POTENTIAL INDICATIONS FOR LAPAROSCOPIC SPLENECTOMY
A. Thrombocytopenia
1.Idiopathic Thrombocytopenic Purpura
a. Adults: if a trial of glucocorticoid therapy fails to produce a persistent improvement in platlet count.
b. Children : if there are important consequences of abnormal bleeding (ie. Intracranial hemorrhage)
2.Thrombotic Thrombocytopenic Purpura
The role for splenectomy in TTP is currently unclear. It may have a role in those resistant to plasmapheresis
B. Anemias
1.Erythrocyte Structural abnormalities
a.Hereditary Spherocytosis- splenectomy at 6 to 8 yrs of age.
b.Hereditary Eliptocytosis- if have symptoms of severe anemia.
c.Hereditary Pyropoikilocytosis- if severe, usually required as a child.
C. Hypersplenism
(Most of these patients will have splenomegaly, and will not be candidates for laparoscopic splenectomy. Although no size guidelines exist, we have had limited success with spleens over 18 to 20 cm in the long axis, and recommend open splenectomy in these patients.)
1. Primary Hypersplenism
2. Secondary Hypersplenism
a.Splenic Vein Thrombosis
b.Gaucher Disease
c.Felty Syndrome
d.SLE
D. Malignancy
Malignancy often confers splenomegaly, which increases the need for an open procedure. Although no real guidelines exist, laparoscopic splenectomy is not recommended for moderate and large sized spleens, as discussed for hypersplenism.
1.Hairy Cell Leukemia
2.Chronic Myelogenous Leukemia
a. Justified for compressive symptoms, or sequestration of cellular elements.
3. Chronic Lymphocytic Leukemia
a. For splenomegaly
4. Primary Splenic Tumors
CONTRAINDICATIONS TO LAPAROSCOPIC SPLENECTOMY
A. Spleen Size
Although there is no real consensus on exactly what is too large, large spleens decrease the likelihood of successful laparoscopic removal. Routinely adding this risk and expense of laparoscopy to cases that are likely to be converted to open, is not an ideal appropriation of resources. Again, we tend to use the open technique for spleens that exceed 20cm in the long axis by CT scan. Borderline sized spleens can be attempted, if the dissection is successful, often placement in the removal bag can be difficult. If this occurs a small incision is made to avoid intra-abdominal fracture.
B. Physiologic Limitations
Those who cannot tolerate operation, or have uncorrectable severe bleeding dyscrasias.
Room Setup
The surgeon stands on the patients left side of the table. The assistant stands across the table from the surgeon, but slightly cranial with respect to the patient. The camera operator stands either to the left of the surgeon, or to the right of the assistant
Illustrations
اضغط على الصورة
02-27-2008, 06:07 AM
Laparoscopic Splenectomy
العرض العادي
