Laparoscopic “double-port” splenectomy. A new minimally-invasiveoption in a giant spleen.

(1)

CASE

REPORT

–

OPEN

ACCESS

InternationalJournalofSurgeryCaseReports51(2018)139–142

Contents lists available atScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Laparoscopic

“double-port”

splenectomy.

A

new

minimally-invasive

option

in

a

giant

spleen

Marco

Casaccia

∗

,

Denise

Palombo,

Rosario

Fornaro,

Andrea

Razzore,

Domenico

Soriero,

Marco

Frascio

SurgicalClinicUnitII,DepartmentofSurgicalSciencesandIntegratedDiagnostics(DISC),GenoaUniversity,Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received28May2018

Receivedinrevisedform17August2018 Accepted20August2018 Keywords: Splenectomy Single-portsplenectomy Hand-assistedsplenectomy Massivesplenomegaly Idiopathicmyeloﬁbrosis Lymphoma

a

b

s

t

r

a

c

t

INTRODUCTION:Incaseofmassivesplenomegaly,laparoscopicsplenectomy(LS)becomeschallenging, uncomfortableandriskybothforthesurgeonandforthepatient.Asaconsequenceofongoingresearch toobtainefﬁcientandcheaper“scarlesssurgery”,single-porttechniqueandhand-assisteddeviceswere developedandimprovedinthisﬁeld.

PRESENTATIONOFCASE:Wepresenttheclinicalcaseofapatientaffectedbyidiopathicmyeloﬁbrosis (MF)andsplenomegalywhowasadmittedtoourDepartmenttoperformasplenectomyforasuspected 5-cmspleniclesion.

DISCUSSION:Thespleniclongitudinaldiametermeasured26cm.Thepatientunderwentsplenectomy bylaparoscopy,combiningasingle-portaccessandagel-portdevice.Theoperationwascompleted laparoscopically.Theoperatingtimewas220minandtheestimatebloodlosswas100ml.Thepatient wasdischargedat11post-operativedayinoverallgoodconditions.Uponpathologicalanalysisthesplenic lesionwasalocalizationofdiffuselargeB-cellLymphomainthecontextofMF.

CONCLUSION:thisnovel“hybridtechnique”ofsplenectomy,combiningtheadvantagesofreduced num-berofabdominalincisionsofthesingle-porttechniquetothoseofthehandassistance,isfeasiblein massivesplenomegalywithgoodresults.Furthermore,theuseofthesovrapubicretrievalincisionasthe introductionsiteforthehandassisteddeviceisconvincing,sinceit’susefulforbothtasks.Furtherstudies withlargecasuistriesarenecessarytoconﬁrmtheeffectivenessofthetechnique.

1. Introduction

Laparoscopicsplenectomy(LS)representsthestandard treat-mentforhematologicdisordersinnormal-sizespleens.Inpatients withmassivesplenomegalyandgiantspleens,LSbecomes techni-callychallenging,becauseofthereducedabdominalworkingspace anddifﬁcultintra-abdominalmanipulationoflargespleens[1].

TheclinicalpracticeguidelinesoftheEuropeanAssociationfor EndoscopicSurgery(EAES)suggestthathand-assistedLSoropen splenectomyshouldbeconsideredinpatientswithmassiveand ultra-massivesplenomegaly[2].

The hand-assisted technique can provide tactile feedback enablingmanipulationofheavy-weightedspleensandcontrolof unexpectedbleeding,sincenondominanthandofthesurgeonis usuallyinsertedthroughamidlineincisionorinleft/right hypocon-drium[3].

∗ Correspondingauthorat:UOCClinicaChirurgica2,IRCCSAziendaOspedaliera UniversitariaSanMartino–IST,MonobloccoXIpiano,LargoRosannaBenzi,10, 16132,Genova,Italy.

E-mailaddress:marco.casaccia@unige.it(M.Casaccia).

