Mustafa Hussain, MD, Alfons Pomp, MD, FACS, FRCSC
Anecdotal reports of splenectomy date back to the 16th century and by 1920 the Mayo Clinic had reported on splenectomy with operative mortality rates of about 10%. Deletaire originally described laparoscopic splenectomy, in 1991.1 Since then, numerous case reports, case series and comparative studies have repeatedly demonstrated the safety (mortality rates <1%) and efficacy of this technique. Indeed, it is now considered standard of care for most elective normal size spleens. Nevertheless, this technique requires knowledge of appropriate indications, as well as advanced technical skills.
The spleen sits underneath the diaphragm, and it generally spans the 9th-11th ribs along the left mid to posterior axillary line. The anterior aspect of the spleen lies along the greater curvature of the stomach and the tail of the pancreas. The tail of the pancreas is generally within 1 cm of the splenic hilum. The splenic flexure of the colon is inferior to the spleen, and the left kidney lies posteriorly. The usual size of the spleen is approximately 11 cm in length and it typically weighs 150 to 200 g.2
It is very important to understand the vascular anatomy of the spleen when planning a splenectomy. The majority of the arterial supply is from the splenic artery, which is one of three major branches off the celiac axis of the aorta. The splenic artery has a serpentine course that crowns the superior boarder of the pancreas. It generally gives off a few pancreatic branches and a branch to the superior pole of the spleen prior to diving into the splenic hilum. Arterial blood supply also arises from the left gastroepiploic artery by way of the short gastric vessels. Larger and pathologic spleens may have aberrant vessels that are parasitized off the diaphragm or spleno-colic attachments, which may complicate an otherwise bloodless field of dissection.
Segmental venous tributaries unite into the main splenic vein in the hilum. The splenic vein is intimately associated with the posterior surface of the tail and body of the pancreas. There are also several pancreatic branches that directly enter this splenic vein.
The spleen is maintained in the left upper quadrant by various “ligamentous” attachments. The gastrosplenic ligament is a cranial extension of the greater omentum that contains the left gastro-epiploic vessels and short gastrics. The spleno-renal ligament attaches the posterolateral surface of the spleen to Gerota’s fascia. Division of this generally avascular plane allows medial rotation of the spleen and tail of pancreas. The splenocolic ligament can be short and may contain vessels to the lower pole of the spleen. There may be attachments from the lower pole of the spleen to the omentum to various degrees. Care must be taken to avoid excessive traction on the omentum, as this is the area that usually results in capsular tears. Attachments to the diaphragm may also be present to varying degrees. Generally, pathologically enlarged spleens tend to have more attachments, and may contain aberrant vessels that may pose as a source of unexpected blood loss.
The spleen has segmental anatomy that is fed by arteries and draining veins. Blood flows from the splenic artery, into arterioles (white pulp-immunologically active), then through the marginal zone (red pulp-removal of senescent red blood cells), then to the splenic vein into the portal vein system and the liver. The capsule of the spleen is quite thin because it is only a few cell layers thick. It consists of a single layer of mesothelium and varying amounts of fibroelastic tissue that can contract to mobilize stored volume of cells in some mammals.3
Accessory spleens are nodules of splenic tissue that are totally distinct from the main body of the spleen. They usually range from 0.5 cm 4 cm in size and are present in 10% to 20% of patients. They can be located anywhere in the abdomen but are most often found in the splenic hilum or omentum near the spleen. Accessory spleens are important in disease processes in which a complete removal of all splenic tissue is mandatory for long-term cure, such as ITP. The routine use of laparoscopic splenectomy to treat this disorder highlights the importance of the accessory spleens, because they may be more difficult to identify with a minimally invasive approach when compared with an open operation. However, several reports demonstrate that accessory spleens can be successfully removed laparoscopically; particularly with the aid of a nuclear medicine spleen scans if needed to identify sources of residual tissue.4
The spleen has two major functions: hematologic and immune. The hematologic action of the spleen primarily occurs in the red pulp. Here, senescent red blood cells are cleared from circulation. Cytoplasmic inclusions, nuclear remnants and byproducts of hemoglobin are also removed from red blood cells as they pass through the red pulp, which acts as a dynamic filtration system. The spleen may also serve as a reservoir of up to 30% of platelet volume. Lastly, the spleen can serve as a site for hematopoesis. This role is more significant in the fetus, but can also be present in patients with bone marrow dyscrasias. This pathologic process often results in splenomegaly.
