Laparoscopic Splenectomy in Hematological Disorders

LAPAROSCOPIC SPLENECTOMY IN HEMATOLOGICAL DISORDERS

Thesis

Submitted in Partial Fulfillment of The M.D. degree in General Surgery

Ahmad Abdalaziz Mohammad Abdalaziz [M.B., B.Ch.; M.Sc., (Cairo University)]

Supervised by:

Prof. Dr. Safwat Abdalkader Salem Professor of General Surgery, Faculty of Medicine, Cairo University

Prof. Dr. Mervat Mohammad Wageh Mattar Professor of Internal Medicine and Hematology, Faculty of Medicine, Cairo University

Prof. Dr. Ayman Essawy Professor of General Surgery, Faculty of Medicine, Alfayoum University

Dr. Tamer Nabil Lecturer of General Surgery Faculty of Medicine, Bani Swef University

Faculty of Medicine Cairo University 2011

ﺒﺴم اﷲ اﻝرﺤﻤن اﻝرﺤﻴم

Acknowledgement

ACKNOWLEDGEMENT

First and foremost, I thank Allah,, who gave me the strength to accomplish this work.

Words cannot express my sincere gratitude and appreciation to Prof. Dr. Safwat Abd Al KaderKader, Professor of General and Plastic Surgery, Faculty of Medicine, Cairo University, for his generous guidance, Keen interest and precious time he offered me throughout this study. His scientific advices were kindly given to me and are beyond acknowledgement.

I would like to express my sincere indebtedness to, Prof. Dr. Ayman EssawyEssawy. Professor of General Surgery, Faculty of Medicine, Alfayuom University, for his continuous guidance, valuable suggestions and keen supervision throughout work.

I wish also to express my deep gratitude to Prof. Dr. Mervat MatterMatter, Professor of Hematology, Faculty of Medicine, Cairo University, Dr. Tamer NabilNabil, Lecturer of General Surgery, Faculty of Medicine, Beni Swef University and DrDrDr.Dr Wael NaeemNaeem, Lecturer of General Surgery, Faculty of Medicine Cairo University, for their continuous support, valuable remarks meticulous supervision and for offering me much of their time and effort throughout this study.

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Contents

CONTENTS

Page

° Introduction …………………………………..………… 1

° Aim of the work ……………………………………….. 4

° Review of Literature ……………………………….. 5

o Anatomy of the Spleen …………………………. 5

O Physiology of the Spleen ……………………. 37

o Haematological Disorders for which Splenectomy is Indicated as a Line of Treatment ………………. 42

o Laparoscopic Splenectomy …………………….... 56

o Surgical Technique ……………………………65

° Patients and Methods ……………………………….. 107

° Results ………………………………………………. 115

° Discussion ……………………………………………. .131

° Conclusion …………………………………………….139

° Summary …………………………………………….. 140

° References …………………………………………… 142

° Arabic Summary ……………….……………………. 157

List of Tables

LIST OF TABLES

No. Title Page 1 Segmental origin of splenic arterial branches. 22 2 Biologic Substances Removed by the Spleen. 40 3 Causes of thrombocytopenia. 50 4 Thrombocytopenia as a result of drugs or toxins. 51 5 Classification of splenomegaly according to spleen length. 62 6 Age distribution of patients. 115 7 Sex distribution. 116 8 Distribution of patients according to the type of their 117 presentation. 9 Laboratory findings. 118 10 Splenic size. 120 11 Results of bone marrow picture. 121 12 Distribution of induction methods for pneumoperitoneium 122 13 Distribution of technique for ligation of splenic vessels. 123 14 Pecentage of complications. 124 15 Intraoperative blood loss. 125 16 Distribution of accessory splenules. 126 17 Methods of splenic extractions. 127 18 Operative time. 128 19 Distribution of postoperative discharge. 129 20 Distribution of postoperative improvement among the 130 studied cases.

