Laparoscopic splenectomy in children: experience from a tertiary care referral institute in North India

Abstract

Aims

The aim of this study was to compare the results of laparoscopic splenectomy (LS) with open splenectomy (OS) in children at a tertiary care referral institute in North India.

Methods

The electronic medical records of all children who had undergone non-emergent splenectomies between July 2014 and December 2019 at our centre were reviewed retrospectively. Patients undergoing splenectomies for trauma or portal hypertension were excluded. During the period from July 2014 to June 2016, splenectomy was performed by an open technique. From July 2016 onwards, all splenectomy procedures were performed laparoscopically. Demographic features, indications for splenectomy, operative time, estimated blood loss, spleen weight, need for conversion, length of stay, time to oral feeds and requirement for analgesia were recorded. Data for children undergoing LS were compared with those undergoing OS.

Results

Between July 2014 and June 2016, 20 children underwent OS. Between July 2016 and November 2019, 16 children underwent LS. The groups were similar in age and sex; hereditary spherocytosis was the commonest indication in both the groups. Operating time was longer in the LS group (186 ± 20.4 min vs 136 ± 12.2 min; P < 0.05), but blood loss and complication rates were similar. Two (12.5%) conversions were necessary, primarily due to spleen size. Children undergoing LS had a shorter length of stay (3.4 ± 0.6 vs 6.8 ± 1.2 days; P < 0.05), shorter time to oral feeds (0.5 vs 2.5 days; P < 0.05), and lesser requirement for analgesia.

Conclusions

LS is feasible and safe in children. It is superior to OS with regard to cosmesis, duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function. However, operating time for LS is longer than OS at our centre currently.

Introduction

Laparoscopic splenectomy (LS) was first attempted in animal models in 1990 [1]. It was rapidly introduced into clinical practice in adults in 1991 [1] and subsequently in children in 1993 [2]. Since then, LS has become the standard of care for children with hematologic diseases. Compared with open splenectomy (OS), its advantages include shorter hospitalization, reduced need for postoperative analgesia, and excellent cosmetic results. Disadvantages of LS include longer operative time, increased cost, and difficulty in removing large spleens [3].

Pediatric minimal access surgery (MAS) was started in India more than 2 decades ago and has a great impact on the way we manage pediatric surgical problems in our country today. Today, advanced MAS procedures, including LS are competently performed and taught at all major pediatric surgical centres across the country. Despite multiple reports in the western literature describing advantages of LS in comparison to OS in children [4,5,6,7,8,9,10,11,12,13,14], there are as yet no published comparisons of this technique in children from India. We, therefore, reviewed our center's recent experience with LS and standard OS in children.

Methodology

The electronic medical records of all children who had undergone non-emergent splenectomies between July 2014 and December 2019 at our centre and were operated by the primary author were reviewed retrospectively. Patients undergoing splenectomies for trauma or portal hypertension during this period were excluded. During the period from July 2014 to June 2016, splenectomy was performed by an open technique in 20 children. From July 2016 onwards, splenectomy was performed laparoscopically in 16 children.

Demographic features, indications for splenectomy, operative time, estimated blood loss, spleen weight, need for conversion, length of stay, time to oral feeds, requirement for analgesia, morbidity and mortality were recorded. Data for children undergoing LS were compared with those undergoing OS by using the Student t test and chi-square test; a P value of less than 0.05 was considered statistically significant.

Preoperative preparation

Preoperatively, all patients were administered polyvalent pneumococcal, meningococcal, and Haemophilus influenzae vaccines at least 2 weeks prior to surgery. Laboratory workup included complete haemogram, clinical chemistry and coagulation profile. All patients underwent ultrasonography to estimate spleen size and the presence of accessory spleens and gallstones. Patients with idiopathic thrombocytopenic purpura (ITP) were given peri-operative stress steroid dosing if steroids were used for medical therapy. Packed red blood cells and platelets were held in reserve, but were not given unless patients met specific transfusion criteria. Routine antibiotic prophylaxis was administered at the onset of surgery.

Surgical technique

OS was performed by left sub-costal incision using standard technique. An upper midline incision was used in cases where a concomitant cholecystectomy was required. Control of the splenic hilum was achieved by individual ligation and division of the splenic artery at the superior border of the pancreas and then ligation and division of the splenic vein. Following removal of the spleen, the abdominal cavity was searched for any accessory spleens. A drain was placed in all cases. The abdomen was closed in standard fashion.