The spleen serves as a site for generation of an immune response to antigens and microorganisms cleared from the circulation. The white pulp has peri-vascular lymphoid aggregations or follicles that, when challenged with antigen, can transform into germinal centers. In particular, humoral response to encapsulated organisms is believed to be generated and augmented in the spleen. The spleen also produces non-specific opsonins such as tuftsin and properiden, which serve to amplify the immune response and enhance phagocytosis of microorganisms.2
The spleen may serve as a site of manifestation of several systemic diseases. Splenectomy is not always required or beneficial. Splenectomy usually does not “cure” the underlying disease processes, but may aid in relieving symptoms or guiding subsequent therapies. Hematologic disorders affecting the spleen can be categorized by the cell type that they affect.
The most frequently encountered hematologic disorder affecting platelets that may benefit from splenectomy is idiopathic thrombocytopenic purpura (ITP). The spleen is typically normal in size, and the etiology is thought to be due to immune mediated enhanced clearance of circulating platelets. There is no one diagnostic test for ITP. Generally, however, thrombocytopenia should be the only cytologic abnormality, the bone marrow should show megakaryocytosis and there should be no evidence of portal hypertension. In children, the disease is generally acute onset and self-limited. Splenectomy, is usually only reserved for refractory and severe thrombocytopenia. In adults, ITP can be more insidious. Treatment generally is still first medical consisting of corticosteroids, intravenous immunoglobulins (IVIG) and more recently retuximab. Surgical therapy is indicated for thrombocytopenia that is refractory to medical therapy, or intolerance to medical therapy.5,6
ITP should be distinguished from TTP, a much more rare disorder which generally has a more dramatic acute clinical course exemplified by fever, thrombocytopenia, renal failure and neurologic changes. The mainstay of this disorder is plasmapheresis (plasma exchange). Splenectomy is rarely indicated, but can be effective in refractory cases.7
Splenectomy may also be indicated for hypersplenism resulting in red cell destruction. Red cell destruction can be due to congenital structural abnormalities of the red cells or hemoglobinopathies (sickle cell or thalassemia) or may be immune mediated. Hereditary spherocytosis is the most common red cell disorder to be treated by splenectomy. It is caused by an abnormaility in the cell membrane protein spectrin, which makes the red cells less deformable, causing hemolysis and trapping in the spleen. While most patients are asymptomatic, some may have varying degrees of symptoms, including painful crises (often in the setting of infection), gallstones and anemia. Splenectomy is curative, and may be performed in conjunction with cholecystectomy.8
Splenectomy may be required for therapeutic or diagnostic purposes in certain leukemias and lymphomas. Splenomegaly may be present in both chronic lymphocytic leukemia and hairy cell leukemia. Each may be associated with cytopenias that may improve after splenectomy. In addition, splenectomy may be used as an adjunct to improve efficacy of chemotherapy. Currently, however, with new chemotherapy regimens, splenectomy is not considered first line treatment for leukemias. Similarly, in lymphoma, splenectomy is only reserved for diagnostic purposes if it is the only site of disease or if there is symptomatic splenomegaly.9 In Hodgkins lymphoma, splenectomy had historically been part of staging. However, with current imaging and treatment algorithms it is rarely indicated.10
Patients with bone marrow myelodysplasic diseases may develop splenomegaly, which can be symptomatic or associated with cytopenias. Splenectomy may be indicated in these cases if symptoms warrant.11
Treatment: Laparoscopic Splenectomy
Patient Selection and Pre-operative Planning
The laparoscopic approach should be considered as a therapeutic option for all patients undergoing elective splenectomy. A few important contraindications to the laparoscopic approach are patients with liver failure with portal hypertension, ascities or unmanageable coagulopathy. In addition, while laparoscopic management of splenic trauma has been reported in the literature, it is not standard of care, and should not be considered in a patient with hemodynamic instability.12
Splenic size is a key factor in determining the feasibility of the laparoscopic approach, and should be determined prior to taking the patient to the OR. Splenic size has been reported in terms of length of greatest dimension in centimeters or in terms of weight. There is no consensus on how to categorize varying degrees of splenomegaly. Generally, normal spleens are <12 cm, moderately enlarged spleens are 12-20 cm and severely enlarged spleens are >20 cm. Special consideration should be given to spleens >20 cm, which are considered to be “giant” sized spleens, and are really difficult to remove laparoscopically due in part to limitations in instrumentation and visualization. More importantly, there is the difficulty to, at first, establish a working space (pneumoperitonium) in an abdominal cavity already stretched with a massive spleen and, secondly, trying to insert a massive spleen into an adequately sized extraction bag in such a restricted working environment. Of course, the greater the size, the greater the difficulty of the case, and more technical ability is required to safely remove the spleen laparoscopically.
