Single-Incision Pediatric Endosurgery (SIPES) Splenectomy: A Case-Control Series

Introduction

Laparoscopic surgery through a single incision began its launch into the mainstream in 2008 with urological procedures. ¹ General surgical applications for cholecystectomy and appendectomy soon followed,^2,3 with the first single-port splenectomy reported in 2009. ⁴ Development of multichannel ports made the procedures faster and simpler and eliminated the need for skin flap creation to place multiple ports next to each other through the fascia. Pediatric surgeons were quick to adopt the new technique, with the first series of pediatric cholecystectomy and appendectomy reported from our institution^5,6 in 2010, where we adopted the term single-incision pediatric endosurgery (SIPES) to differentiate it from the adult literature. We reported the first SIPES splenectomy in a 5-year-old child in 2010. ⁷ Since then, few small pediatric case series of single-incision laparoscopic splenectomy have been published,^8–10 confirming the feasibility and safety of the procedure, but comparison with conventional laparoscopic splenectomy is limited because of the small number of cases.

Our hypothesis was that SIPES splenectomy is comparable to conventional multiport laparoscopic splenectomy in outcome measures of operative blood loss, operating time, length of stay, and surgical complications.

Subjects and Methods

Results

Sixteen children underwent SIPES splenectomy. Ages ranged from 1 to 15 years, with a median of 7 years, and weights were between 10 and 70 kg, with a median of 24 kg. Fourteen control patients had conventional multiport splenectomy in the same time period. The control group was similar in age and weight characteristics (Table 1). The most common indication in both groups was spherocytosis, followed by sickle cell disease and thrombocytopenic purpura. One patient in the SIPES group had autoimmune hemolytic anemia. One patient in the control group had a history of lymphoma and underwent partial splenectomy for a new splenic mass. We included the partial splenectomy procedure in our series because it did not stand out from other cases in any of the measured variables. All other patients underwent total splenectomy. There were two conversions to the open technique due to bleeding in SIPES group and one in the laparoscopic group due to a massive spleen (1145 g) with dense adhesions. There were no conversions from SIPES to multiport laparoscopy. Operative times were 40–190 minutes (median, 84 minutes) in the SIPES group and 51–154 minutes (median, 99 minutes) in the laparoscopic group. Three accessory spleens were found and removed in the SIPES group, and two were found and removed in the laparoscopic group. Median length of stay was 2 days in both groups. Five patients in the SIPES group went home on postoperative Day 1, whereas this was the case for only 1 patient in the control group, the patient who had a partial splenectomy. There were three perioperative complications in the SIPES group and two in the control group. Outcomes are summarized in Table 2.

Follow-up ranged between 1 month and 2 years. Twenty-eight of the 30 patients had resolution of their hematologic issues on follow-up. One patient was lost to follow-up, and the patient who underwent laparoscopic partial splenectomy for splenic mass was diagnosed with recurrent lymphoma and postoperatively received chemotherapy.

Operations were performed by five pediatric surgeons and five pediatric surgery fellows. All surgeons were proficient in advanced multiport laparoscopy including splenectomy, as well as the SIPES technique for appendectomy and cholecystectomy, before attempting their first SIPES splenectomy. Both conversions to the open procedure in the SIPES group were due to bleeding and occurred during the first SIPES splenectomy for both the attending and the fellow on the case. They were cases 7 and 11 in the series. Two other cases in this series were done as the first SIPES splenectomy for the attending and the fellow. They were cases 1 and 4 in the series, and both surgeries were completed without complications in 84 and 73 minutes, respectively.

