1. Laparoscopy for Splenic Conditions George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Splenic Conditions ITP Spherocytosis Splenic cysts Wandering spleen J Pediatr Surg 28:689-692, 1993

3. 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)

4. Patient Positioning

6. Personnel Positions

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

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

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

10. Laparoscopic Splenectomy Please use this link if you experience problems viewing the video above.this link

11. Single Site Umbilical Laparoscopic Surgery Umbilical Portals (U.S.)

12. SSULS Splenectomy Please use this link if you experience problems viewing the video above.this link

13. SSULS Splenectomy

14. Prospective Randomized Trial SSULS vs 4-Port Laparoscopic Splenectomy Alpha – 0.05 Power – 0.80 60 patients total 10 patients to date www.cmhclinicaltrials.com

15. Issues How large is too large? 28 cm. – Splenic artery ligation helpful Can divide spleen (spherocytosis) with harmonic, if necessary

16. 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

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

18. Laparoscopic Splenic Cystectomy First step is decompression of cyst

19. Laparoscopic 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

20. European Experience 3 European centers (Mainz, Mannheim, Hannover) 1995 - 2005 14 pts (median 8.5 yr) 10 recurrences (71%) APSA 2006

21. Wandering Spleen

23. Laparoscopic Splenopexy J Pediatr Surg 42:E23-27, 2007 Please use this link if you experience problems viewing the video above.this link

24. I.U. Experience 1995 - 2006 231 patients Mean age 7.7 yrs Lap splenectomy – 223 211 -total 12 -partial Lap splenic cystectomy – 6 Lap splenopexy- 2 Ann Surg, in Press

25. I.U. Experience 1995 – 2006 Complications Ileus -5 Bleeding -4 Acute chest syndrome- 5 Pneumonia -2 Portal vein thrombosis -1 HUS -1 Diaphragm perforation 2 Colon injury -1 Port site hernia -1 Total splenectomy after partial -1 Recurrent cyst -1 11% overall, 22% in SCD Ann Surg, in Press

26. QUESTIONS www.cmhmis.com