List of Figures

LIST OF FIGURES

No. Title Page 1 Shapes of the spleen. 6 2 Location of the spleen. 7 3 Borders of the spleen. 7 4 Close relations of the spleen. 9 5 Sagittal view of peritoneum covering the spleen. 10 6 Different ligaments of the spleen. 11 7 Types of splenic pedicle. 13 8 Major ligaments of the spleen. 15 9 Splenomental criminal fold of Morgenstern. 16 10 Suspensory ligaments of the spleen. 17 11 Types of splenic vasculature. 21 12 General scheme of levels of division of splenic artery 23 branches. 13 Anatomy of splenic vein. 24 14 Relation of splenic artery and vein. 25 15 Segmental anatomy of the spleen. 27 16 Microstructure of the spleen. 31 17 Development of splenic primordium. 33 18 Development of peritoneal reflections of the spleen. 33 19 Development of the splenic ligaments. 34 20 Structure of the spleen in relation to open and closed 38 blood flow routes. 21 Orientation of the spleen in the lateral approach. 65 22 Operating room arrangement with positions of surgeon 67 and Assistant. 23 Patient’s position for LS. 68 24 Port position for anterolateral approach. 70 25 A more medial port position for anterolateral approach. 71 26 Locations of accessory spleens. 72 27 Intraoperative picture of an accessory spleen. 72 28 Diagram of Inferolateral dissection. 73 29 Intraoperative picture of Inferolateral dissection. 73 30 Intraoperative pictures of dissection of lateral splenic 74 attachments.

List of Figures

No. Title Page 31 Intraoperative picture of the splenic tent after opening 74 the lesser sac. 32 Diagram of the medial dissection. 75 33 Intraoperative pictures of dissecting the short gastric 75 vessels. 34 Diagram for dealing with the hilum. 76 35 Intraoperative picture for hilar division with a linear 77 stapler. 36 Showing intraoperative picture of a completely detached 78 spleen. 37 Showing intraoperative picture of bagging and 79 morcellation of the spleen. 38 Port placement for posterolateral approach. 82 39 Diagram of inferolateral dissection. 83 40 Intraoperative picture of dissection of the posterolateral 83 splenic attachments. 41 Different steps of medial dissection. 84 42 Intraoperative picture of dissection of gastrosplenic 84 vessels. 43 Diagram of division of the hilum. 85 44 Intraoperative picture of hilar division. 85 45 Patient and port position in supine approach. 87 46 Intraoperative picture of dissecting the gastrocolic 88 ligament. 47 Intraoperative picture of stapled division of the hilum in 89 supine approach. 48 Age distribution of patients 115 49 Sex distribution 116 50 Distribution of patients according to the type of their 117 presentation. 51 Splenic size. 120 52 Results of bone marrow picture of the studied cases. 121 53 Distribution of induction methods for 122 pneumoperitoneum. 54 Distribution of technique for ligation of splenic vessels. 123 55 Percentage of complications. 124 56 Intraoperative blood loss. 125 57 Distribution of accessory splenules. 126

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List of Figures

No. Title Page 58 Methods of splenic extractions. 127 59 Operative time. 128 60 Distribution of post operative discharge. 129 61 Distribution of post operative improvement among the 130 studied cases. 62 Division of phrenico-colic ligament. 133 63 Division of lower pole attachments. 133 64 Division of lienorenal ligament . 134 65 Division of short gastric vessls. 134 66 Division of the hilar vessls using stapler . 135 67 Shows a splenul in the omentum. 136

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Abstract

ABSTRACT

What's already known, that splenectomy may be indicated as a line of treatment in some hematological disorders. But the study showed that, laparoscopic splenectomy is safe, efficient and with better compliance to the patients of some hematological disorders in whom splenectomy is indicated.

Keywords: Spleen Blood diseases Laparoscopy Treatment Complications

Introduction

INTRODUCTION

The spleen is a hematopoietic organ which is capable of supporting elements of erythroid, myeloid, megakaryocytic, lymphoid, and monocyte-macrophage (i.e., reticuloendothelial) systems (John et al., 2002) .

Accordingly, the spleen participates in cellular and humoral immunity through its lymphoid elements and is involved with the removal of senescent red blood cells, bacteria, and other particulates from the circulation (monocyte-macrophage system). An increase in this function (i.e. hypersplenism) may be associated with varying degrees of cytopenia, while removal of the spleen may render the patient susceptible to bacterial sepsis, especially with encapsulated organisms (John et al., 2002) .

Since splenectomy was initially described for hereditary spherocytosis (HS) by Sutherland and Burghard in 1910 and for idiopathic thrombocytopenic purpura (ITP) by Kaznelson in 1916, it has been well recognized as an effective cure for some hematological disorders (Greene et al., 2002) .

Since the first laparoscopic splenectomy was reported in 1991, laparoscopic splenectomy has been performed and recommended for a wide variety of indication of benign splenic diseases when the spleen largest diameter does not exceed 20-22 cm, including immune thrombocytopenia, hemolytic anaemia and splenic artery aneurysm (Cuschieri et al., 1992) .

Laparoscopic splenectomy (LS) has rapidly become the surgical approach of choice for patients that require elective splenectomy in the treatment of hematologic disorders (Brodsky et al., 2002) .