In addition to splenic size, imaging should also be reviewed for the presence of accessory spleens. Some have suggested that a major pitfall to laparoscopic splenectomy is the limited ability to explore the abdomen for accessory spleens. Given that the majority (>80%) of accessory spleens are in the hilum near the vascular pedicle or omentum near the spleen this concern has not been shown to be clinically significant. Nevertheless, as the amelioration of certain disease processes is dependent on the removal of all splenic tissue, the review of preoperative imaging is prudent. Some have advocated obtaining liver-spleen nuclear medicine scintigraphy for this purpose, but it is likely an unnecessary adjunct to routine CT scanning.
In the elective setting, patients should be counseled regarding risks of splenectomy, including the risk of infection from encapsulated organisms. Appropriate vaccination against Pneumococcus and H. influenza should be administered weeks prior to surgery. Meningococal vaccination should be offered to pediatric patients or younger patients who live in dormitories (college, military).
Patients with thrombocytopenia should generally be maintained with a platelet number above 30,000, although internal bleeding is rare unless there are persistent counts <5000. In the case of ITP, transfusion of platelets should be avoided until after surgery or during surgery after “inflow” vascular isolation. If it is necessary to increase platelet count in these patients prior to surgery, usually a steroids bolus or parenteral IVIG can boost platelet count prior to surgery. Similarly, ideally hemoglobin should be at least 10 g/dl prior to surgery.
As these patients may be chronically dependent on steroids, adrenal insufficiency may be a concern and peri-operative stress dose steroids may be considered.
Various techniques have been described as well as criteria for determining which patients are suitable to undergo laparoscopic splenectomy. The original approach described was the anterior approach, with the patient in the supine position. This approach reflects the familiarity of most surgeons with the anatomy of a patient in a supine position. It can be seen as a natural adaptation from common laparoscopic operations such as laparoscopic cholecystectomy. Conversion to open surgery is certainly easier and more natural for most surgeons when the patient is in the supine position. Other advantages may be early control of the splenic hilum and ease of performing concomitant operations. Major technical disadvantages to the anterior approach exist, however, as the spleen must be lifted off its posterior attachments requiring the use of additional working ports and working against gravity. As splenic size increases, doing the operation in this position becomes more challenging. This approach is even more challenging in obese patients.
Gagner, Pomp and Park described the lateral approach with the patient in lateral decubitus.13 This was an adaptation from the technique of laparoscopic adrenalectomy. We continue to believe this approach offers the safest approach with the least direct manipulation and retraction on the spleen, as the weight of the spleen acts as a retractor. The spleen falls away from the posterior and lateral attachments, and often only three ports are necessary.
Once full general anesthesia in induced, the patient is intubated and an orogastric tube is inserted, the patient should be placed in a right lateral decubitus position. It is advantageous to use a vacuum beanbag, so that the patient can be placed in the most optimal position while protecting pressure points. An axillary roll should be placed to protect against brachial plexus injury, and pillows should be placed between the legs and arms for support. It is best to have the anterior part of the patient’s abdomen as close to the edge of the bed as possible, and flex the bed, such that the distance between the costal margin and iliac crest is maximized. The sterile field should be prepared from a couple centimeters to the right of the midline to a few centimeters posterior to the posterior axillary line.
Trocars are generally placed 4-6 cm below the costal margin. We prefer placing the first trocar via a cut-down Hassan type technique. Veress needle entry is also used, but the chance for catastrophic complications may outweigh the potential time saved using this technique. The first trocar should be 10-12 mm to allow the use of a stapler device, and is generally placed in the mid-axillary line. Then additional working trocars are placed at a distance to allow for comfortable working angles (approximately 10 cm on either side). We find most splenectomies are possible with the use of two 5 mm working ports, but less experienced surgeons might prefer the use of 3 additional ports and using 10-12 mm trocars. We routinely use two insufflators; this allows the liberal use of suction during dissection without losing the working space of the pneumoperitoneum.