Withtheadventofthelaparoscopictechniquethroughasingle access[4],thisapproachhasspreadtothepointofbeingusedalso forsplenectomy,bringingundoubtedbeneﬁtsintermsoflesspain andbettercosmetics[5].Recently,fewreportsdescribetheuseof single-portaccessforthetreatmentofbenignspleensassociated tomassivesplenomegaly[6,7].Somedifferencesexistinsplenic malignancies associatedtomassive splenomegaly[8]. Since the spleenneedstoberetrievedintactforanatomo-pathologic exam-ination,alargeincisionneedstobemadeforspleenretrieval.In suchcases,thehand-portincisioncanbeusedtoanadvantage, facilitatingtheextractionofthelargespecimenfromtheabdomen [9].The hand-assisted techniquehasalwaysbeenassociated to conventional multi-portlaparoscopy.Todate,theassociationof single-portlaparoscopywiththehandassistancehasneverbeen described,andaboveall,itsuseinthetreatmentofsplenic malig-nancies.Wepresentour“hybridtechnique”thatcombinestheuse ofthesingle-porttechniquewiththehandassistanceincaseof massivesplenomegaly.Theworkhasbeenreportedinlinewith theSCAREcriteria[10].

https://doi.org/10.1016/j.ijscr.2018.08.033

(2)

CASE

REPORT

–

OPEN

ACCESS

140 M.Casacciaetal./InternationalJournalofSurgeryCaseReports51(2018)139–142

Fig.1.CTscanshowinganintra-parenchimallesionof5cmina26-cminterpole

diameterspleen.

2. Casereport

InJanuary 2018,a 57-year-oldwomanwasadmitted toour Department toperforma splenectomy fordiagnostic purposes. Thepatient’s medical history wassignificantfor celiac disease, highbloodpressureandidiopathicmyelofibrosis(MF)diagnosed in2014,confirmedwithabonemarrowbiopsyandtreatedwith oncocarbidefor4years.Duringthehematologicalfollow-up,the patientdevelopedasplenomegaly(spleenlongitudinaldiameter: 26cm)andanintra-parenchimallesionof5cmhaving standard-izeduptakevalues(SUV)of14atpositronemissiontomography (PET)/computerizedtomography(CT)scan(Fig.1).

Splenic 2-deoxy-2-[18F]ﬂuoro-d-glucose (FDG) uptake was consideredsuspectedoflymphomaorsarcoma.

Abdominalexaminationshoweda palpablespleenintheleft upper quadrant. No ascites or declivous edemas were evident. No previousabdominal surgery was reported. Thepatient was classiﬁed American Society of Anesthesiologists (ASA) score 2. Laboratorytestsandotherroutineexamsincludingplatelets, bio-chemicalinvestigationsandserologicalviralmarkerswerenormal. 2.1. Surgicalprocedure

Undergeneralanaesthesia,thepatientwasplacedinthe semi-lateraldecubitus,tiltedata15◦reversetrendelenburgpositionand bendedattheumbilicus.Antibioticproﬁlaxiswith2grofCefazolin wasgivenattheinductionofanaesthesia.Theﬁrstoperatorandthe cameraholderstoodattherightsideofthepatient.A3cm-long intraumbilicalincisionwasrealizedandasingle-portdevice(Single Port,UnimaxMedicalSystemsInc.,Taipei,Taiwan)wasintroduced. Aftercreationofa12mmHgCO2pneumoperitoneum,thedevice forthehandassistance(Gelport,AppliedMedicalResources Cor-poration,RanchoSantaMargarita,California,USA)wasintroduced froma 7-cmsuprapubicincision.TheUnimaxport wasusedto accomodatea30◦angled10-mmtelescope,acurvedgrasperand a radiofrequencydevice(Ligasure; CovidienItalia, Segrate(Mi), Italy).TheGelportwasusedtoaccomodatealternatively,theleft handoftheassistantplacedontheleftsideofthepatientanda retractor.Thesurgicaltechniquewassimilartothatusedin stan-dardLS[11].

