate the spleen, leading to faster dissection and less risk of injury to the splenic capsule [17, 19]. This results in decreased operative time compared to the anterior approach  and, therefore, decreased operative cost and general anesthetic time.
The anterior approach may be beneficial in situations where a concomitant laparoscopic cholecystectomy will be performed. In contrast to the lateral approach, this technique involves initial control of the vascular pedicle  and may provide a benefit of reduced arteriovenous fistula formation when the vessels are individually ligated . After induction of general anesthesia, a Foley catheter and a nasogastric tube are placed. Pneumoperitoneum is established at the umbilicus via similar techniques as mentioned above. Additional ports are placed under direct visualization along the left costal margin medially and laterally and an additional port site at the xiphoid process. Modification in port site placement may be necessary for concomitant procedures.