Laparoskopische Splenektomie - Technik und Ergebnisse

Zusammenfassung

Die laparoskopische Splenektomie entwickelte sich zum Standardverfahren bei bestimmten Indikationsgruppen, insbesondere bei hämatologischen Erkrankungen. Patienten und Methode: Im Zeitraum vom Juni 1997 bis Juli 2005 führten wir 32 laparoskopische Splenektomien durch. Es wurde der anteriore Zugang mit wahlweise 3 oder 4 Trokaren gewählt. Ergebnisse: Die folgenden Erkrankungen stellten Indikationen zur Operation dar: idiopathische thrombozytopenische Purpura (n = 18), Non-Hodgkin-Lymphome (n = 7), Milzhämangiom (n = 2 ), Sphärozytose (n = 3), Hypersplenismus (n = 1), verkalkte Milzzyste (n = 1). Die mediane Operationszeit betrug 100 min (40-175 min ). Bei 5 Patienten (15,6 %) musste intraoperativ konvertiert werden. Die häufigste intraoperative und postoperative Komplikation stellte die Blutung dar. 2 Patienten entwickelten eine Thrombose der V. portae. Schlussfolgerung: Die laparoskopische Splenektomie stellt ein alternatives Verfahren zur konventionellen Splenektomie dar. Die Methode ist sicher und mit einer geringen Komplikationsdichte durchführbar. Sie stellt mittlerweile das Standardverfahren zur Entfernung der Milz bei hämatologischen Erkrankungen dar. Wegen der Gefahr der Pfortaderthrombose sollte eine postoperative verlängerte Thromboseprophylaxe durchgeführt werden.

Abstract

Laparoscopic splenectomy is considered as standard approach for specific indications, especially hematologic diseases. Patients and methods: Between June 1997 and July 2005 we performed 32 laparoscopic splenectomies. We chose for anterior approach with alternatively 3 or 4 trocars. Results: Following diseases are indications for laparoscopic operation: idiopathic thrombozytopenic purpura (n = 18), Non-Hodgkin-Lymphoma (n = 7), splenic hemangioma (n = 2), spherocytosis (n = 3), hypersplenism (n = 1), calcified splenic cyst (n = 1). Median operation time amounts 100 min (40-175 min). Intraoperative conversion was necessary in 5 patients (15,6 %). Bleeding appears as most frequent intraoperative and postoperative complication was. In 2 patients thrombosis of vena portae developed. Conclusions: Laparoscopic splenectomy represent alternative procedure to conventional splenectomy. Method is feasible sure with low complication rate and is considered as standard approach in removing the spleen in hematologic diseases. Because of the risk of postoperative thrombosis of the vena portae extended thrombosis prophylaxis should be performed.