LS was performed by lateral approach using four ports [15]. After induction of general anesthesia and endotracheal intubation in the supine position, a urinary catheter and an orogastric tube were inserted. The patient was then turned to right lateral decubitus position with a roll under the flank to increase the distance between the left iliac crest and the 12th rib. Video monitor was placed on the left of the operating table while the surgeon and the surgical assistant stood on the right (Fig. 1a). The patient was tilted in a 15° reverse Trendelenburg position. Access to the abdomen was gained by inserting a 10-mm port at the umbilicus by an open technique. Pneumoperitoneum was created and maintained at 10 to 12 mmHg with CO2 flow at 2–4 L/min. Under direct vision with a 30° telescope, two 5-mm ports were inserted in the midline, one just below the xiphoid process, and the other midway between the xiphoid and the umbilicus. Another 5-mm port was inserted in the left lower quadrant for inserting the right-hand instruments (Fig. 1b).

Fig. 1
figure1

a Patient position. b Port positions

With an instrument (we used a 5-mm suction tube) in the sub-xiphoid port to elevate the lower pole of the spleen, dissection began using an L hook monopolar cautery or the Harmonic scalpel (Ethicon Endosurgery, Inc., Cincinnati, OH). The spleno-colic ligament was divided first, allowing the colon to fall away. A small opening was then made in the gastro-splenic ligament. The stomach was grasped and retracted to the right while the short gastric vessels were individually divided with the harmonic scalpel. With the lesser sac open, a careful search was made for accessory spleens. The splenic artery was then visualized at the superior border of the pancreas, dissected, clipped with hemlock clips on either side and divided (Fig. 2a). The splenic vein was then similarly dissected, clipped and divided, taking care not to injure the tail of the pancreas (Fig. 2b). Further, the spleno-renal and spleno-phrenic ligaments were divided with the spleen retracted superiorly and to the right (Fig. 3a). Once the spleen was completely free of all attachments, it was placed in an endobag (Covidien, Mansfield, Massachusetts) (Fig. 3b). The mouth of the endobag was delivered outside through the 10-mm umbilical port. The spleen was morcellated with a sponge-holding forceps and finger fracture technique to allow for piecemeal removal. In three cases, spleen could not be placed in the endobag due to its large size and was delivered by a Pfannenstiel incision. After ensuring hemostasis, a drain was inserted and port sites were closed. Orogastric tube was removed before extubation.

Fig. 2
figure2

a Dissected splenic hilar vessels showing splenic artery (white arrow) and vein (black arrow). b Splenic vessels clipped on either side with hemlock clips and divided (arrow)

Fig. 3
figure3

a Division of spleno-renal ligament (arrow) with the spleen retracted superiorly and to the right. b Spleen placed in an endobag for removal via umbilical port

Post-operative management

All patients were extubated at the end of the procedure. The patients undergoing LS were offered fluids on the evening of their surgery and solids the following day. OS patients were allowed orally once the ileus resolved. Pain management consisted of intravenous analgesia with a patient-controlled analgesia (PCA) pump. Drains were usually removed after 48–72 h, once the drainage was minimal. Patients were discharged once they resumed full diet and were pain free with oral analgesics.

Results

During the study period (July 2014 to December 2019), a total of 36 splenectomies (excluding those done for trauma or portal hypertension) were performed for various indications by the primary author. Between July 2014 and June 2016, 20 children underwent OS. Between July 2016 and November 2019, 16 consecutive LS were performed. The patients ranged in age from 5 to 16 years; the mean age being 12.1 years in the OS group and 11.3 years in the LS group. The groups were similar in sex distribution. The most common indication for splenectomy was hereditary spherocytosis (16 patients), followed by ITP (11 patients) (Table 1). Mean length of postoperative follow-up was 46 months and 15 months for the OS and LS groups, respectively.

Table 1 Demographics and clinical variables

Operating time was significantly longer in the LS group as compared to the OS group (186 ± 20.4 min vs 136 ± 12.2 min; P < 0.05). Four patients in the OS group required a concomitant cholecystectomy (Table 2). There was no significant difference in the estimated intra-operative blood loss between the two groups and none of the patients required an intra-operative blood transfusion. Two patients (12.5%) in the LS group required conversion to open surgery, primarily due to spleen size. Excluding these two patients in addition to the three who required a Pfannenstiel incision for delivery of the spleen, 11 patients in the LS group underwent a total or pure laparoscopic procedure. Mean weight of spleen removed was similar in both the groups (678 ± 152 gms vs 458 ± 124 gms, P > 0.05).

