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BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.

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Splenectomy remains the definitive treatment for idiopathic thrombocytopenic purpura (ITP). Issues related to timing of splenectomy, perioperative management of platelet count, deep vein thrombosis prophylaxis, and preoperative vaccination are not standardized. Predicting the outcome of splenectomy is desirable but, again, consistent evidence for a particular approach is lacking. Laparoscopic splenectomy, first introduced in 1991, has removed some of the barriers to acceptance of splenectomy and may well change its place in the various treatment algorithms. This article reviews current knowledge with respect to laparoscopic splenectomy and provides an analysis of current evidence regarding issues of safety, efficacy, and cost effectiveness. Surgical technique is briefly reviewed. The information is drawn from a comprehensive analysis of the literature, as well as my own large experience with laparoscopic splenectomy, the majority of which has been focused on laparoscopic splenectomy for ITP.

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Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.

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Anastomotic ulcers are a rare late complication of ileocolic resection in children. The authors describe the cases of two patients who presented 10 and 8 years, respectively, after ileocolic resection. Both had suffered from iron-deficiency anemia caused by an anastomotic ulcer. In one patient the anemia improved after resection of the ulcer; in the second patient cholestyramine and a lactose-free diet resolved the problems of anemia and diarrhea. Anastomotic ulceration should be suspected in any child who has undergone an ileocolic anastomosis and subsequently presents with persistent iron-deficiency anemia and occult blood in the stool.

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The authors reviewed retrospectively 368 breast lumps subjected to fine-needle aspiration cytology alone or to open biopsy as well. Of those lumps for which the results of both studies were available, there were 39 true-positive results, 32 true-negative, 1 false-positive and 7 false-negative results when the definitive findings of fine-needle aspiration biopsy were compared with the histologic features. Also, in the 40 patients in whom the aspirate was suggestive of malignancy or the findings were atypical, 22 had malignant disease on open biopsy and 18 had benign disease. These results are consistent with those reported in the literature and point to the importance of a positive or suggestive report and the current unreliability of a negative report.

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