BACKGROUND
Laparoscopic splenectomy has become the treatment of choice for a variety of splenic pathology.1 It is commonly performed for idiopathic thrombocytopenic purpura (ITP), but poor surgical outcome is associated with retained splenunculi or splenosis.1,2
TECHNIQUE
In patients in whom computed tomography (CT) can identify accessory or residual splenic tissue, hookwire localisation may be used to facilitate definitive laparoscopic surgery. Prior to surgery, a CT-guided hookwire is passed percutaneously to lie alongside the splenunculus. For excision of residual splenic tissue in the region of the native spleen, we employ the following configuration: right lateral decubitus position, a 10-mm port placed lateral to the umbilicus and 2 × 5-mm ports (below mid-line xiphisternum and left costal margin at the mid-axillary line). With this arrangement, the splenic flexure can be easily mobilised. The splenunculus is identified at the end of the wire and excised.
Figures 1 and 2 illustrate the application of this technique.
Figure 1.
CT scan demonstrating splenunculus with localising hookwire.
Figure 2.
Laparoscopic view of splenunculus with hookwire in place.
DISCUSSION
After previous surgery, the technical difficulty of finding a splenunculus is increased, especially for laparoscopy.3 Several techniques of intra-operative localisation and laparoscopy have been described, including the use of gamma probes, after injection of technetium.3–5 This is the first report of CT-directed guidewire localisation of accessory splenic tissue.
References
- 1.Katkhouda N, Hurwitz MB, Rivera RT, Chandra M, Waldrep DJ, Gugenheim J, et al. Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients. Ann Surg. 1998;228:568–78. doi: 10.1097/00000658-199810000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gigot JF, Jamar F, Ferrant A, van Beers BE, Lengele B, Pauwels S, et al. Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases. Surg Endosc. 1998;12:101–6. doi: 10.1007/s004649900607. [DOI] [PubMed] [Google Scholar]
- 3.Mercan S, Ridvan S, Yesim E. Laparoscopic treatment of accessory splenic tissue. Surg Laparosc Endosc. 1996;6:330–1. [PubMed] [Google Scholar]
- 4.Akwari OE, Itani KM, Coleman RE, Rosse WF. Splenectomy for primary and recurrent immune thrombocytopenic purpura—current criteria for patient selection and results. Ann Surg. 1987;206:529–51. doi: 10.1097/00000658-198710000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Antevil J, Thoman D, Taller J, Biondi M. Laparoscopic accessory splenectomy with intraoperative gamma probe localization for recurrent idiopathic thrombocytopenic purpura. Surg Endosc. 2002;12:371–4. doi: 10.1097/00129689-200210000-00015. [DOI] [PubMed] [Google Scholar]