Maindifferenceswererepresentedbytheuseofintraperitoneal handprovidinginitialtractiononthesplenicﬂexureofthecolonto allowdivisionofthesplenocolicligament.Then,the intraabdomi-nalhandpushedthespleenlaterallytoallowtheentrytothelesser

Fig.2.TheUnimaxportispositionedintheumbilicusandtheGelportina supra-pubicincision.TheGelportaccommodatestheassistant’slefthandintheﬁrstpart oftheoperation.

Fig.3. Theassistant’shandputsthegastro-splenicligamentintensiontoenterthe lessersac.

sac(Figs.2and3).Theshortgastricvesselswerethensequentially divided.Theinstrumentswerethenmovedtotheposteriorface ofthespleenandthetablewastiltedtotherighttotake advan-tageofgravity andtoexposetheretro-splenicarea. Thespleen wasretractedmediallybythehand,enablingthedissectionofthe posteriorandlateralattachments.

Thepancreatictailandsplenichilumwerethenlocalizedwith theintraperitonealhand.Afterisolation ofthehilum,the pedi-cle wasdividedwitha 6-cm vascularstapler (Echelon, Ethicon Endo-Surgery)introducedfromtheumbilicalport.Followinghilar division, the inserted hand was retracted from the Gelport to placea retractortoexpose theremainingsuperiorattachments (Fig.4).A15-mmendobag(EndocatchII;Covidien,Mansﬁeld,MA, USA) wasinserted throughthe Gelport and theintraperitoneal handbecameinstrumentalinguidingthespecimenintothebag. ThebagwaspulledtotheGelporthand-assisteddeviceandthe spleenwasretrievedintact(Fig.5).Uponspecimenremoval, pneu-moperitoneumwasre-establishedandthevascularstaplelinewas reinspectedbeforeclosure.Anabdominaldrainagewasleftinplace. Theoperatingtimewas220minandtheestimatebloodloss was100ml.During thepostoperativecourse,thepatient devel-opedfever,splenicandpartialportalveinthrombosisandpleural

(3)

CASE

REPORT

–

OPEN

ACCESS

M.Casacciaetal./InternationalJournalofSurgeryCaseReports51(2018)139–142 141

Fig.4.TheGelportdeviceaccommodatesaretractorforthedissectionofthe

supe-riorpoleofthespleen,asthesplenicdissectionproceeds.

Fig.5.Thespecimenisretrievedintotoforanatomo-pathologicalexamination.The

splenicnodularlesionappearedwhitish,solidandwelldemarcated.

effusion.Thepatientwastreatedwithanticoagulantandantibiotic therapyfor10daysanddischargedat11post-operativedayin over-allgoodconditions.Uponpathologicalanalysisthespleniclesion wasalocalizationofdiffuselargeB-cellLymphomainthecontext ofMF.Thepatientisaliveandinhealthycondition4monthsafter theoperation.

3. Discussion

Withthedevelopmentofthelaparoscopictechniquethrough a singleaccess, this approach hasspread tothe point ofbeing usedalsoforsplenectomy[4,5].Reportsshowedthatsingle-port splenectomy achieved similar results to thetraditional laparo-scopicapproach,bringingundoubtedbeneﬁtsintermsoflesspain and better cosmetics [12,13]. Laparoscopic single-port splenec-tomyofnormal-sizespleensisbroadlyspreading,whereasitsusein splenomegalyisstilllittleexplored[6,7].Inmassivesplenomegaly, themainissueisrepresentedbytheextractionofthepiecethatfor anatomo-pathologicalpurposesmustberetrievedintoto.Hence theneedforaservicemini-laparotomywhichpartiallyaffectsthe beneﬁtsof laparoscopy[14]. Thanksto our experienceof liver resectionin whichthespecimenisretrievedfromasuprapubic incision,fortotallylaparoscopicsplenectomywehavetherefore shiftedfromasubcostaltoasuprapubicaccess.