The necessary laparoscopic equipment includes: 10 mm and 5 mm 30 degree angled scopes, atraumatic graspers, dissecting graspers, suction/irrigator, ultrasonic or bipolar energy device (e.g. Ligasure; Covidien Boulder CO), articulating stapler with a 2.0 mm height vascular (gray) load, 5 mm clip applier and a sturdy retrieval bag.
The surgeon and assistant should stand on the right side of the table. Dissection is initiated at the inferior pole of the spleen by detaching any omental attachments if present. Next the splenic flexure of the colon is mobilized, followed by sequential dissection of the lateral peritoneal attachments of the spleen, the splenorenal ligaments and the splenophrenic ligaments. Tilting the patient towards the surgeon allows for greater exposure of the lateral and posterior surface of the spleen. Attempts should be made to leave a cuff of peritoneum on the splenic side to facilitate retraction, if possible. Once the posterolateral attachments are freed, the patient can be tilted away from the surgeon such that the anterior dissection is easier. There is often a separate vessel to the lower pole inferior to the hilar bundle that may need to be separately clipped, and this is usually the only place that we use clips (clips used near the hilum may effect the ability to safely staple the vascular structures). The short gastric vessels and attachments to the stomach may be taken next, leaving the spleen completely mobilized, and only attached by the hilum. Dissection and ligation of individual hilar vessels can result in unnecessary bleeding or injury to the tail of the pancreas. Instead, a linear cutting stapler with a vascular load can be used to divide the hilum. This theoretically also seals the tail of the pancreas if inadvertent injury occurs. Bioaborbable buttressing material can be used to enhance hemostasis. Many times only one firing of the stapler is necessary.
The final, and at times most challenging, step can be retrieval of the spleen. A bag made of durable material should be used. For spleens smaller than 20 cm the bag should be inserted in the abdomen, opened, and then kept stationary in the left upper quadrant, and then the spleen is brought to the bag. Using the staple line or peritoneum on the spleen as a handle can prevent splenic rupture during manipulation. Adjuncts include putting the patient in a steep Trendelenberg position in order to let gravity facilitate splenic manipulation. The bag is then brought out through the initial (and largest) trocar site and the spleen is morselized in the bag and brought out piecemeal.14 Preserving the complete architecture of the spleen for the pathologist is rarely necessary for most indications of splenectomy. Drainage after elective splenectomy is not indicated unless there has been significant injury to the pancreatic tail and there is concern for pancreatic fistula.
Most elective splenectomies can be achieved through the lateral approach and it is now the most widespread technique. The anterior approach should be considered in cases when other concomitant laparoscopic procedures may need to be done, such as cholecystectomy or in cases of massive splenomegaly. When the tip of the spleen reaches the iliac crest, trocar placement for the lateral position becomes prohibitive. In these cases as well, conversion or hand assist may be required, making the anterior approach more feasible. Larger spleens may also require a different extraction strategy; for example using a Pfannenstiel type incision.
The patient should be placed in a modified lithotomy position, and the surgeon stands between the legs of the patient. Abdominal entry is generally done through the umbilicus in the mid-line. The patient should be placed in steep reverse Trendelenberg to retract the viscera away from the left upper quadrant. A retractor may be necessary to retract the left lobe of the liver. Up to four additional trocars may be used and placed in a semi-circle under the left costal margin.
Dissection is initiated by dividing the gastrocolic ligament, revealing the lesser sac and lower pole of the spleen. Control of the splenic artery away form the splenic hilum can be achieved on the superior surface of the pancreas. Hilar dissection can then be achieved from an inferior to superior fashion. Individual clipping of hilar vessels can be done, or en “block” stapling. In addition, the use of bipolar Ligasure (Covidien Boulder CO) has been described for this purpose. The disadvantage to the anterior approach is if bleeding occurs during this step, blood will pool at the hilum, an obscure further dissection. Once the hilum and then the short gastric vessels are ligated, the lateral and posterior attachments of the spleen are divided. This step may require significant traction on the spleen, resulting in avulsion of the splenic parenchyma. Lastly, inserting the spleen into a retrieval bag for removal can also be challenging if the anterior approach is employed for very large spleens.