Schlüsselwörter

Laparoskopie - Splenektomie - Indikation - Technik - Pfortaderthrombose

Key words

laparoscopy - splenectomy - indication - technique - thrombosis V. portae

Literatur

• 1 Delaitre B, Maignien B. [Splenectomy by the laparoscopic approach. Report of a case].  Presse Med. 1991;  20 2263
• 2 Delaitre B, Blezel E, Samama G. et al . Laparoscopic splenectomy for idiopathic thrombocytopenic purpura.  Surg Laparosc Endosc Percutan Tech. 2002;  12 412-419
• 3 Flowers J L, Lefor A T, Steers J, Heyman M, Graham S M, Imbembo A L. Laparoscopic splenectomy in patients with hematologic diseases.  Ann Surg. 1996;  224 19-28
• 4 Klingler P J, Tsiotos G G, Glaser K S, Hinder R A. Laparoscopic splenectomy: evolution and current status.  Surg Laparosc Endosc. 1999;  9 1-8
• 5 Kojouri K, Vesely S K, Terrell D R, George J N. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications.  Blood. 2004;  104 2623-2634
• 6 Ozdemir A, Karakoc D, Hamaloglu E, Kologlu M, Ozenc A. Laparoscopic splenectomy for haematological diseases.  Acta Chir Belg. 2004;  104 555-558
• 7 Park A, Targarona E M, Trias M. Laparoscopic surgery of the spleen: state of the art.  Langenbecks Arch Surg. 2001;  386 230-239
• 8 Carbonell A M, Kercher K W, Matthews B D, Joels C S, Sing R F, Heniford B T. Laparoscopic splenectomy for splenic abscess.  Surg Laparosc Endosc Percutan Tech. 2004;  14 289-291
• 9 Pomp A, Gagner M, Salky B. et al . Laparoscopic splenectomy: a selected retrospective review.  Surg Laparosc Endosc Percutan Tech. 2005;  15 139-143
• 10 Tanoue K, Okita K, Akahoshi T. et al . Laparoscopic splenectomy for hematologic diseases.  Surgery. 2002;  131 S 318-S 323
• 11 Uranues S, Alimoglu O. Laparoscopic surgery of the spleen.  Surg Clin North Am. 2005;  85 75-90
• 12 Vavra A K, Sweeney J F. Laparoscopic splenectomy - a review.  J Long Term Eff Med Implants. 2004;  14 347-358
• 13 Yoshizumi T, Iso Y, Yasunaga C, Kitano S, Sugimachi K. Laparoscopic splenectomy for splenic hamartoma.  Surg Endosc. 1997;  11 848-849
• 14 Zia H, Zemon H, Brody F. Laparoscopic splenectomy for isolated sarcoidosis of the spleen.  J Laparoendosc Adv Surg Tech A. 2005;  15 160-162
• 15 Brunt L M, Langer J C, Quasebarth M A, Whitman E D. Comparative analysis of laparoscopic versus open splenectomy.  Am J Surg. 1996;  172 596-599
• 16 Cavaliere D, Torelli P, Panaro F. et al . Outcome of laparoscopic splenectomy for malignant hematologic diseases.  Tumori. 2004;  90 229-232
• 17 Cordera F, Long K H, Nagorney D M. et al . Open versus laparoscopic splenectomy for idiopathic thrombocytopenic purpura: clinical and economic analysis.  Surgery. 2003;  134 45-52
• 18 Balague C, Targarona E M, Cerdan G. et al . Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis.  Surg Endosc. 2004;  18 1283-1287
• 19 Bolton-Maggs P H, Stevens R F, Dodd N J, Lamont G, Tittensor P, King M J. Guidelines for the diagnosis and management of hereditary spherocytosis.  Br J Haematol. 2004;  126 455-474
• 20 Wu J M, Lai I R, Yuan R H, Yu S C. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura.  Am J Surg. 2004;  187 720-723
• 21 Contini S, Dalla V R, Villani L G, Zinicola R. Lateral approach for laparoscopic splenectomy: a real advantage for beginners?.  Surg Laparosc. Endosc. 1996;  6 417
• 22 Edwin B, Skattum X, Rader J, Trondsen E, Buanes T. Outpatient laparoscopic splenectomy: patient safety and satisfaction.  Surg Endosc. 2004;  18 1331-1334
• 23 Friedman R L, Hiatt J R, Korman J L, Facklis K, Cymerman J, Phillips E H. Laparoscopic or open splenectomy for hematologic disease: which approach is superior?.  J Am Coll Surg. 1997;  185 49-54
• 24 Peitgen K, Swienty O, Beelen D W, Noppeney R, Walz M K. [Laparoscopic splenectomy by the “Essen-manoeuvre” for treatment of benign and malignant haematological diseases].  Zentralbl Chir. 2002;  127 543-549
• 25 Petroianu A, Berindoague N R. Laparoscopic subtotal splenectomy.  Minerva Chir. 2004;  59 501-505
• 26 Rescorla F J, Engum S A, West K W, Tres S L, Rouse T M, Grosfeld J L. Laparoscopic splenectomy has become the gold standard in children.  Am Surg. 2002;  68 297-301
• 27 Losanoff J E, Jones J W. Splenosis after laparoscopic splenectomy.  Surg Endosc. 2001;  15 1497
• 28 Rogers J, Yousuf A, Kleinhaus S. Laparoscopic accessory splenectomy in recurrent chronic immune thrombocytopenic purpura.  Surg Laparosc Endosc. 1997;  7 83-85
• 29 Kercher K W, Matthews B D, Walsh R M, Sing R F, Backus C L, Heniford B T. Laparoscopic splenectomy for massive splenomegaly.  Am J Surg. 2002;  183 192-196
• 30 Targarona E M, Espert J J, Balague C, Piulachs J, Artigas V, Trias M. Splenomegaly should not be considered a contraindication for laparoscopic splenectomy.  Ann Surg. 1998;  228 35-39
• 31 Targarona E M, Balague C, Trias M. Is the laparoscopic approach reasonable in cases of splenomegaly?.  Semin Laparosc Surg. 2004;  11 185-190
• 32 Patel A G, Parker J E, Wallwork B. et al . Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy.  Ann Surg. 2003;  238 235-240
• 33 Pross M, Wolff S, Mantke R, Lippert H. Intra- und postoperative Komplikationen nach Laparoskopischer Splenektomie.  Min Invas Chirurgie. 2000;  9 26-30
• 34 Targarona E M, Espert J J, Bombuy E. et al . Complications of laparoscopic splenectomy.  Arch Surg. 2000;  135 1137-1140
• 35 Wolff S, Pross M, Marusch F, Gastinger I, Lippert H. Die laparoskopische Splenektomie - Alternative zum offenen Eingriff.  Chirurgische Allgemeine. 2001;  3 370-372
• 36 Targarona E M, Espert J J, Cerdan G. et al . Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery.  Surg Endosc. 1999;  13 559-562
• 37 Ikeda M, Sekimoto M, Takiguchi S. et al . High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: a prospective study with contrast-enhanced CT scan.  Ann Surg. 2005;  241 208-216
• 38 Pietrabissa A, Moretto C, Antonelli G, Morelli L, Marciano E, Mosca F. Thrombosis in the portal venous system after elective laparoscopic splenectomy.  Surg Endosc. 2004;  18 1140-1143
• 39 Sapucahy M V, Faintuch J, Bresciani C J, Bertevello P L, Habr-Gama A, Gama-Rodrigues J J. Laparoscopic versus open splenectomy in the management of hematologic diseases.  Rev Hosp Clin Fac Med Sao Paulo. 2003;  58 243-249
• 40 Vavra A K, Sweeney J F. Laparoscopic splenectomy - a review.  J Long Term Eff Med Implants. 2004;  14 347-358
• 41 Watson D I, Coventry B J, Chin T, Gill P G, Malycha P. Laparoscopic versus open splenectomy for immune thrombocytopenic purpura.  Surgery. 1997;  121 18-22