Abstract
Abstract
Purpose:
Certain splenic conditions in children require surgical interventions, the majority of which are approached via standard laparoscopy with multiple incisions. The single-incision laparoscopic (SIL) technique is gaining popularity. The aim of this study is to review our institutional experience using the SIL technique to surgically manage different splenic pathology in the pediatric population.
Methods:
A retrospective review was performed of the patients who underwent SIL splenic procedures at Miller Children's Hospital (Long Beach, CA) from January 2009 to December 2010.
Results:
Seven patients underwent a SIL technique for different splenic diseases. Five patients underwent splenectomy, 1 patient underwent a splenic cystectomy and omental patching, and 1 patient underwent reduction of splenic torsion and splenopexy. There were no conversions to open. Six procedures were successfully performed without the need for an additional trocar. However, 1 patient required an additional grasper through a separate stab incision. There were no intraoperative complications. One patient had a superficial wound infection at 2-week postoperative follow-up, which resolved with local wound care.
Conclusions:
Our preliminary experience shows the SIL technique for the management of splenic pathology in children is safe and feasible.
Introduction
Methods
A retrospective review of all pediatric patients who underwent the SIL technique for splenic conditions from January 2009 to December 2010 was performed after approval by the Institutional Review Board. Data points collected included procedure type, age, weight, mean operating time, intraoperative complications, blood loss, conversion to open, initiation of diet, length of stay, and postoperative complications.
Surgical technique
With the patient's left side elevated at 30° on a beanbag, the operation was performed using a three-trocar technique either via a single periumbilical incision or using a specially designed multiport device (Covidien®, Norwalk, CT) through a trans-umbilical incision. Either three standard 5-mm laparoscopic instruments or two standard 5-mm laparoscopic instruments plus a roticulated grasper were used to facilitate retraction. The LigaSure® (Covidien) was used to seal and divide the splenic vessels and splenic parenchyma. In the cases of splenectomy, the vessels were taken individually right on the splenic capsule. For the splenic cystectomy, there was significant inflammation; therefore, splenectomy was not possible. Instead, 85% of the cyst wall was removed, and the remaining cavity was obliterated with electric cautery and filled with omentum. With regard to the patient with splenic torsion, the spleen was too large to easily reduce. A 3-mm accessory instrument through a stab incision in the left flank was required to facilitate the reduction. Once the torsed spleen was reduced, a 25 cm×20 cm Proceed mesh (Ethicon Endo-Surgery, Inc., Cincinnati, OH) was used to pex the spleen. A “U” shape slit was made in the middle of the mesh. The multiport device was removed and the mesh was introduced into the abdomen. One of the edges of the mesh was easily placed around the splenic hilum. The mesh was secured to the lateral abdominal wall using a 5-mm Endotack device (Covidien).
Results
Seven patients (6 female and 1 male) were identified in the study period who underwent a SIL technique to treat splenic pathology. The indications for splenectomy included spherocytosis (3 patients) and idiopathic thrombocytopenic purpura (1 patient). One of the patients with spherocytosis underwent a combined splenectomy/cholecystectomy due to presence of gallstones. A detorsion and splenopexy was performed in 1 patient with splenic torsion, and 1 patient underwent a subtotal resection of a 15-cm splenic cyst with omental patching. The average age of the patients was 11.3 years (5–16 years), and the average weight was 46.2 kg (19–82 kg). Mean operating time was 136 minutes (96–180 minutes), including the patient who received the combined procedures. The operative time for the splenic detorsion and splenopexy was 123 minutes. There were no intra-operative complications or conversions to open. However, the splenic torsion patient required an additional 3-mm grasper through a separate stab incision to facilitate the reduction. The remaining 6 patients were successfully performed without the need for additional trocars. The average blood loss was 30 cc (0–100 cc). Diet was initiated on postoperative day 1 in all patients; average time to full oral intake was <2 days. The average length of stay was 3.2 days (1–8 days), with the patient with splenic torsion requiring a much longer hospital stay. At an average of 8-month follow-up, all of the patients had satisfactory recovery with excellent cosmetic results. One patient developed a superficial wound infection at 2-week follow-up, which resolved with local wound care (Table 1).
Pt, patient; OP time, operative time; EBL, estimated blood loss; ITP, idiopathic thrombocytopenic purpura.
Discussion
Standard laparoscopy has become a preferred surgical approach in the management of many splenic conditions. It offers many advantages, including decreased pain, improved scarring, shorter hospital stay, faster recovery, and improved cosmesis. However, the technique requires multiple small incisions. SIL potentially improves on these outcomes and provides even better cosmetic results.1–5 SIL technique is becoming the more popular approach to treat surgical conditions and has been well reported in the adult literature.1–3 In pediatric patients, SIL surgery has been utilized in appendectomy, cholecystectomy, nephrectomy, and splenectomy procedures.4–9,15–18 Despite its increasing popularity, reports of SIL technique for treatment of splenic pathology is still limited.10–13,19
In 2009, Dutta and his colleagues first reported their experience with (SIL) splenectomy in 6 pediatric patients with 2 of them undergoing combined splenectomy/cholecystectomy procedures. 15 Subsequently, multiple centers have reported their experience with SIL splenectomy in children.16–18 Here, we report one of the largest series in the pediatric population who have undergone SIL to treat different splenic pathology.
Most of the previous reports in children are limited to SIL splenectomy.14–18 In this study, we have expanded the utilization of SIL to different modalities. One patient underwent splenic cystectomy and omental packing for a large inflamed epidermoid cyst. In this patient, splenectomy was not possible because of intense inflammation. Instead, 85% of the cyst was excised. The remaining cyst wall was obliterated with electric cautery. At 6-month follow-up ultrasonography, she had no sign of recurrence. Additionally, another patient had a successful reduction of splenic torsion and splenopexy. During the course of this study, we have learned that single-incision procedures can be done safely using standard laparoscopic instruments through separate fascial incisions. However, we believe that the specially designed multi-port provides better angulation, minimizes trocar collision, and improves cosmesis. Since we use the 15-mm Endocatch II (Ethicon Endo-Surgery, Inc.) to retrieve the spleen, a 2-cm transumbilical incision allows us the portal for retrieval and still maintains a well-concealed scar within the umbilical fold. Furthermore, we have learned that having at least one roticulating instrument facilitates the dissection. This instrument gives us the ability to retract the spleen and decrease instrument collisions as we experienced with the straight graspers. Earlier reports described using endostaplers to ligate and divide the hilar vessels. In our series, we have used the LigaSure (Covidien). We believe that this device can provide sufficient sealing as long as the vessels are taken individually and right on the splenic capsule. We favor using the LigaSure because it is a 5-mm instrument. Even though the endostapler is a roticulating device, it is a 10-mm instrument that limits the mobility of the instruments going through a small fascial site.
Conclusion
A SIL approach to treat different splenic pathology in children is feasible and safe. The results appear to be comparable to the standard laparoscopic approach with much improved cosmetic outcomes. However, there are limitations in this study because it is a retrospective review with small numbers. A larger series is needed to further validate this technique.
Footnotes
Disclosure Statement
No competing financial interests exist.