Hand Assisted Laparoscopic Splenectomy
Hand-assisted laparoscopic surgery (HALS) is performed with the aid of a plastic device inserted in a 7.5 to 10 cm incision. The hand port is a sealed cuff that allows the surgeon to insert a hand into the abdomen without loss of pneumoperitoneum during the operation. The optimal site of the incision for the hand port can be the upper midline, the right upper quadrant, the left iliac fossa, and, for very large spleens, the Pfannenstiel position. Generally the further away from the area of dissection is better, otherwise the hand obscures the field of dissection and manipulation is easiest when it is the wrist or lower arm, which is in the hand port. The surgeon’s non-dominant hand should be used.
This technique may be useful with larger spleens and when compared to conventional splenectomy, it appears to have similar outcomes. This technique can be employed as an intermediate stage as the surgeon gains more experience in laparoscopy. Theoretically, however, with larger incisions, this technique may have increased costs, as the cost of laparoscopic equipment is combined with postoperative recovery from a larger incision.15 The precise role and indications for HALS have not been definitively described.
Preoperative Splenic Artery Embolization
Though not routinely done, or recommended, preoperative splenic artery embolization can be an adjunct to help reduce the size of larger spleens. Although it is now no longer frequently used, it remains a useful tool in the armamentarium of the surgeon. If done, coils or foam should be used, rather than microspheres or powder, as this can result in a significant necrosis and inflammatory reaction. In addition, care must be made to avoid devascularization of the pancreas. Embolization can result in significant pain, because of the response to ischemia, and should be used judiciously.16
Outcomes and Complications
There have been no randomized prospective trials comparing open and laparoscopic splenectomy. There will likely never be such trials because of the widespread acceptance of the laparoscopic technique coupled with patient demand for less invasive surgery. While open elective splenectomy may not necessarily be a technically challenging operation, the specific anatomic position of the organ along with the baseline disease states that require its excision portend a relatively high complication rate. Mortality from historical series of open splenectomy is as high as 6%. Reported morbidities include subphrenic abscesses, bleeding requiring re-operation and severe pulmonary complications. Most laparoscopic series do report morbidity rates between 6-18%. Pomp et al. reported an overall morbidity rate of 12%, but only 3% developed subphrenic collections and 1.5% had pneumonia, there were 2 post-operative deaths out of 131 patients, both of which were related to the patients’ underlying disease.
Several patient-related factors may contribute to increased morbidity and complexity of splenectomy. Increasing patient age, malignancy and size of spleen all have been suggested to increase complication rate, and difficulty of operation. In our series, patients undergoing splenectomy for TTP had the greatest number of complications, likely reflecting the systemic nature of the disease.17
Conversion to open surgery from laparoscopy should be left to the surgeon’s discretion and judgment. It does represent the least cost effective strategy, as the price is paid for the laparoscopic instrumentation as well as the longer hospital stay of the open procedure. Conversion usually occurs due to bleeding either from the hilum or a tear in the splenic capsule due to excessive traction. Conversion rates are generally in multiple series range from 3-8%. As mentioned above we routinely use two insufflators; this allows the liberal use of suction during dissection without losing the working space of the pneumoperitoneum. Other strategies include insertion of a small lap pad to use in keeping the area of dissection dry; this obviously will require the entire operating team’s awareness to decrease the risk of retained foreign body. Portal hypertension and uncorrected coagulopathy increases the likelihood of bleeding, and laparoscopy should not be attempted in these patients. Massive spenomegaly (>2000 g or 20 cm) may also increase the chances of failure of the laparoscopic approach and HALS may be considered in this setting.
Operative times range form 140-180 minutes in most series and length of stay is generally 2-6 days.12,17-19 Operative times are influenced by surgeon experience and may be longer in teaching institutions. Length of stay may also be prolonged in patients undergoing splenectomy for diagnoses other than ITP, where patients are generally young and otherwise healthy.