Introduction

That is primarily because patients undergoing LS have less postoperative pain, a shorter length of hospital stay, and faster recovery when compared with patients who undergo open splenectomy (Kercher et al., 2002) .

The most common indication for elective splenectomy is idiopathic thrombocytopenic purpura (ITP) (Heniford et al., 2001) .

Patients with this benign hematologic disorder typically have normal to slightly enlarged spleens and benefit the most from LS (Torelli et al., 2002) .

The outcomes of LS in patients with other forms of benign hematologic disorders are typically not as good as those described for ITP (Rosen et al., 2002) .

These patients often have splenomegaly, which has been associated with longer operative times, increased blood loss, higher open conversion rates, and longer hospital stays (Ailawadi et al., 2002) .

The role of LS for patients with malignant hematologic disorders is much less clear. These patients often have extremely large spleens, which can make LS technically more difficult and result in increased complications (Targarona et al., 2002) .

Furthermore, even if the operation can be performed laparoscopically, an abdominal incision is often required in order to place a large spleen into a specimen retrieval bag or to remove the spleen intact (Targarona et al., 2002) .

Introduction

The advance of medical technology applied the use of harmonic scalpel, and ligaSure which are dissecting and haemostatic vessel sealing tools, to the laparoscopic procedures as they operate on the base of ultrasound wave vibrations that are transmitted from it to the tissue causing cutting and haemostasis simultaneously (Hamamci et al., 2002) .

Aim of the Work

AIM OF WORK

This study is conducted to review the role of laparoscopic splenectomy (LS) in the treatment of some hematological disorders such as idiopathic thrombocytopenic purpura, hemolytic anaemia, lympho-prolifrative disorders like lymphoma, for which splenectomy is indicated either due to failure of medical treatment or dependence on medical treatment or development of intolerable adverse effects of medical treatment.

Through this study it is thought that laparoscopic splenectomy will be evaluated as a therapeutic option of hematological disorders regarding feasibility, operative time, operative outcome, approaches, perioperative morbidities and need for blood or platelets transfusion. The effect of laparoscopic approach for splenectomy is going to be evaluated as well.

Review of Literature

ANATOMY OF THE SPLEEN

The spleen consists of a large encapsulated mass of vascular and lymphoid tissue situated in the upper left quadrant of the abdominal cavity (Borley, 2005) .

1. Size, Shape, Topography and relations of the spleen: Size: The size and weight of the spleen vary with age and between the sexes. In adult it is usually 12 cm long, 7 cm broad and between 3 and 4 cm wide. Its average adult weight is about 150 gm although the normal range is wide, between 80 gm and 300 gm. It is large compared to other abdominal organs in the young child, and although its weight increases during puberty, by adulthood it is relatively smaller in comparison to the neighbouring organs. It tends to diminish in size and weight with age (Borley, 2005) .

Shape: According to Michels, the spleen has three forms. It is wedge- shaped in 44% of specimens, tetrahedral in 42%, and triangular in 14% (Michels, 1955) .

A more useful system, also suggested by Michels, notes two forms of the spleen. The first (30%) is a compact type of spleen with almost even borders and a narrow hilum in which the arterial branches are few and large. The second (70%) is a distributed type, with notched borders and a large hilum, in which the arterial branches are small and numerous (Michels, 1955) .

Review of Literature

Fig. (1): Showing shapes of the spleen (Skandalakis et al., 2004)

Topography: The spleen is located in the left upper quadrant of the abdomen bounded by the diaphragm posterolaterally, the stomach anteromedially, the left kidney and left adrenal gland posteromedially, the phrenicocolic ligament below, and the chest wall laterally. The tail of the pancreas in most cases is related to the splenic hilum (Skandalakis et al., 2004) .

The spleen is associated with the posterior portions of the left ninth, tenth, and eleventh ribs with the long axis of the organ roughly paralleling the course of the tenth rib. It is separated from them by the diaphragm and the costodiaphragmatic recess. The spleen is oriented obliquely. Its upper end is situated some 5 cm from the dorsal midline, approximating the level of the spinous processes of the tenth and eleventh thoracic vertebrae. The lower end lies just behind the midaxillary line (Hamilton et al., 1976) .

Review of Literature

The spleen is concealed at the left hypochondrium. It is not palpable under normal conditions. With splenomegaly, the spleen is palpable below the left costal margin, with its long axis extending down and forward along the tenth rib (Healey, 1969) .

