LAPAROSCOPIC SPLENECTOMY IN HEMATOLOGICAL DISORDERS Thesis Submitted in Partial Fulfillment of The M.D. degree in General Surgery By 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 ii 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. iii 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 iv 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. v 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. vi 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 vii 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 viii 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 ix 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) . 1 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