Thisincision,inwhichmuscleﬁbersaresplitandnotcutoff, giveslesspainandlessrespiratoryproblems.Thenecessitytomake anincisionattheendoftheprocedurehaspushedustousethis accesssincethebeginningoftheoperationforthehandassistance andnotonlythereforeforthespecimenretrieval.

The hand assistance, by regaining of tactile feedback, also increasesthesafetyoftheprocedure,sinceitenablesthesurgeon torapidlyidentifyvascularstructuresand,inthecaseofaccidental bleeding,allowsimmediatehemostaticcontrolbydigital compres-sion.Furthermore,manualmanipulationofthespleen,particularly whenitisalargeone,isprobablysaferandeasierthanmanipulation withlaparoscopicinstruments[3].

Contrarytowhatisdescribedintheclassichand-assisted tech-nique,inourcaseitisnotthehandofthesurgeontobeusedbut thatoftheassistant,insertedintraperitoneallythrougha suprapu-bicPfannestielincision.Usuallythesurgeon’snon-dominantleft handisinsertedintraperitoneallythrougha7-cmabdominal inci-sion[3].Inourcaseit’stheassistant’slefthandtobeused,thus leavingtheoperatortheabilitytousethelaparoscopicinstruments withbothhands.

Atheoreticaldisadvantageofhavingthesurgeon’shandinthe abdomenincludeslimitingtheoperativeworkingspace.Inourcase, thisissuehasnotbeenexperiencedbecausetheassistant’shand arrivedlaterallyontheoperatingfield,limitingthereductionofthe visualfieldtoaminimum.Inaddition,theassistantwasafemale residentwithathinarmandasmallhandthatperfectlyfittedthe task.

Forsplenectomy,severalsitesforthesurgeon’shand introduc-tionwereproposed:uppermidline,leftorrighthypocondriumand rightiliacfossaincaseofmassivelyenlargedspleens[5,11].

Thisistheﬁrstcasewherethesuprapubicincisionwasadopted. Themaindrawbackisthatthisincisionislocatedfarfromthe surgi-calsite,anditcouldrepresentaproblem,especiallyintallpatients. Infact,inourcasethesuperiorpoleofthespleenwasnot reach-ablebythehand.Thisproblemhasbeenovercomebyintroducing aretractorfromtheGelportdevice.Thisdeviceshowedgreat ver-satility,enablingthesurgeontoalternativelyintroducethehandor thelaparoscopicinstrumentswithouttheneedofatrocar.

In conclusion, this novel “hybrid technique” combining the advantagesofreducednumberofabdominalincisionsofthe single-porttechniquetothoseofthehandassistanceisfeasibleinmassive splenomegalywithgoodresults.Furthermore,theuseofthe supra-pubicretrievalincisionastheintroductionsiteforthehandassisted deviceisconvincing,sinceit’susefulforbothtasks.Furtherstudies withlargecasuistriesarenecessarytoconﬁrmtheeffectivenessof thetechnique.

Conﬂictsofinterest None.

Funding

Thisresearchdidnotreceiveanyspeciﬁcgrantfromfunding agenciesinthepublic,commercial,ornot-for-proﬁtsectors.

Ethicalapproval

TheEthicalCommitteeoftheIRCCSOspedalePoliclinicoSan Martino hasexemptedthe workfromethicalapproval because it involvesonly negligibleriskfor thepatient; furthermore,the patientdatapubliclyrecordedcontainonlynon-identiﬁabledata abouthim.

(4)

CASE

REPORT

–

OPEN

ACCESS

142 M.Casacciaetal./InternationalJournalofSurgeryCaseReports51(2018)139–142

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorscontribution

MarcoCasaccia,DenisePalombo:studydesign,writing. RosarioFornaro,AndreaRazzore:acquisitionofdata,writing. DomenicoSoriero:acquisitionofdata.

