Laparoscopic splenectomy in children with benign hematological diseases: Leaving nothing behind policy.

CONTEXT: Laparoscopic splenectomy (LS) is considered the standard approach for the treatment of children with nonmalignant hematological diseases due to the advances in the minimal invasive surgery over the conventional splenectomy (CS). Different techniques are involved in the operation to secure the hilum. AIM: The use of (Ligasure™) is a safe, effective, less time consuming and with less complications rate.
MATERIALS AND METHODS: Sixty children (33 with thalassemia, 20 with immune thrombocytopenic purpura [ITP] and seven with spherocytosis) were operated during the period from June 2007 to December 2014. These children had undergone LS using (Ligasure™). Three ports were used in small-sized spleens while four ports were used in large spleens.
RESULTS: There were 60 children (37 girls and 23 boys) with a mean age of 10.2 years had LS using Ligasure™ with mean operative time of 85 min for cases of ITP and 120 min for other cases. There was no mortality. Two cases were converted to CS.
CONCLUSIONS: Use of Ligasure™ alone was safe, less time consuming with less complications rates.

INTRODUCTION

Splenectomy addresses the role of the spleen in the hematology disorders particularly that of the cellular sequestration and destruction and antibody production.[1]

Laparoscopy has been increasingly used for splenectomy in children. It was introduced more than two decades ago by Delaitre in France, Carrol in USA and Pouline in Canada. Hence, laparoscopic splenectomy (LS) has become the procedure of choice for the management of most hematological diseases in children.[23]

There are different techniques that have been used to control the splenic vascular supply including endovascular staplers, clips, bipolar sealing device (BSD), suture ligature, monopolar electric devices, and ultrasonic shears.[4]

Ligasure™ has been used on splenic and renal vessels in experimental and clinical studies, and they remained sealed without acute or chronic hemorrhages.[5]

We evaluated the use of Ligasure alone in securing the splenic hilum in benign hematological diseases of children with the added benefits of leaving nothing behind the policy.

MATERIALS AND METHODS

A total of 60 children underwent LS during the period from June 2007 to December 2014. We excluded cases with mean splenic span more than 15.5 cm and patients who had upper abdominal conventional operations. Cases included 33 children with thalassemia, 20 with immune thrombocytopenic purpura (ITP) and seven with spherocytosis.

All children received vaccines against capsulated organisms at least 2 weeks before the operation.

The patients were operated upon while they were in right side lateral position tilting about 60° and elevation of the waste of the patient at the operating table.

We used three ports, camera port 10 mm at the umbilicus, midline port 5 mm midway between the umbilicus and xiphoid process and port 10 mm at the left mid-clavicular line just below the left costal margin for the Ligasure™. An additional port 5 mm at the left mid-axillary line below the costal margin was used in cases with large spleens.

Ligasure™ was used to control all the vessels supplying spleen in all our cases. We started the procedure with the division of the splenocolic ligament and secured the vessels at the lower pole of the spleen [Figure 1]. The short gastric vessels (SGV) were secured. The lesser sac was then entered, and the splenic artery and vein were identified [Figure 2]. We secured first the splenic artery and then the vein. If the size of main vessels seemed to be > 7 mm, we move further distally to segmental vessels and sealed them with the Ligasure. Any adhesions between spleen, the diaphragm, and lateral abdominal wall were divided. Extraction bag was passed through the umbilical port, and after the spleen was retrieved in the bag we dragged it to the umbilical port where the mouth of the bag was at the skin of umbilicus then we started morcellation of spleen within the bag using Kocher forceps. The spleen was cut into small pieces that were extracted out. We used this maneuver in small-sized spleens. In cases of splenomegaly, we extracted spleens through a mini-pfannenstiel incision as this incision is in the lower abdomen, transverse and healed with better cosmetic appearance.

Figure 1

Sealing at the lower pole of spleen

Figure 2

Sealing the hilum

RESULTS

This study included 60 children. Thirty-three had with thalassemia; 20 had ITP, and seven had spherocytosis.

There were 37 girls and 23 boys with a mean age of 10.2 years. The mean operative time was 85 min for ITP patients and 120 min for patients suffering from thalassemia and spherocytosis [Table 1].

