Hybrid natural orifice transluminal endoscopic surgery splenectomy: A case report.

Laparoscopic splenectomy has become an established standard of care in managing surgical diseases of the normal-sized spleen. Natural orifice transluminal endoscopic surgery (NOTES) is a step forward in making laparoscopic surgery even less invasive. In addition, the spleen can be accessed easily with the hybrid transvaginal approach. We present the case of a 38-year-old woman with medical refractory immune thrombocytopenic purpura. Hybrid notes splenectomy was performed using three working 5-mm abdominal trocars and a 10-mm camera port through the posterior fornix of the vagina. The organ was retrieved intact transvaginally. The patient had minimal post-operative pain and was discharged on the 1st post-operative day. Transvaginal hybrid NOTES approach is feasible for operative visualisation, dissection, clipping and specimen extraction in patients requiring splenectomy. It may offer better cosmesis and faster recovery. Comparative studies with conventional laparoscopic approach are desirable.

INTRODUCTION

Laparoscopic splenectomy (LS) has become the preferred approach for splenectomy for various indications. Delaitre and Maignien, in 1991, reported the first LS in a single patient.[1] The current literature suggests that LS improves patient morbidity, reduces the length of hospital stay and perioperative pain and provides enhanced cosmesis. However, spleen morcellation and removal require an enlargement of the port site, especially for extracting the intact spleen.[23] Transvaginal extraction of the resected spleen was described in the early 90’, but rarely used, and it did not avoid using multiple large-diameter trocars (10–12 mm) through the abdominal wall. Targarona et al. performed transvaginal splenectomy using a flexible endoscope through posterior fornix and firing endoscopic stapler through posterior fornix.[4] Natural orifice transluminal endoscopic surgery (NOTES) transvaginal surgery technique has been described for gall bladder,[5] but it has not been applied commonly for splenectomy due to low case volume and technical difficulties.

CASE REPORT

A 38-year-old female had a history of ecchymotic spots over her arms, legs and easy bruising over her thigh for the past 2 years; in addition, she had a history of menorrhagia for the previous year. On evaluation, she was diagnosed with immune thrombocytopenic purpura (ITP) and received medical treatment for 2 years. Her body mass index (BMI) was 24. Her platelet counts ranged between 10,000 and 26,000 per microliter (mcL) at the beginning of the medical treatment, and she responded well to steroid therapy, with platelet counts rising to 140,000/mcL. During the ongoing medical treatment, the disease became steroid refractory, and splenectomy was contemplated. Ultrasound revealed the spleen size as 9.8 cm in the long axis. The patient signed a detailed informed consent form. Further, she was fully aware of the potential risks of the transvaginal approach, such as vaginal bleeding, infection and dyspareunia.

Preoperative planning

The patient underwent a thorough preoperative assessment. She received vaccination against Haemophilus influenzae, pneumococcus and meningococcus 2 weeks before the surgery. The rapid urease test for Helicobacter pylori was also negative. Preoperative platelet counts were 1.19 lac.

Operative technique

The patient was placed on the operating table in a 30° right lateral decubitus position with the legs abducted and slightly flexed at the knees. The abdomen, pelvis and vaginal canal were disinfected with 10% povidone-iodine solution. The camera assistant sat between the patient's legs. The surgeon stood on the patient's right side and the assistant surgeon on the patient's left side with the monitor placed near the patient's left shoulder. Pneumoperitoneum was created through a 5-mm safety trocar placed at the upper umbilical crease. Intra-abdominal pressure was maintained at 15 mmHg. One 5-mm port was inserted in the epigastric region and another in the left flank region [Figure 1]. The camera port trocar was inserted under direct vision through a 10-mm posterior colpotomy [Figure 2]. Three 5-mm abdominal ports were used for dissection and retraction, and a 10 mm, 45° bariatric telescope through the posterior fornix was used for visualization. Dissection of the inferior pole of the spleen and the division of the short gastric vessels was done with the harmonic ace vessel sealing system [Figure 3]. The splenic artery and vein were clipped with 5-mm hemlock clips and divided. The operating time was 130 min. The blood loss was minimal (<30 ml). A drain was placed in the left subdiaphragmatic space. No nasogastric tube or urinary catheters were placed.

Figure 1

Port placement

Figure 2

Optical trocar posterior fornix

Figure 3

Short gastric division

The patient was ambulated 4 h after surgery and was allowed to take liquids and soft diet on the 1st post-operative day. The hospital stay was uneventful, the drain was removed and she was discharged on the 1st post-operative day. She required paracetamol 1 g, diclofenac75 mg i/v at night and post-operative day 1; no additional analgesics were required. Platelet count on days 3, 7 and 11 were 3 lac, 6 lac and 12 lac per mcL, respectively. The abdominal and vaginal wound healed well, and the patient had no specific complaints. Aspirin (75 mg) once daily was initiated because of thrombocytosis. Her platelet count after 8 weeks of surgery was 408,000/mcL without steroids. Follow-up after 3 months, the patient platelet counts were 3.59 lacs/mcL. The histopathological examination showed a normal spleen of 140 g and 11 cm × 9 cm × 3 cm in size.

DISCUSSION

Over the last few years, there has been much evolution in minimally invasive surgical techniques, resulting in less pain, shorter hospital stay and better cosmetic results without compromising patient safety. Transvaginal route has been used for hysterectomy or tubal ligation for over 100 years. The other alternatives to access the peritoneal cavity, like the colon and stomach, have the potential of intra-abdominal infection due to defective closure of the wall of the viscera. The NOTES technique is described for cholecystectomy, appendectomy, ovarian cysts, tubal surgery, splenic surgery, hernia repair and nephrectomy.[6] Here, we describe a hybrid laparoscopic transvaginal splenectomy in a patient with ITP. Hybrid NOTES technique (<5-mm trocars) can also be used successfully for splenectomy; as there is minor abdominal wall trauma, there is almost no risk of an incisional hernia, less post-operative pain and a superior cosmetic outcome. In our case, the transvaginal splenectomy with rigid instruments was technically feasible. One crucial challenge of transvaginal surgery is the safety of vaginal access. Pure transvaginal approaches use blind access through the vagina, and it has the possibility of adjacent organ injuries. Wood et al. reported a rectal injury due to blind vaginal access during a pure transvaginal ventral hernia repair.[7] We used three 5-mm abdominal working ports for laparoscopic dissection and retraction of the spleen. The main advantage of this technique is that it reduces the port numbers, avoids larger (10–15 mm) ports, reduces visible scars, the risk of hernia formation and fascial suturing that increases the post-operative pain. Our patient required minimal post-operative analgesia, and there was no incision-related complication. Extraction of the spleen without any fragmentation through the pouch of Douglas was easy [Figures 4 and 5]. Intact spleen retrieval may be beneficial in diseases of the spleen like hydatid or malignancy in which splenic morcellation is undesirable. Despite the above-mentioned advantages, this technique still has some obstacles, especially in obese and tall patients with BMI >30. The distance between the spleen and the vagina and the inadequate length of the instruments may pose difficulty in tall and obese patients. We think that the limitations of this approach are technology-dependent and can be overcome by the development of new endosurgical equipment.

Figure 4

Specimen extraction

Figure 5

Intact spleen

CONCLUSIONS

Hybrid notes approach for splenectomy seems to be feasible and effective. It can be performed with conventional laparoscopic instruments and avoids 10–15-mm abdominal trocars and potential morbidity associated with it. Operative time is comparable to conventional LS. In addition, vaginal access is obtained under vision, avoiding potential injury to adjacent viscera. However, more extensive feasibility studies are needed; technology developments are required, especially for obese patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.