Indications for laparoscopic splenectomy are the same as indications for open splenectomy with the following exceptions: acute traumatic hemorrhage is better managed at laparotomy, and extreme splenomegaly prohibiting dissection and removal of the spleen through a small incision is a relative contraindication. The most common indications include hematologic disorders such as idiopathic thrombocytopenic purpura (ITP), which accounts for more than 40% of reported laparoscopic splenectomies. Hereditary spherocytosis, idiopathic autoimmune hemolytic anemia, Felty syndrome, thalassemia, sarcoidosis, sickle cell disease, Gaucher’s disease, congenital and acquired hemolytic anemia, thrombotic thrombocytopenic purpura, and AIDS-associated ITP are rare diseases for which splenectomy may be indicated. Laparoscopic splenectomy is also indicated for secondary hypersplenism, splenic artery aneurysm, splenic cyst, and splenic tumor.
Preoperative prophylactic anticoagulation and vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended for all elective splenectomies, unless specifically contraindicated.
For patients with ITP, preoperative imaging such as technetium or indium scanning and postoperative denatured red blood cell scintigraphy may be used to detect accessory spleens. Handheld gamma probe for perioperative examination has shown 100% sensitivity for detection of any accessory spleens.
General endotracheal anesthesia with complete neuromuscular blockade is required. A nasogastric or orogastric tube is placed after induction for decompression of the stomach, allowing better access to the operative site. Bilateral sequential compression devices are placed, as is a Foley catheter. Preoperative antibiotics are administered.
Once asleep, the patient is placed in the right lateral decubitus position with the left side up at approximately 45 degrees (Figure 1). This position has been called “the leaning spleen.” A beanbag or large gel roll is employed to stabilize the patient. All pressure points should be padded and an axillary roll placed. A pillow is placed between the partially flexed knees. The left arm is elevated in a neutral position, and the operating table is flexed to open the operating space between the anterior superior iliac spine and costal margin. Once in the correct position, all air is sucked from the beanbag, and the patient is taped in place with wide cloth tape across the pelvis and across the chest, above the level of the xiphoid. The table is then “airplaned” to the left and right, 30 degrees in either direction, then into steep reverse Trendelenburg to make sure the patient is well secured to the table (Figure 2).
The patient is shaved from the anterior midline to the posterior midline on the left side between the xiphoid and the pubis, prepped in the same distribution, and draped in a sterile manner. The surgeon and camera operator ...