Fig. (2): showing the location of the spleen (Skandalakis et al., 2004)

Surfaces and Borders of the Spleen: The spleen has a superolateral diaphragmatic and an inferomedial visceral surface. It has superior and inferior borders and anterior and posterior poles (Borley, 2005) .

The diaphragmatic surface is convex, smooth and faces mostly superiorly and laterally. The visceral surface faces inferomedially towards the abdominal cavity and is irregular, carrying several visceral impressions (Borley, 2005) .

Fig. (3): showing borders of the spleen (Skandalakis et al., 2004)

Review of Literature

Relations: The diaphragmatic surface is related to the abdominal surface of the left dome of the diaphragm which separates it from the basal pleura, the lower lobe of the left lung and the ninth to eleventh left ribs (Borley, 2005) .

The visceral surface faces inferomedially is marked by gastric, renal, pancreatic and colic impressions.

The gastric impression faces anteromedially and is broad and concave where the spleen lies adjacent to the posterior aspect of the fundus, upper body and upper greater curvature of the stomach. It is separated from the stomach by a peritoneal recess, which is limited by the gastrosplenic ligament.

The renal impression is slightly concave and lies on the lowest part of the visceral surface. It is separated from the gastric impression above by a raised strip of splenic tissue and the splenic hilum. It faces inferomedially and slightly backwards, being related to the upper and lateral area of the anterior surface of the left kidney and sometimes to the superior pole of the left suprarenal gland.

The colic impression lies at the inferior pole of the spleen and is usually flat. It is related to the splenic flexure of the colon and the phrenicocolic ligament.

The pancreatic impression is often small when present and lies between the colic impression and the lateral part of the hilum. It is related to the tail of the pancreas which lies in the splenorenal ligament.

Review of Literature

The hilum of the spleen lies in the visceral surface closer to the inferior border and anterior extremity. It is a long fissure pierced by several irregular apertures through which the branches of the splenic artery and vein as well as nerves and lymphatics enter and leave the spleen (Borley, 2005) .

The superior border separates the diaphragmatic surface from the gastric impression and is usually convex. Near the anterior extremity there may be one or two notches persisting from the lobulated form of the spleen in early fetal life. These notches are often absent and are not a reliable guide to the identification of the spleen during clinical examination.

The inferior border separates the renal impression from the diaphragmatic surface and lies between the diaphragm and the upper part of the lateral border of the left kidney. It is more blunt and rounded than the superior border and corresponds in position to the eleventh rib's lower margin.

The posterior extremity, or superior pole, usually faces the vertebral column. The anterior extremity, or inferior pole, is larger and less angulated than the superior pole and connects the lateral ends of the superior and inferior borders. It is related to the colic impression and may lie adjacent to the splenic flexure and the phrenicocolic ligament (Borley, 2005) .

Fig. (4): Diagram showing close relations of the spleen (Ellis, 2006)

Review of Literature

Surgical and clinical applications: 1. In splenomegaly, the anterior border, anterior diaphragmatic surface and superior border may become clearly palpable below the left costal margin; the notches are often exaggerated and may be clearly palpable. 2. In splenomegaly, the spleen is always located in front of the splenic flexure of the colon. Adhesions are almost always present and are sometimes extensive and vascular. 3. Fractures of the overlying lower left ribs may cause sharp penetrating injuries to the splenic capsule and pulp (Skandalakis et al., 2004) .

Peritoneum and Ligaments and Mobility of the Spleen: The right and left layers of the greater omentum separate to enclose the spleen almost completely, except at the hilum, providing its serosal covering, or capsule. The capsule formed by the visceral peritoneum is easily injured (Skandalakis et al., 2004) .

Fig. (5): showing sagittal view of peritoneum covering the spleen (Skandalakis et al., 2004)

Review of Literature

The peritoneal layers that enclose and suspend the spleen form the two chief ligaments of the spleen, the gastrosplenic ligament and the splenorenal ligament. These are portions of the embryonic dorsal mesentery, the leaves of which separate to surround the spleen. These two ligaments form the splenic pedicle (Skandalakis et al., 2004) .

The spleen remains connected to the posterior abdominal wall, anterolateral abdominal wall and stomach by three folds of peritoneum. The posterior connection is the splenorenal ligament, the anterolateral connection is the phrenicocolic ligament, and the anterior connection is the gastrosplenic ligament (Borley, 2005) .

In addition, there are several minor splenic ligaments. These are the splenophrenic ligament, splenocolic ligament; pancreaticosplenic ligament, presplenic fold, and pancreatico-colic ligament (Skandalakis et al., 2004) .

Fig. (6): showing different ligaments of the spleen (Skandalakis et al., 2004)