Table 1

Demographic data and indications for LS

Two cases were converted to conventional splenectomy. This occurred during the early period of the study due to the injury of the splenic hilum. One case (thalassemia) had an injury to the splenic vein and four cases (one ITP, two spherocytosis, and one thalassemia) had an injury of the SGV. The mean estimated amount of blood loss was 230 mL in thalassemic, 180 mL in spherocytosis patients and 125 mL in ITP patients. None of our cases were in need for intra or postoperative blood transfusion. During the postoperative period, all patients received oral feeding on the 2nd day and discharged on the 3rd day. We had five cases of subphrenic collections (three thalassemia, one ITP and one spherocytosis). Two cases required ultrasound guided drain and the other three cases were treated conservatively and recovered [Table 2].

Table 2

Operative and postoperative data

DISCUSSION

Different techniques were incorporated to control the splenic vascular supply including endovascular staplers, clips, BSD, suture ligature, monopolar electric devices and ultrasonic shears.[4]

Bipolar vessel-sealing devices have increasingly found their place into modern surgical practice. Ligasure™ create vessel seals as a result of the heat generated when a current is passed through tissue, with the jaws of the device providing both the source of pressure (on the tissue) and the means to measure and regulate current flow. The combination of compression and heat causes proteins within the tissue to denature and subsequently re-anneal, to form an amalgam.[67]

The use of Ligasure™ has several aims; it avoids electrical hazards and thermal injuries when compared with monopolar systems. It plays a role in reduction the overall operative time as it reduces the frequent instrument interchange because dissection, grasping, coagulation and cutting are carried out by the instrument at the same time.[8]

The maximum diameter of a blood vessel that's vulnerable to the action of Ligasure™ should be no more than 7 mm. Hence, this system allows alone to control splenic hilum especially in children without the need for any endovascular staplers.

Kennedy et al., effectively sealed vessels from 1 to 7 mm in diameter and showed that these seals can withstand a minimum of three times normal systolic pressure using BSD.[9]

Bleeding is the main complication and cause of conversion during LS. The use of endovascular staplers is reported to shorten and facilitate hilar dissection compared with ligation and or clipping, but on the other hand Romano et al., reported use of Ligasure™ was safe, as well as lower blood loss, shorter operative time and lower costs than staplers.[101112]

Yüney et al., performed LS for 10 adult patients with ITP using Ligasure™ for all the procedure and showed that the mean blood loss was 60 mL and the average operating time was 93 min, without any conversions or complications in postoperative period.[13]

This difference in the estimated amount of blood loss between our work and Yüney et al., may be attributed to cases in whom injuries to splenic vessels occurred during the procedure especially in early cases of study.

Gelmini et al., reported the performance of 63 laparoscopic splenectomies using Ligasure™ as the only means of achieving hemostasis with a conversion rate of 7.9%, an average blood loss ranging 0-100 mL and average operative time 120 min.[5]

The mean intra-operative blood loss reported in some series is high, between 138 mL and 524 mL and conversion rate ranged between 5% and 10%.[31415]

In terms of stapling techniques for transacting the splenic pedicle, the use of endovascular staplers requires proper positioning of the device for the hilar vascular control and accurate hilar dissection with meticulous skeletonization to exclude extraneous tissues, positioning as close to the spleen as possible away from the tail of pancreas. Prominent splenic vessels, perihilar fat, and relatively narrow jaw opening may lead to excess bleeding from the staple line. Moreover, the tail of pancreas can be retained between the jaws of the stapler causing pancreatic fistula or clinical pancreatitis.[516]

We documented no injury of the pancreas during LS using Ligasure™ as if compared with the use of endovascular staplers to secure the hilar vessels.

Hemostasis thus has to be considered the essential step in LS. Furthermore, due to the complex splenic blood supply, a tremendous number of clips are sometimes required and lift in addition to staples as foreign bodies. These metals may be potentially harmful, and this feature is against the policy of leaving nothing behind.[3]

Several studies showed that Ligasure™ offered advantage of time-saving when compared to other instruments as it reduces the frequent instrument interchange because grasping, coagulation, and cutting are done at the same time so saving time and avoid accidental capsular injuries.[5]

A review of the literature pertaining to LS performed with the use of Ligasure™ revealed 10 studies including the resent study. The review showed that the procedure was completed using Ligasure™ as the only method of achieving hemostasis without the use of clips and endovascular staplers [Table 3].[458131617181920]

Table 3

Review table comparing our study with previous series

CONCLUSIONS

We believed that the use of Ligasure™ during LS in children with benign hematological diseases is a safe, time saving, economic and associated with less rate of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.