Table 2 Intra-operative and post-operative outcomes

In the postoperative period, oral feeds were tolerated significantly earlier in the LS group (mean: 0.5 vs 2.5 days, P < 0.05) (Table 2). The patients undergoing LS were offered fluids on the evening of their surgery and solids the following day. OS patients were allowed orally once the ileus resolved. Intravenous (iv) analgesics were used for a mean duration of 1.6 days for patients in the LS group versus 3.1 days for patients in the OS group (P < 0.05). The duration of postoperative i.v. analgesia was defined as the number of hours from the end of anesthesia until the last dose of i.v. pain medication administered in the hospital. 11 patients experienced Grade 1 postoperative complications [16] during their hospitalization: seven belonged to the OS group and four to the LS group (P > 0.05) (Table 2). None of the complications in either group required surgical, endoscopic or radiological intervention. Complications in the OS group included basal atelectasis, fever, prolonged ileus and wound infection, whereas in the LS group, fever, port site infection and muscular pain were reported. Children undergoing LS had a shorter length of stay compared to those undergoing OS (3.4 ± 0.6 vs 6.8 ± 1.2 days; P < 0.05).

Discussion

To our knowledge, the experience reported here represents the first analysis from India directly comparing LS and OS techniques exclusively in children. We demonstrate that LS is feasible and safe in children. The advantages of LS in our study include those of minimally invasive surgery in general, including smaller and more cosmetically acceptable incisions, shorter duration of postoperative analgesia, reduced hospital stay, and faster recovery of bowel function. These advantages have been well documented in various reports in the western literature [4,5,6,7,8,9,10,11,12,13,14].

Feng et al. [3] conducted a systematic review and meta-analysis to compare the clinical outcomes between LS and the traditional OS in children. Among the 922 pediatric participants included in the 10 studies, 508 had received LS and 414 OS. The authors reported shorter length of hospital stays, less blood loss, and longer operative times with the LS approach compared with OS. However, no significant difference was found between LS and OS in the secondary outcome, such as the removal of accessory spleens or postoperative complications including postoperative high fever, ACS (acute chest syndrome), and ileus.

Operating time was significantly longer in the LS group as compared to the OS group in our study, as previously reported by various authors [4,5,6, 9, 13]. This is related to the known learning curve for the laparoscopic technique. Although the small sample size in our study did not provide the power needed to perform a learning curve calculation, there was a trend for the more recent procedures to have shorter operating times. In our experience, the commonest complication seen in OS and LS group was basal atelectasis and muscular pain, respectively. Muscular pain in the LS group may have been related to the lateral positioning of the patient with a roll under the flank. Two patients (12.5%) in the LS group required conversion to an open procedure, primarily due to the lack of working space because of massive spleen size. The conversion rate in our series is similar to the 9 to 19% rate reported in the literature [4]. None of the patients in either group developed post-splenectomy sepsis in follow-up.

Since the first description of LS in 1993, there have been numerous modifications of the technique [5]. Placing the patient in a supine or the right lateral decubitus position has been the most common approach for LS. We prefer the lateral approach as described by Delaitre [17], in which the spleen essentially “hangs” in the left upper quadrant, thereby facilitating its removal. Trias et al. [18] also noted decreased operative time and shorter hospital stay with the lateral approach compared with the anterior approach. In this latter technique, one instrument elevates the spleen and another holds traction on the splenic attachments while the operator uses the ultrasonic scalpel to divide structures.

There are various limitations to our study, as it is neither prospective, nor randomized. Also, we did not undertake a cost analysis of OS versus LS, this being an important issue for hospitals in our country dealing with patients from poor socio-economic background. The cost of laparoscopic procedures is in general greater than open surgery, especially if the operating time is longer and disposable instruments are used [15]. We usually tend to use reusable laparoscopic instruments and ports in our practice to reduce cost. Also, a shortened hospital stay and more rapid return of the parent to work may more than compensate economically for the higher costs of LS.

Conclusions

LS is feasible and safe in children. It is superior to OS with regard to cosmesis, duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function. However, operating time for LS is longer than OS at our centre currently.

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Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AM, AG and RH. The first draft of the manuscript was written by AM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ankur Mandelia.

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The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval was waived by the ethics committee of the institute in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

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Mandelia, A., Gupta, A., Haldar, R. et al. Laparoscopic splenectomy in children: experience from a tertiary care referral institute in North India. J Ped Endosc Surg (2020). https://doi.org/10.1007/s42804-020-00066-6

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Keywords

  • Laparoscopic splenectomy
  • Open splenectomy
  • Children
  • Pediatric splenectomy