Laparoscopic Ultrasound Splenectomy in Children with Hematologic Disorders
Laparoscopic Ultrasound Splenectomy in Children with Hematologic Disorders
ABSTRACT & COMMENTARY
Synopsis: Laparascopic surgery is feasible and safe in children with hematologic disorders. Although it requires more operative time than the open approach, it is superior with regard to duration of postoperative analgesics, duration of hospital stay, and recovery of bowel function.
Source: Farah RA, et al. Comparison of laparascopic and open splenectomy in children with hematologic disorders. J Pediatr 1997;131:41-46.
Farah and associates performed retrospective reviews of 16 laparascopic and 20 open splenectomies for a variety of hematologic disorders. Concomitant cholecystectomy was performed on a number of these children. The laparascopic operations took more time, but postoperative analgesia to regain bowel function were shorter time and time again. Discharge from hospital was also earlier in the laparascopic group. Postoperative complications were similar, and the hematologic response was similar in the two groups.
COMMENT BY JOHN H. SEASHORE, MD
The laparoscopic revolution proceeds apace. It has been less than 10 years since laparascopic abdominal surgery was introduced in the United States, and these procedures have been applied to children’s surgery for only five or six years. The role of laparascopic surgery is still being defined, and most publications are intended to demonstrate safety and efficacy of new procedures. Cholecystectomy is the only procedure for which laparoscopy is clearly the best approach. The paper by Farah et al is the largest series to date of laparoscopic splenectomy in children and makes a reasonable argument that this procedure is, in fact, safe and effective. In this nonrandom comparison with open splenectomy, there was no difference in complication rate and only one conversion to an open procedure. In contrast to previous smaller reports, Farah et al documented faster recovery, less narcotic use, and shorter hospital stay in the laparoscopic group. The higher operating room costs for time and supplies was balanced by the shorter hospital stay, so the overall costs were comparable.
There are a number of caveats. Experience is still far too limited to state that laparoscopy is the approach of choice for splenectomy. Although the author’s description of the technique sounds easy, it is technically challenging, and there is a steep learning curve. It still takes 2-3 times as long to perform as an open splenectomy in children. Of concern is that Farah et al did not find any accessory spleens in the laparoscopy group. One would expect to find accessory spleens in 10-20% of patients, and, in fact, they were found in 25% of the open group. This may be random variation, but it raises a question about the adequacy of laparoscopic exploration. Splenic size is an unresolved issue. Some children with hematologic disorders (e.g., thalassemia) have very large spleens that may not be amenable to laparoscopic removal because of difficulties handling, retracting, and bagging the enlarged organ.
Despite these concerns, it is likely that laparoscopic splenectomy will be performed with increasing frequency. The technical problems will abate with experience and the development of better instrumentation. As with cholecystectomy, patients will be an important driving force. The advantages to the patient of less pain, shorter hospital stay, and more rapid return to normal activities are obvious. The large scar from open splenectomy is particularly bothersome to teenagers. Up to one-third of these patients require concomitant cholecystectomy, which requires an even longer transverse incision or an unattractive midline incision in the open approach but only one additional port site laparoscopically. Patients who express interest in laparoscopic splenectomy should be referred to a pediatric surgeon who has experience with this technique who can discuss the risks and benefits of both approaches. The next few years will certainly see much more widespread use of laparoscopic splenectomy, but there will probably always be some patients for whom the open procedure is better. (Dr. Seashore is Professor of Pediatric Surgery, Yale University School of Medicine.)
Laparascopic splenectomy compared to open splenectomy:
a. is associated with shorter anesthesia time.
b. is less expensive.
c. is associated with shorter hospital stays.
d. has a higher rate of operative complications.
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