1. LAPAROSCOPIC SPLENECTOMY

2. INDICATIONS Thrombocytopenia 1.Idiopathic Thrombocytopenic Purpura
a. Adults: if a trial of glucocorticoid therapy fails to produce a persistent improvement in platlet count.
b. Children : if there are important consequences of abnormal bleeding (ie. Intracranial hemorrhage)
2.Thrombotic Thrombocytopenic Purpura
The role for splenectomy in TTP is currently unclear. It may have a role in those resistant to plasmapheresis 

3. Anemias
1.Erythrocyte Structural abnormalities
a. Hereditary Spherocytosis- splenectomy at 6 to 8 yrs of age.
b. Hereditary Eliptocytosis- if have symptoms of severe anemia.
c. Hereditary Pyropoikilocytosis- if severe, usually required as a child.

4. C. Hypersplenism
(Most of these patients will have splenomegaly, and will not be candidates for laparoscopic splenectomy. Although no size guidelines exist, we have had limited success with spleens over 18 to 20 cm in the long axis, and recommend open splenectomy in these patients.)
1. Primary Hypersplenism
2. Secondary Hypersplenism
a. Splenic Vein Thrombosis
b. Gaucher Disease
c. Felty Syndrome
d. SLE
In general, indications remain same as for Conventional surgery

5. D. Malignancy
Malignancy often confers splenomegaly, which increases the need for an open procedure. Although no real guidelines exist, laparoscopic splenectomy is not recommended for moderate and large sized spleens, as discussed for hypersplenism.
1. Hairy Cell Leukemia
2. Chronic Myelogenous Leukemia
Justified for compressive symptoms, or sequestration of cellular elements.
3. Chronic Lymphocytic Leukemia
For splenomegaly
4. Primary Splenic Tumors

6. CONTRAINDICATIONS
Spleen Size - No real consensus on exactly what is too large. Large spleens decrease the likelihood of successful laparoscopic removal. Borderline sized spleens can be attempted, if the dissection is successful, often placement in the removal bag can be difficult. If this occurs a small incision is made to avoid intra-abdominal fracture.
B. Physiologic Limitations - Those who cannot tolerate operation, or have uncorrectable severe bleeding dyscrasias.

7. Pre operative Vaccination Optimise Blood parameters
Arrange for blood components like for ITP

8. Position Modified Lithotomy ( Semi frog leg ) Right Lateral
Position : Surgeon preference
We use the second position

9. Mod. Lithotomy Liver retraction necessary ( Extra port )
Can combine with cholecystectomy in patients with congenital hemolytic anaemia

10. Setup Right Lateral Position Monitor – Left side near Head End
Surgeon – Right side
1st and 2nd Assistant – Right side
Scrub nurse – Right side

11. Modified Lithotomy
Disadvantage : Liver retraction necessitates an extra port
Advantage : Can combine with cholecystectomy without
change in position especially in patients with
Congenital Hemolytic Anaemia

12. Patient Position Reverse Trendelenburgh with Left side up
( Right tilt )

13. Ports Camera ( 10 mm ) – Midline Supraumbilical
Right Hand Working ( 10 mm ) – Left Midclavicular
Left Hand Working ( 5 mm ) – Midline Epigastric
Retractor ( 10 mm ) – Midline Subxyphoid

14. Determination of Port Position
Preoperatively confirm Spleen size
Exact port position depends on patient habitus and Spleen size
In general, Smaller the Speen – Ports tend to be closer to the costal margin like ITP

15. Instruments ( 10 mm ) 30 degree Telescope Fan Blade Retractor
Babcock Forceps
Clip Applicator

16. Instruments ( 5 mm ) Dissecting Forceps - Curved Atraumatic Forceps
Neddle holder
Scissor – Regular, Hook
Suction / Irrigation

17. Additional 10 mm Harmonic Scalpel 10 mm Ligasure
12 mm Endoscopic Stapling device
Retrieval Bag

18. Technique Pneumoperitoneum – Veress Adequate distension
First, Camera port
Note findings
Rest of the ports

19. Technique Mobilise Splenic flexure of Colon inferiorly
Divide Splenocolic ligament to mobilise lower pole
Divide Splenorenal attachment

20. Technique Divide Gastrosplenic ligament
Retract Stomach superiorly and to the right with Babcock forceps
Make a small opening in Gastrosplenic ligament to enter the lesser sac

21. Technique
Continue division of the ligament superiorly along the greater curvature to divide the short gastric vessels by clipping and cautery. We use Harmonic Scalpel
Reposit the Babcock forceps frequently to maintain visibility during the above step

22. Technique
Highest short gastric vessels will be best visualised by gentle retraction of the spleen
Some prefer Gastrosplenic ligament division first followed by posterior mobilisation of the Splenic attachments

23. Technique – Vasculature
Carefully dissect adipose tissue to visualise Splenic vessels and Distal Pancreas
Create a window around the Splenic artery
Doubly ligate the artery with Silk before division
Similarly divide the vein

24. Technique – Vasculature
Look for branches especially to the upper pole
Also note the change in colour to confirm the absence of branches
Usually the upper pole has a separate branch

25. Technique – Vasculature
Another method of division is Endoscopic Linear Stapling device passed through a left lateral port.
Stapler is passed cephalad along the left colic gutter so as to lie perpendicular to the vein
NEVER Open the device repositioning without firing as this may tear the vein
Another option is Ligasure

26. Technique
Divide the posterior attachments of the upper pole using Stapler, Cautery or Harmonic
Check for Haemostasis

27. Extraction Extend Right hand working port incision
Supraumbilical Midline Minilaparotomy incision
Pfannensteil incision

28. Extraction Retrieval Bag Extend incision
Morcellize Spleen using Kocher’s clamp
Remove Spleen in pieces, suctioning blood from bag as needed
Take care not to damage the bag
This may be a time consuming process so be patient

29. Closure & Drainage Approximate defect with 1-0 prolene suture
Re-insert the Right hand working port with clamp on the skin incision to prevent leak
Haemostasis confirmed
Wash given
Large bore drain through left axillary line – fix drain immediately

30. Closure Abdomen deflated Close all ports
Approximate linea in midline ports
Subcuticular sutures

31. Post operative orders Nil orally until patient passes flatus
Peri-operative Antibiotic cover
Analgesic ( Routine – Diclofenac suppository )
IVF
Monitor Drain output

32. Complications
Basal Atelectasis is less common as compared to Open Surgery
Bleeding
Wound Infection
OPSI

33. Special Precautions Optimise Blood parameters pre-operatively
Excellent visualisation of vessels
We suggest suture ligation of vessels
Haemorrhage is common reason for conversion
Gentle retraction of Spleen
Look for Splenenculi

34. Thank You