The presence of accessory spleens has been noted in 10-30% of published series, and the presence of residual splenic tissue has been reported to be as high as 50%. This is certainly concerning, especially as the most common indication for elective splenectomy is ITP where the removal of all splenic tissue is required.20 Attention must be paid to the identification of accessory spleens. The spleen should be carefully removed, avoiding tearing the splenic capsule or spilling the morselized spleen. Missed accessory spleens or splenosis can result in persistent disease. If there is refractory disease after splenectomy, investigation for accessory spleens should be carried out with imaging including Technetium labeled RBC scans and CT scanning. If there is doubt, then laparoscopic or open re-exploration may be indicated.4
Special Considerations and Expanded Indications
With current vaccination strategy and the understanding of splenic immune function the incidence of OPSI (overwhelming post-splenectomy sepsis) is low. Nevertheless, concern for OPSI, particularly in children, has led to splenic preservation strategies. This was initially undertaken in the trauma setting, where there is no associated splenic pathology. Techniques of partial splenectomy have also been expanded to certain elective situations where splenic resection is indicated, but where complete removal of splenic parenchyma is not critical to addressing the pathology. These clinical situations may include splenectomy for diagnostic purposes, certain lymphomas, thalassemias and spherocytosis.
Laparoscopic partial splenectomy has been described as feasible. Partial splenectomy is made possible by the segmental nature of the splenic blood supply. Ligation of terminal branches of the splenic vessels results in visible demarcation of ischemic splenic tissue. Once this is done, the splenic capsule can be incised within a 5 mm margin of the ischemic tissue, and the devascularized segment can be resected with the use of a combination of clips, staplers and energy devices. The patient is placed in the same lateral decubitus position, with similar port placement. The spleen should be mobilized in a similar fashion, as to easily allow for completion splenectomy, in case partial resection is technically difficult or unsafe.21,22
In one study comparing laparoscopic total splenectomy to laparoscopic partial splenectomy in a pediatric population with spherocytosis, partial splenectomy resulted in longer hospital stay, greater use of narcotics, and increased blood loss. Major complications, transfusion rate and resolution of symptoms from spherocytosis were similar.23 Longer-term follow-up would be necessary to determine if infectious complications are actually reduced.
Single Access Surgery
Single incision or single access laparoscopic surgery is a technique whereby a single skin incision is used for both the camera port and working ports. Often articulating instruments are required to overcome the resultant in-line visualization. The advantages of this technique are largely cosmetic, and at least theoretically in reduced analgesic usage, though this has not been adequately studied.
Single access port splenectomy has been described as feasible in certain reports. Clearly, this technique requires advanced skill, and its safety for routine use has yet to be determined.24,25
Another alternative, which enhances safety and feasibility, while maintaining cosmetic consideration is the use of a needlescopic (<3 mm) instruments. Needlescopic technique for splenectomy have been described as resulting in virtually no visible scars and documented reduced narcotic use. Disadvantages are increased costs of fragile instruments.26
Traumatic injury to the spleen may often necessitate splenectomy. The major determinant for the need to perform splenectomy is hemodynamic stability of the patient. Splenic preservation is deemed feasible, as long as the patient maintains a blood pressure about 90 mmHg, and is maintained in a monitored setting. At times, adjuncts such as angioembolization can increase the likelihood of splenic preservation in higher-grade splenic injuries. If splenic injury is evident in a hemodynamically unstable patient, then splenectomy should proceed rapidly through a laparotomy. Laparoscopy in the management of splenic trauma remains controversial. It has been reported in certain clinical situations, where stable patients with splenic injuries cannot be observed, undergo angiography or are thought to present a high likelihood of failure of conservative management. Successful execution in 10 selected patients was recently reported without the need of conversion.27 It requires very judicious patient selection, adept surgical skills and liberal use of hemostatic adjuncts. While possible, it is not yet considered standard practice.
Laparoscopy has been demonstrated to be safe and effective for most indications requiring splenectomy. The evolution of the technique has come with better understanding of the surgical anatomy of the spleen, making the lateral approach preferable in most instances. As compared with open splenectomy, laparoscopic splenectomy results in decreased length of stay, decreased narcotic use, improved cosmesis and an overall low complication rate. Understanding the physiology of the spleen as well as the diseases that involve the organ allows for appropriate patient selection, and portends success of the technique. The pre-operative determination of splenic size and the presences of accessory splenic tissue with appropriate imaging are crucial. Larger spleens are technically more challenging, but can be removed laparoscopically by experts with technique modification. Experienced specialists are also expanding the use of laparoscopy for splenic pathology by way of partial resection, fewer incisions and in the trauma setting. The success of these expanded indications has yet to be determined by long-term and comparative data.
1. Delaitre B, Magnien B. Splénectomie par voie laparoscopique, 1 observation. Presse Médicale. 1991;20:2263.
2. McClusky DA III, Skandalakis L, Colborn GL, et al. Tribute to a triad: history of splenic anatomy, physiology, and surgery—part 1. World J Surg. 1999;23:311–325.
