Laparoscopy for Splenic Conditions George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

Splenic Conditions ITP Spherocytosis Splenic cysts Wandering spleen J Pediatr Surg 28: , 1993

Pre-Operative Preparation Ultrasound Often done by pediatrician, hematologist Rarely needed for splenectomy, except may be useful for extremely large spleen CT Scan – Useful in planning splenic cystectomy WinRho Bone marrow stimulant Usually used to platelet count Useful pre-operatively to platelet count in ITP pt. Immunizations –Pneumococcus (Prevnar, Pneumovax)

Patient Positioning

Personnel Positions

Laparoscopic Splenectomy ITP, spherocytosis Port placement (2) cannulas (5, 12) (2) stab (3 mm) incisions Instruments Harmonic scalpel (5 mm) Articulating stapler (12 mm)

Laparoscopic Splenectomy Operative Steps Divide spleno-colic ligament, then short gastrics Clip artery Autotransfuse pt Protects stapler malfxn

Laparoscopic Splenectomy Operative Steps Divide spleno-renal lig. Articulating stapler across hilum Bag specimen, morcellate extracorporally

Issues How large is too large? Measurement (LeClair) Earlier splenic artery ligation helpful Can divide spleen (spherocytosis) with harmonic, if necessary

Issues Postoperative platelet ct. > 500,000 Reports of splenic vein/portal vein thrombosis following splenectomy (open and laparoscopic) Baby aspirin ( 81 mg) QD for 6 mos Re-check at 3 months & 6 months

Splenic Cysts Primary epithelial lining Pseudocysts (secondary) no epithelial lining often develop after trauma

Splenic Cystectomy First step is decompression of cyst

Splenic Cystectomy Excise cyst as close as possible to splenic parenchyma with harmonic scalpel Coagulate lining with Argon beam coagulator ? Place omentum adjacent to exposed cyst lining

European Experience 3 European centers (Mainz, Mannheim, Hannover) pts (median 8.5 yr) 10 recurrences (71%) APSA 2006

CMH Experience pts (6 – 18 yrs) 4 open, 4 laparoscopic ALOS: 2.75 days (open) 1.75 days (laparoscopic) No recurrences ( 6 CT scans)

Laparoscopic Cystectomy

Wandering Spleen

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