Laparoscopic splenectomy is most commonly performed for immune (idiopathic) thrombocytopenic purpura (ITP) or other splenic conditions causing anemia or neutropenia. Massive trauma to the spleen as well as overly large spleens are still best approached with an open laparotomy. However, virtually all other indications for splenectomy listed in Chapter 90 apply for laparoscopic splenectomy. A complete hematologic evaluation, including bone marrow studies, is essential. The patient must be informed of the lifelong consequences of increased susceptibility to bacterial infection. Ideally, the patient should receive polyvalent pneumococcal, Haemophilus influenzae, and
Neisseria meningitidis vaccination prior to surgery.
Patients for elective splenectomy are usually referred to the surgeon by hematologists or oncologists, because their treatment with blood products, corticosteroids, plasmaphoresis, gamma globulins, or chemotherapy can no longer safely control the primary disease. Accordingly, the patient may require transfusion of blood products to raise the hematocrit or platelet counts to safe levels for general anesthesia and coagulation during surgery. Packed red cells may be given in advance of planned surgery, whereas platelets, with their short life span, may be infused just prior to and during the procedure. When platelet transfusions are contraindicated, endogenous platelet counts are often temporarily boosted with a few days of increased corticosteroid therapy, immune globulin or Rho D immune globulin (winrho) prior to surgery. If steroids are used, then they must be continued during and immediately after surgery. The patient should have a type and screening blood test, and blood products must be available for infusion. The size of the spleen should be determined by physical examination or imaging studies, as massive spleens are usually more safely approached by open splenectomy.
General anesthesia with endotracheal intubation is required. Two large, well-secured intravenous catheters are placed for easy access by the anesthesiologist. The intravenous sites and any finger pulse oximeters should not be positioned distal to an arm blood pressure cuff. A Foley catheter and an orogastric (OG) tube are passed and pneumatic sequential compression stockings are applied to the lower legs. Care must be taken in the placement of the endotracheal, OG, and Foley tubes in patients with marked thrombocytopenia lest bleeding occur.
The patient is placed in a lateral position with the left arm crossing the chest and lying on top of the right arm. Liberal padding is used between and around both arms. The left hip and chest are elevated with pillows, leaving the flank area open and the left knee flexed, with a padding of blankets between the legs. The patient is secured across the chest and hips to the table with wide adhesive tape, as the operating room table will be tilted.
The skin is prepared from the lower chest to the pubis in a ...