Current Perspective of Laparoscopic Splenectomy

Abstract

The spleen combines the innate and adaptive immune system in a uniquely organized way. The structure of the spleen enables it to remove older erythrocytes from the circulation and leads to the efficient removal of blood-borne microorganisms and cellular debris. This function, in combination with a highly organized lymphoid compartment, makes the spleen the most important organ for antibacterial and antifungal immune reactivity. Although laparoscopic surgery increasingly has achieved acceptance as the standard approach for normo splenic patients requiring splenectomy, open splenectomy (OS) is still widely practiced. Traumatic rupture of the spleen continues as the most common indication for OS. Several other clinical scenarios favor an OS approach, including massive splenomegaly, ascites, portal hypertension, multiple prior operations, extensive splenic irradiation, and possible splenic abscess. During OS, the patient is placed in the supine position with the surgeon situated at the patient's right. A left subcostal incision paralleling the left costal margin and lying two fingerbreadths below it is preferred for most elective splenectomies. A midline incision is optimal for exposure when the spleen is ruptured or massively enlarged or when abdominal access is needed for a staging laparotomy for Hodgkin's disease.

The spleen is one of the most common solid organs removed by laparoscopic techniques. Laparoscopic splenectomy (LS) was first performed by Delaitre in 1992 and is one of the most challenging laparoscopic procedures because of the bulk and vascularity of the spleen and the wide range of pathological conditions that affect it. Although conversion rates for laparoscopic splenectomy have been higher than those reported for most other advanced laparoscopic procedures, laparoscopic splenectomy has become the preferred method of splenectomy in patients with normal or near normal sized spleens.

Indications for laparoscopic splenectomy are the same for open splenectomy except when emergent splenectomy and exploratory laparotomy for traumatic injuries are needed. Laparoscopic splenectomy is indicated for various benign hematologic diseases, malignant hematologic diseases, secondary hypersplenism, and other anatomical disorders of the spleen.

Advanced laparoscopic surgery has become an increasingly common practice as a result of technological developments, surgical curiosity, and medical ambition. In the past 30 years, laparoscopic interventions have been used in various fields for treatment of many malignant and benign diseases. Currently, laparoscopy is preferred as an alternative to open surgery due to its low complication rates, less postoperative pain, achievement of better cosmetic results, and quicker return of patients to their daily lives. The instruments used in laparoscopic surgery are similar to those of open surgery at the tips but are different in that they are attached to a long rod that can be placed through laparoscopic ports. Standard-length instruments possess a 30-cm-long shaft, but longer instruments (up to 45 cm in length) have been developed for bariatric surgery. The handles come in many varieties and must be chosen based on comfort and ergonomics, as well as the need for a locking or no locking mechanism. The shaft of most hand instruments is 5 mm wide; however, some specialized dissectors are available only in a 10-mm width. Pediatric laparoscopy instrumentation is generally 2 or 3 mm in diameter.

Minimal access surgery (laparoscopic surgery) offers dramatic advantages in terms of the quality of life after the operation, Postoperative pain is reduced, which decreases postoperative narcotic use and its complications. This also aids in lower pulmonary complications, smaller wounds are associated with fewer wound complications, less scarring, and better cosmoses, results in reduction of postoperative adhesions, Patients stay in the hospital for a shorter period and recover faster.

Laparoscopy is a minimal invasive surgery since it represents a quick and effective treatment combining minimal discomfort and trauma for the patient with safety standards comparable to conventional surgical interventions. Not only technical performance and safety, but predominantly the patient's comfort and minimal trauma, are the relevant end point.

Laparoscopic surgery is rapidly becoming a popular alternative to traditional surgery for a variety of diseases. For example (laparoscopic splenectomy, laparoscopic biliary surgery, appendectomy, hernia surgery) as it offers shorter hospital stays and a more rapid return to full activity In addition to avoiding large, painful access wounds of conventional surgery, laparoscopy allows the operation to be carried out with minimal parietal trauma with the avoidance of exposure, cooling, desiccation, handling, and forced retraction of abdominal tissues and organs. Thus the overall traumatic assault on the patient is reduced drastically, and as a result of this

Laparoscopy results in multiple postoperative benefits including fewer traumas, less pain, less pulmonary dysfunction quicker recovery and shorter hospital stay. These advantages are regularly emphasized and explained.

Disadvantages of Minimal Access Surgery as, Initial capital cost is associated with laparoscopy because new equipment and training are necessary, Loss of tactile sensation occurs, which is perhaps the major disadvantage of minimal access surgery, Controlling bleeding laparoscopically is difficult.

“Steep” learning curves are usually used to describe procedures that are difficult to learn. However, this is a misnomer as it implies that large gains in proficiency are achieved over a small number of cases. Instead the curve for a procedure that requires a lot of cases to reach proficiency should be described as “flattened”.

Problems regarding the procedure concerning the learning curve with the technique are still hazardous and restricted to expert surgeons with advanced laparoscopic skills. Also the cost for the use of laparoscopic vascular staplers is still high and prohibitive for community hospitals.