Abstract
Background
Laparoscopic splenectomy is an effective treatment for many patients with immune thrombocytopenic purpura (ITP) who fail or relapse after treatment with steroids. Patients with an incomplete response to splenectomy and those who experience recurrence of symptoms should be evaluated for the presence of an accessory spleen. The clinical effectiveness of laparoscopic excision of an accessory spleen after a previous splenectomy for ITP has varied in different studies. Laparoscopic intraoperative identification of an accessory spleen can be difficult. The authors report their experience with laparoscopic accessory splenectomy (LAS) and the use of perioperative localization methods for this procedure.
Methods
This study reviewed seven consecutive patients who underwent LAS, after initial splenectomy failed to cure ITP, at a tertiary care center between April 9, 2003 and March 31, 2008. Demographics, diagnostic and localization studies, technical success, and the effect on thrombocytopenia were examined. The location of the accessory spleen also was recorded. A novel method for localizing accessory spleen was used. It consisted of preoperative computed tomography (CT)-guided injection of methylene blue at the accessory spleen’s site, preoperative intravenous injection of 99m-technetium-labeled, heat-damaged red blood cells, or both. Intraoperatively, the dye was used for visual identification, and the gamma probe was used to aid in locating and confirming the presence of the accessory spleen in the excised specimen.
Results
Seven patients with recurrent ITP after initial failed splenectomy underwent LAS during the study period. Five of these patients had the initial splenectomy performed laparoscopically. All seven patients had successful laparoscopic removal of the accessory spleen based on a final pathologic examination. One patient required the second laparoscopic exploration with perioperative localization after a failed attempt without it. These perioperative localization methods were used in subsequent operations on other patients. These methods were found to be helpful in the intraoperative identification of the accessory spleens. The accessory spleens missed at initial splenectomy were found in unusual locations. Five of the seven patients had sustained improvement in platelet counts after LAS. One patient had a postoperative ileus that resolved with nonoperative management. No other complications or mortality was observed.
Conclusion
The LAS procedure after previous splenectomy is feasible and safe. Perioperative localization methods aid in the intraoperative identification of an accessory spleen. Accessory spleens missed at initial splenectomy are generally found in unusual locations. Treatment of recurrent or unresolved ITP with LAS can be effective for some patients.
Similar content being viewed by others
References
Friedman RL, Fallas MJ, Carroll BJ, Hiatt JR, Phillips EH (1996) Laparoscopic splenectomy for ITP: the gold standard. Surg Endosc 10:991–995
Schwartz J, Leber MD, Gillis S, Giunta A, Eldor A, Bussel JB (2003) Long-term follow-up after splenectomy performed for immune thrombocytopenic purpura (ITP). Am J Hematol 72:94–98
Shimomatsuya T, Horiuchi T (1999) Laparoscopic splenectomy for treatment of patients with idiopathic thrombocytopenic purpura: comparison with open splenectomy. Surg Endosc 13:563–566
Szold A, Kamat M, Nadu A, Eldor A (2000) Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura and hemolytic anemia. Surg Endosc 14:761–763
Rogers J, Yousuf A, Kleinhaus S (1997) Laparoscopic accessory splenectomy in recurrent chronic immune thrombocytopenic purpura. Surg Laparosc Endosc 7:83–85
Velanovich V, Shurafa M (2000) Laparoscopic excision of accessory spleen. Am J Surg 180:62–64
Amaral JF, Meltzer RC, Crowley JP (1997) Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura. Surg Laparosc Endosc 7:340–344