Discussion

The SIPES technique can be used in many pediatric laparoscopic procedures. It is especially well suited for ablative procedures restricted to one quadrant of the abdomen where manipulation of the target organ is minimal. A good example is appendectomy, which is in the authors' opinion is the best starting procedure for surgeons who want to introduce SIPES into their practice. For SIPES splenectomy, instrument angles obtained through a multichannel umbilical port are suitable for all steps of the operation. Published reports mention use of articulating instruments to achieve better triangulation and facilitate dissection. In our experience, this is not necessary. Use of expensive disposable instrumentation can significantly increase the cost of the procedure. SIPES somewhat limits the surgeon's freedom of lateral movement because of clashing of instruments. This can be overcome by using more movement in the to and fro and up and down directions. For splenectomy, this works very well for dissection and retraction purposes, as well as use of tissue sealing/dividing devices and staplers.

It is our opinion that there is a cosmetic benefit of SIPES in comparison with conventional laparoscopic splenectomy. The scar resulting from a 15-mm incision can be well concealed within the umbilicus even in small children (Fig. 1). Although cosmesis is not objectively assessed in the study, it has been our experience that the vast majority of our SIPES patients (over 800 cases) and parents are very happy with the lack of any visible surgical scar.

OPEN IN VIEWER

FIG. 1.

Umbilical scar 1 month after single-incision pediatric endosurgery splenectomy in a 4-year-old patient.

In addition to cosmesis, avoidance of port placement-related injuries may be another possible advantage of the SIPES technique. At this point, this is merely speculation as large numbers of SIPES procedures will need to be reviewed to find differences in such rare complications.

Vascular and visceral injuries are rare but serious complications of laparoscopic surgery. Reported incidence varies between 0.1% to 1%.^11–17 Major morbidity can be associated with these injuries, especially if they are unrecognized intraoperatively, and fatalities have been reported.^13,18

Placement of the multichannel port is done in an open fashion similar to the Hasson technique, under direct visualization. The peritoneum is entered bluntly with a finger or a right-angle clamp while the fascia and peritoneum are lifted off the abdominal contents. Epigastric vessel injuries are avoided by accessing the abdomen only through the umbilicus. Our experience, as well as other published large series, has not encountered any port placement-related injuries with single-incision laparoscopic procedures.^{8–10,19–22} While accessing the peritoneal cavity with a Veress needle is a safe and widely accepted technique that we continue to use for all non-SIPES cases, the open technique does add an additional layer of safety by direct visualization.

Further large-volume clinical trials are needed to answer these questions as well as other outcome measures of SIPES compared with multiport laparoscopy that are controversial at this point: incidence of incisional hernia, postoperative pain, length of stay, and return to full activity.

We noticed that in comparison with conventional laparoscopic splenectomy, with the SIPES technique one larger 1.5-cm incision facilitates fragmentation and extraction of the spleen with ring forceps. In our limited experience, the operative times, blood loss, rate of complications, and length of stay are comparable between SIPES and conventional laparoscopic splenectomy. However, there were two intraoperative complications of bleeding in the SIPES group (12.5%) resulting in conversion to the open procedure, which is high in comparison with the 6.6% conversion rate reported in a meta-analysis of laparoscopic versus open splenectomy. ²³ Other authors of single-incision splenectomy articles in children have not encountered any conversions to the open technique in their experience.^8–10,21 Both instances of bleeding were caused by a technical error during dissection of hilar vessels. Small sample size and surgeon variability contribute a significant bias to our study. However, the bleeding complications are a source of concern about the safety of the SIPES technique. Careful dissection of the splenic hilum must be performed under optimal visualization, with optimal instrument angles in order to maximize patient safety, whether SIPES or conventional laparoscopy is used. With the SIPES technique, diligent adjustments of instruments and camera are crucial to achieve good visualization and a three-dimensional perspective in order to perform the procedure safely. This can be achieved in the majority of cases without additional trocars or articulating instruments. Additional trocars should be used without hesitation if required to maintain maximum safety of the procedure.

In conclusion, the SIPES technique is becoming used more widely for increasing numbers of laparoscopic procedures. At this point, the evidence is lacking to support it as superior over multiport laparoscopy in any of the outcome measures. Limited data available suggest it is safe, feasible, and comparable to conventional laparoscopy in terms of outcomes. Further large-volume studies are needed to elucidate significant differences between the two techniques.