3. Skandalakis PN, Colborn G., Skandalakis LJ, et al. The surgical anatomy of the spleen. Surg Clin N Am. 1993;73:747–768.
4. Morris KT, Hovarth KD, Jobe BA, et al. Laparoscopic management of accessory spleens in immune thrombocytopenic purpura. Surg Endosc. 1999;13:520-522.
5. George JN, el-Harake M., Raskob GE. Chronic idiopathic thrombocytopenic purpura. N Engl J Med. 1994;331:1207-1211.
6. Stasi, R., et al. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura. Blood. 2001;98(4):952-7.
7. Aqui NA, Stein SH, Konkle BA, et al. Role of splenectomy in patients with refractory or relapsed thrombotic thrombocytopenic purpura. J Clin Apheresis. 2003;18:51-54.
8. Eber S, Lux SE. Hereditary spherocytosis—defects in proteins that connect the membrane skeleton to the lipid bilayer. Semin Hematol. 2004;41:118-141.
9. Tallman MS, Hakimian D, Peterson L. Massive splenomegaly in hairy cell leukemia. J Clin Oncol. 1998;16:1232-1233.
10. Brodsky J, Abcar A, Styler M. Splenectomy for non-Hodgkin's lymphoma. Am J Clin Oncol. 1996;19:588.
11. Tefferi A, Messa R, Nagorney DM, et al. Splenectomy in myelofibrosis with myeloid metaplasia: a single-institution experience with 223 patients. Blood. 2000;95:2226-2233.
12. Park AE, Birgisson G, Mastrangelo MJ, et al. Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases. Surgery. 2000;128:660.
13. Park A, GagnerM., Pomp A. The lareral aproach to laparoscopic splenectomy. Am J Surg. 1997;174(2):126-30.
14. Trelles N, Gagner M, Pomp A, Parikh M. Laparoscopic splenectomy for massive splenomagaly: technical aspects of initail ligation of splenic artery and extraction without hand-assisted technique. J Laparoendosc Adv Surg Tech A. 2008;18(3):391-395.
15. Targarona EM, Balague C, Cerdan G, et al. Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly: a comparison analysis with conventional laparoscopic splenectomy. Surg Endosc. 2002;16:426.
16. Poulin EC, Mamazza J., Schlachta CM, Splenic artery embolization before laparoscopic splenectomy: an update. Surg Endosc. 1998;12:870.
17. Pomp A, Gagner M, Salky B, Caraccio A, Nahouraii R, Renier M, Herron D. Laparoscopic splenectomy: a seleceted retrospective review. Surg Laparosc Endosc Percutan Tech. 2005;15(3):139-43.
18. Poulin EC, Mamazza J. Laparoscopic splenectomy: lessons from the learning curve. Can J Surg. 1998;41:28.
19. Katkhouda N, Hurwitz M, Rivera RT, et al. Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients. Ann Surg. 1998;228:568.
20. Gigot JF, et al. Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases. Surg Endosc. 1998;12(2):101-6.
21. Uranues S, Grossman D, Ludwig L, Bergamaschi R. Laparoscopic partial splenectomy. Surg Endosc. 2007;21(1):57-60.
22. Henry G, Becmur F, Mefat L, Kalfa D, Lutz L, Guys JM, de Lagausie P. Laparoscopic partial splenectomy: indications and results of multicenter retrospective study. Surg Endosc. 2008;22(1):45-9.
23. Morinis J, Dutta S, Blanchette v, Butchart S, Langer JC. Laparosocpoic partial total splenectomy in children with hereditary spherocytosis. J Pediatr Surg. 2008;43(9):1649-52.
24. Malladi P, Hungness E, Nagle A. Single access laparoscopic splenectomy. JSLS, 2009;13(4):601.
25. Barbarous U, Dinccag A. Single incision laparoscopic splenectomy: the first two cases. J Gastrointest Surg. 2010;14(9):1473.
26. Gagner M. Needlescopic splenectomy: A safer alternative to single incision laparoscopic splenectomy (SILS). J Gastrointest Surg. 2010;14(9):1473.
27. Carobbi A., et al. Laparoscopic splenectomy for severe blunt trauma: initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc. 2010;24(6)1325-30.