Antevil J, Thoman D, Taller J, Biondi M (2002) Laparoscopic accessory splenectomy with intraoperative gamma probe localization for recurrent idiopathic thrombocytopenic purpura. Surg Laparosc Endosc Percutan Tech 12:371–374
Chung CW, Lee WJ, Choi JS, Ko YW, Han JS, Min YH, Kim BR (1999) Laparoscopic splenectomy for immune thrombocytopenic purpura: long-term result of 40 laparoscopic splenectomies. Yonsei Med J 40:578–582
Katkhouda N, Hurwitz MB, Rivera RT, Chandra M, Waldrep DJ, Gugenheim J, Mouiel J (1998) Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients. Ann Surg 228:568–578
Schlinkert RT, Mann D (1995) Laparoscopic splenectomy offers advantages in selected patients with immune thrombocytopenic purpura. Am J Surg 170:624–626; discussion 626–627
Silecchia G, Boru CE, Fantini A, Raparelli L, Greco F, Rizzello M, Pecchia A, Fabiano P, Basso N (2006) Laparoscopic splenectomy in the management of benign and malignant hematologic diseases. JSLS 10:199–205
Szold A, Schwartz J, Abu-Abeid S, Bulvik S, Eldor A (2000) Laparoscopic splenectomies for idiopathic thrombocytopenic purpura: experience of sixty cases. Am J Hematol 63:7–10
Gigot JF, Jamar F, Ferrant A, van Beers BE, Lengele B, Pauwels S, Pringot J, Kestens PJ, Gianello P, Detry R (1998) Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy: a shortcoming of the laparoscopic approach in hematologic diseases. Surg Endosc 12:101–106
Targarona EM, Espert JJ, Balague C, Sugranes G, Ayuso C, Lomena F, Bosch F, Trias M (1998) Residual splenic function after laparoscopic splenectomy: a clinical concern. Arch Surg 133:56–60
Akwari OE, Itani KM, Coleman RE, Rosse WF (1987) Splenectomy for primary and recurrent immune thrombocytopenic purpura (ITP): current criteria for patient selection and results. Ann Surg 206:529–541
Chirletti P, Cardi M, Barillari P, Vitale A, Sammartino P, Bolognese A, Caiazzo R, Ricci M, Muttillo IA, Stipa V (1992) Surgical treatment of immune thrombocytopenic purpura. World J Surg 16:1001–1004; discussion 1004–1005
Facon T, Caulier MT, Fenaux P, Plantier I, Marchandise X, Ribet M, Jouet JP, Bauters F (1992) Accessory spleen in recurrent chronic immune thrombocytopenic purpura. Am J Hematol 41:184–189
Gigot JF, Healy ML, Ferrant A, Michaux JL, Njinou B, Kestens PJ (1994) Laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Br J Surg 81:1171–1172
Morris KT, Horvath KD, Jobe BA, Swanstrom LL (1999) Laparoscopic management of accessory spleens in immune thrombocytopenic purpura. Surg Endosc 13:520–522
Olsen WR, Beaudoin DE (1969) Increased incidence of accessory spleens in hematologic disease. Arch Surg 98:762–763
Coventry BJ, Watson DI, Tucker K, Chatterton B, Suppiah R (1998) Intraoperative scintigraphic localization and laparoscopic excision of accessory splenic tissue. Surg Endosc 12:159–161
Diaz J, Eisenstat M, Chung RS (1996) Laparoscopic resection of accessory spleen for recurrent immune thrombocytopenic purpura 19 years after splenectomy. J Laparoendosc Surg 6:337–339
Mercan S, Seven R, Erbil Y (1996) Laparoscopic treatment of accessory splenic tissue. Surg Laparosc Endosc 6:330–331
Kang CM, Lee JG, Kim KS, Choi JS, Lee WJ, Kim BR, Ko YW, Han JS, Min YH (2007) Long-term follow-up of laparoscopic splenectomy in patients with immune thrombocytopenic purpura. J Korean Med Sci 22:420–424
Wallace D, Fromm D, Thomas D (1982) Accessory splenectomy for idiopathic thrombocytopenic purpura. Surgery 91:134–136
Rudowski WJ (1985) Accessory spleens: clinical significance with particular reference to the recurrence of idiopathic thrombocytopenic purpura. World J Surg 9:422–430
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Altaf, A.M.S., Sawatzky, M., Ellsmere, J. et al. Laparoscopic accessory splenectomy: the value of perioperative localization studies. Surg Endosc 23, 2675–2679 (2009). https://doi.org/10.1007/s00464-008-0258-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-008-0258-5