MarcoFrascio:ﬁnalapprovaloftheversiontobesubmitted.

Registrationofresearchstudies

NA.

Guarantor

MarcoCasaccia. DenisePalombo.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

References

[1]S.W.Grahn,J.Alvarez,III,K.Kirkwood,Trendsinlaparoscopicsplenectomy

formassivesplenomegaly,Arch.Surg.141(2006)755–762.

[2]B.Habermalz,S.Sauerland,G.Decker,etal.,Laparoscopicsplenectomy:the

clinicalpracticeguidelinesoftheEuropeanAssociationforEndoscopic

Surgery(EAES),Surg.Endosc.22(2008)821–848.

[3]G.K.Kaban,D.R.Czerniach,R.Cohen,etal.,Hand-assistedlaparoscopic

splenectomyinthesettingofsplenomegaly,Surg.Endosc.18(2004)

1340–1343.

[4]J.R.Romanelli,D.B.Earle,Single-portlaparoscopicsurgery:anoverview,Surg.

Endosc.23(2009)1419–1427.

[5]E.M.Targarona,M.B.Lima,C.Balague,etal.,Single-portsplenectomy:current

updateandcontroversies,J.Minim.AccessSurg.7(2011)61–64.

[6]S.Li,M.Li,W.Xu,etal.,Single-incisionlaparoscopicsplenectomyusingthe

suturesuspensiontechniqueforsplenomegalyinchildrenwithhereditary

spherocytosis,J.Laparoendosc.Adv.Surg.Tech.A25(2015)770–774.

[7]R.Zorron,S.H.Cunha,M.C.Barreto,etal.,Singleportlaparoscopic

splenectomyforwanderingspleenwithsplenomegalyinapatientwith

Wolf-Hirschhornsyndrome,J.Minim.AccessSurg.13(2017)135–138.

[8]R.S.Berman,A.M.Yahanda,P.F.Mansﬁeld,etal.,Laparoscopicsplenectomyin

patientswithhematologicmalignancies,Am.J.Surg.178(1999)530–536.

[9]T.W.Swanson,A.T.Meneghetti,S.Sampath,etal.,Hand-assistedlaparoscopic

splenectomyversusopensplenectomyformassivesplenomegaly:20-year

experienceataCanadiancentre,Can.J.Surg.54(2011)189–193.

[10]R.A.Agha,A.J.Fowler,A.Saetta,I.Barai,S.Rajmohan,D.P.Orgill,fortheSCARE

Group,TheSCAREstatement:consensus-basedsurgicalcasereport

guidelines,Int.J.Surg.34(2016)180–186.

[11]M.Casaccia,Minimallyinvasivesplenectomyformassivesplenomegaly,in:

C.T.Frantzides,M.A.Carlson(Eds.),VideoAtlasofAdvancedMinimally

InvasiveSurgery,ElsevierSaunders,Philadelphia,2012,pp.183–190.

[12]Y.Fan,S.D.Wu,J.Kong,etal.,Feasibilityandsafetyofsingle-incision

laparoscopicsplenectomy:asystematicreview,J.Surg.Res.186(2014)

354–362.

[13]K.K.Choi,M.J.Kim,H.Park,etal.,Single-incisionlaparoscopicsplenectomy

versusconventionalmultiportlaparoscopicsplenectomy:aretrospective

comparisonofoutcomes,Surg.Innov.20(2013)40–45.

[14]M.Casaccia,P.Torelli,A.Pasa,etal.,Putativepredictiveparametersforthe

outcomeoflaparoscopicsplenectomy:amulticenteranalysisperformedon

theItalianRegistryofLaparoscopicSurgeryoftheSpleen(IRLSS),Ann.Surg.

251(2010)287–291.

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.